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OSTEOPOROSIS IN WOMEN
Osteoporosis is a progressive, systemic, skeletal disease characterized by decreased bone mass and microarchitectural deterioration of bone tissue leading to increased bone fragility and susceptibility to fractures.
The more risk factors (eg history of fracture, advanced age, comorbidities, etc) that are present, the greater the risk of fracture.

Definition

  • Osteoporosis is a progressive, systemic, skeletal disease characterized by decreased bone mass and microarchitectural deterioration of bone tissue leading to increased bone fragility and susceptibility to fractures
    • Bone strength, reflecting both density and quality of the bone, is compromised thus increasing fracture risk
    • Fractures commonly occur in the hip, spine, and wrist with the hip fractures having a high morbidity
  • Though osteoporosis in Asia is very much underdiagnosed and undertreated, it is projected that by 2050, >50% of osteoporotic hip fractures will happen in Asia
    •  In most developing Asian countries, DXA is expensive and is widely unavailable particularly in the rural areas  
  • Calcium intake in almost all Asian countries is below the FAO/WHO recommendations of 1-1.3 g/day
  • Studies done in both sexes and all age groups in different Southeast Asian countries demonstrated widespread incidence of vitamin D deficiency or insufficiency 

Signs and Symptoms

  • Common presentations: Back pain, low-trauma fracture, height loss, increasing dorsal kyphosis

Risk Factors

Postmenopausal women >50 years old must be evaluated for risk of osteoporosis
The more risk factors that are present, the greater the risk of fracture

Non-modifiable

  • Female
  • Previous history of fracture as an adult
  • History of osteoporotic hip fracture in 1st-degree relative
  • Advanced age [low body weight and older age (Osteoporosis Self-Assessment Tool for Asians or OSTA)]
  • Poor health/frailty
  • Ethnic group (Asians generally have lower risk compared to Caucasians)
  • Early natural or surgical menopause before 45 years or prolonged premenopausal amenorrhea >1 year
  • Genetic diseases: Cystic fibrosis, osteogenesis imperfecta, Ehlers-Danlos, hemochromatosis, Marfan syndrome

Modifiable

  • Recurrent falls
  • Decreased body weight (<57.6 kg or <127 lb)
  • Impaired vision
  • Medical conditions: Rheumatoid arthritis, estrogen deficiency, vitamin D deficiency due to lack of sunlight exposure or low intake, thyrotoxicosis, or prolonged Levothyroxine intake
  • Cigarette smoking
  • Excessive alcohol and caffeine intake (≥3 drinks/day)
  • Low calcium (Ca) intake, excessive salt or vitamin A intake
  • Oral glucocorticoid use ≥5 mg/day of Prednisone for ≥3 months
  • Sedentary lifestyle (lack of physical activity)
  • Secondary osteoporosis
  • Lack of sun exposure

Factors Associated with Steroid-Related Fractures

  • Low bone density
  • Cumulative steroid dose
  • Age >65 years
  • Body mass index (BMI) ≤20 kg/m2
  • Smoking, excessive alcohol use
  • Diseases associated with low bone density (eg rheumatoid arthritis, inflammatory bowel disease), sex hormone deficiency, family history of osteoporosis, history of fracture and immobilization

Using the Fracture Risk Assessment (FRAX) score to categorize patient’s risk for glucocorticoid-induced osteoporosis, treatment is recommended for postmenopausal women with:

  • Low risk of fracture (<10%) and intake of ≥7.5 mg daily of prednisolone or its equivalent for >3 months
  • Medium risk of fracture (10-20%) and intake of glucocorticoid at any dose for >3 months
  • High risk of fracture (>20%) and intake of glucocorticoid at any dose for any length of time
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