Menopause, also known as the climacteric, is the time in most women’s lives when menstrual periods stop permanently. Menopause typically occurs between 45 and 55 years of age.
Medical professionals often define menopause as having occurred when a woman has not had any menstrual periods for a year. It may also be defined by a decrease in hormone production by the ovaries.
Why does bone loss speed up after the menopause?
The rapid dip in bone density after the menopause is caused by falling levels of the female hormone oestrogen. Oestrogen helps to protect bone strength.
Women can lose up to 20% of their bone density in the five to seven years after the menopause. This makes post-menopausal women more at risk of osteoporosis (weak bones) and fractures.
Why postmenopausal women are at greatest risk of osteoporotic fractures?
- Between the ages of approximately 25 and menopause, bone resorption (breakdown) and formation are balanced to maintain total bone mass. After menopause, bone resorption exceeds bone formation, leading to a rapid decline in bone mass.
- Menopause-induced bone loss is most severe after surgical removal of the ovaries, or from the use of aromatase inhibitor therapy in cancer patients.
What is the burden of osteoporosis and fractures on postmenopausal women ?
- Worldwide, one in three women aged over 50 years will suffer a fracture caused by osteoporosis.
- In women aged over 45 years, osteoporosis accounts for more days spent in hospital than many other diseases, including diabetes, myocardial infarction (heart attack) and breast cancer.
How women can reduce osteoporosis and fracture risk
- An individual’s risk of developing osteoporosis and fragility fractures is determined by a number of factors, some of which can be changed (modifiable) while others cannot (non-modifiable).
|MODIFIABLE RISK FACTORS||NON-MODIFIABLE RISK FACTORS|
|Acid base balance of the diet||Glucocorticoid treatment|
|Lifestyle factors||Diseases of malabsorption|
|Pre mature menopause|
Studies have shown that individuals with a sedentary lifestyle are more likely to have a hip fracture than those who are more active. For example, women who sit for more than nine hours a day are 43% more likely to have a hip fracture than those who sit for less than six hours a day
Exercise has been shown to lead to small but statistically significant increases in bone mineral density (BMD) of the order of 1-2%
The positive effect of exercise on bone in older people is dependent upon both the type of exercise and intensity.
Generally, resistance training becomes more beneficial as one ages.
For fragility fracture sufferers, exercise programmes have been shown to assist recovery of function, prevent recurrent injurious falls and improve quality of life.
- Exercise maintains bone strength and increases muscle mass in order to improve balance and strength, which are important risk factors for falls and fractures.
- Exercises to improve posture and reduce rounded shoulders may reduce fracture risk, particularly at the spine.
- An exercise programme for people with osteoporosis should specifically target posture, balance, gait, coordination, and hip and trunk stabilization rather than general aerobic fitness.
- Calcium is a major building block of our skeleton. Calcium in our bones acts as a reservoir for maintaining levels in the blood, which is essential for nerve and muscle function.
- Calcium needs change throughout life and are higher in the teenage years during the period of rapid growth, as well as in people aged over 50, as the body’s ability to absorb calcium declines with advancing age.
- Recommended daily calcium intake varies country to country. World Health Organization recommendations for postmenopausal women are 1300 mg daily.
- Diet should be the primary source of calcium. For people who cannot get enough through their diet, calcium (or calcium with vitamin D) supplements may be beneficial. Calcium supplements should however be limited to 500–600 mg per day.
- Vitamin D is primarily synthesized in the skin after sun exposure and plays a crucial role in bone and muscle development, function and preservation.
- Vitamin D can contribute to reducing fracture risk by regulating calcium levels in the body, and by improving muscle performance and balance – thus reducing falls risk.
- IOF vitamin D recommendations are 800–1000 IU per day for fall and fracture prevention in adults aged 60 and older.
- Low levels of vitamin D in the population are a cause of concern around the world, with insufficiency prevalent globally.
- Body composition changes after middle age, including increases in fat mass and decreases in lean muscle mass.
- Studies show that participants with the highest protein intake lost 40% less lean mass than those with the lowest protein intake.
- In order for the beneficial effect of protein on bone mass density (BMD) to be realized, it should be accompanied with adequate calcium intake.
Acid-base balance of the diet
- Acidic environment may have negative effects on bone preservation. This occurs when the intake of acid-producing foods (cereal grains and protein), is not balanced by enough alkali-producing fruits and vegetables.
- Diets rich in fruit and vegetables have been shown to be associated with higher BMD and/or lower propensity for bone loss.
- SMOKING current and past smokers are at increased risk of any fracture, compared to non-smokers. It is also associated with several risk factors for osteoporosis including early menopause and thinness.
- ALCOHOL long-term heavy alcohol use increases fracture risk and the risk of falls.
- MAINTAINING A HEALTHY WEIGHT people with a body mass index (BMI) of 25 kg/m2 have a two-fold increased risk of fracture compared to people with a BMI of 20 kg/m2 .
- PREVIOUS FRAGILITY FRACTURES a prior fracture at any site is associated with a doubling of risk for future fracture. Postmenopausal woman who have suffered a fragility fracture should seek advice from a doctor on how to reduce their future risk.
NON- MODIFIABLE FACTORS
- Family history of osteoporosis and fractures:
Genetics have a considerable influence on an individual’s peak bone mass.
Patients taking any of the following medications should consult with their doctor about increased risk to bone health: glucocorticosteroids; certain immunosuppressants; excess thyroid hormone treatment; certain steroid hormones; aromatase inhibitors; certain antipsychotics, anticonvulsants or antiepileptic drugs; lithium; antacids; proton pump inhibitors.
- Glucocorticoid treatment is the most common cause of drug-induced osteoporosis, with rapid bone loss occurring in the first 6 months of treatment.
- Diseases of malabsorption.
- Rheumatoid arthritis.
- Premature menopause (before age 40 years) and early menopause (between ages 40–45 years).
SPECIFIC CONSIDERATIONS FOR WOMEN WITH OSTEOPOROSIS
An exercise programme for people with osteoporosis should specifically target posture, balance, gait, coordination, and hip and trunk stabilization rather than general aerobic fitness.
Several exercises are not suitable for people with osteoporosis
Sit-ups and excessive trunk flexion can cause vertebral crush fractures.
Twisting movements such as a golf swing can also cause fractures
Exercises that involve abrupt or explosive loading, or high-impact loading, should be avoided.
Daily activities such as bending to pick up objects can cause vertebral fracture.
WHAT ARE THE MAIN BENEFITS OF EXERCISES FOR HEALTHY POSTMENOPAUSAL WOMEN
WHO DO NOT HAVE OSTEOPOROSIS
Besides maintaining bone strength, the main goal of exercise therapy in postmenopausal women is to increase muscle mass in order to improve parameters of muscle function such as balance and strength, which are both important risk factors for falls and – independent of bone density – risk factors for fractures.
Exercise should be tailored to the individual’s needs and capabilities. Overall, most people should aim to exercise for 30 to 40 minutes three to four times each week, with some weight-bearing and resistance exercises in the programme.
Examples of weight-bearing exercises include:
Examples of muscle-strengthening exercises include:
– Using elastic exercise bands
-Using weight machines
-Lifting your own body weight
-Standing and rising on your toes
Balance, posture and functional exercises also have an important role to play:
- Balance: Exercises which strengthen the legs and test your balance (e.g. Tai Chi) can reduce falls risk
- Posture: Exercises to improve posture and reduce rounded shoulders may reduce fracture risk, particularly at the spine
- Functional exercises: Exercises which help with everyday activities
Actions to take for a break-free future
- Menopause is a critical point in a woman’s lifetime to discuss bone health with her doctor
- Regardless of risk, women should take preventative action
- Doctors should use fracture risk assessment calculators such as FRAX http://www.shef.ac.uk/FRAX/tool.jsp?locationValue=9 to identify those individuals who are at increased risk of fracturing in the near future.
- Patients at high risk need drug therapies the most commonly available drug therapies for the treatment of osteoporosis and prevention of fractures include bisphosphonates, denosumab, raloxifene, strontium ranelate, and teriparatide.
- Overall, the common medically approved therapies have been shown to be safe and effective. While it is important to be aware of possible adverse effects, patients and doctors should keep in perspective the risk of stopping treatment versus the rare occurrence of serious side effects.
- Patients must adhere to treatment plans: up to half of osteoporosis sufferers stop their treatment after only one year. By adhering to treatment, patients benefit from larger increases in BMD, lose less bone mass, and reduce their fracture risk.