important menopause information
The previous article about osteoporosis discussed the huge burden of this disease, and how important it is to treat patients with the diagnosis to prevent fractures.
Let’s look at some questions that many women ask.
What are the risk factors for osteoporosis?
When should you get your first scan and how often thereafter?
What is a dexa scan?
How do you interpret the results?
What is a FRAX score?
The typical women who has osteoporosis is Caucasian or Asian, menopausal and small-framed. Women are 4 times more likely than men to get osteoporosis, and they live longer which is another risk. Family history is extremely significant, as your bone structure is largely inherited. If your parent or grandparent broke a hip, your risk increases. Lifestyle with exercise and diet does make a difference, but probably less so than heredity. A history of fractures must be evaluated. Certain disease and medications increase the risk. Smoking and heavy use of alcohol also decrease the bone density.
Here is a list of medical conditions that increase the risk of osteoporosis:
Rheumatic and autoimmune diseases: ankylosing spondylitis, lupus, rheumatoid arthritis
Endocrine disorders: adrenal insufficiency, Cushing’s disease, diabetes, hyperparathyroidism, thyrotoxicosis
Gastrointestinal disorders: celiac disease, gastric bypass, GI surgery, inflammatory bowel disease, malabsorption, pancreatic disease, primary biliary cirrhosis
Lifestyle factors: low calcium intake, high caffeine intake, alcohol (3 or more drinks per day), active or passive smoking, high salt intake, sedentary lifestyle, falling, excess Vitamin A, aluminum from antacids, immobilization, being thin
Medications: anticoagulants (heparin), anticonvulsants, aromatase inhibitors, barbiturates,chemotherapy, glucocorticoids like prednisone, lithium, gonadotropin releasing hormone agonists, medroxyprogesterone acetate
Genetic factors: cystic fibrosis, hemochromatosis, Marfans, osteogenesis imperfecta,
parental history of hip fractures,
Hypogonadal states: anorexia, bulimia, athletic amenorrhea, hyperprolactinemia,
premature ovarian failure, menopause, Turner’s syndrome
Miscellaneous conditions: alcoholism, congestive heart failure, depression, emphysema, end stage renal disease, epilepsy, scoliosis, multiple sclerosis, muscular dystrophy, prior fracture as an adult, leukemia, lymphoma, multiple sclerosis, sickle cell anemia, and thalassemia
When should you get your first bone density scan?
All women should have a bone density scan by the age of 65, but women who have risk factors should be tested sooner. The bone density often decreases after menopause with the loss of estrogen, which is protective for the bones. If a women is at increased risk of osteoporosis, obtaining a DXA scan at menopause can serve as a baseline.
The frequency of testing depends on the results of the previous scan, and whether medication for osteoporosis is being administered, or if there are changes in medical history. Often, when a person is being monitored for low bone density, the test is repeated about every two years. If a person has a very good DXA scan, it might not be repeated for 5 years or more. If a women has a significant fracture, the bone density should be evaluated. In certain cases, the bone density may be evaluated after one year, if a certain intervention is being monitored.
What is a DXA scan?
A DXA scan, dual-energy X-ray absorptiometry of the lumbar spine and hip is the most commonly used test to evaluate bone density. Studies that evaluate the heel and wrist are predictive, but are not sufficient to monitor treatment effects.
The test is done by a trained technician. The patient lies on a table and the scanner passes over the lumber spine and hip after the patient is properly positioned. The amount of radiation of the x-ray is very low. The beams of the scanner are able to evaluate the density of the bone. The test is painless. Often, a vertebral fracture assessment is obtained. By lying on your side, the vertebrae are measured to see if there is any compression or fracture.
How do you evaluate the results?
After the test is completed, the technician will evaluate the scans that are obtained. A calculation, or T-score is obtained. The T-score compares your bone density to the bone density of a 30 year old women. The T-score is reported in standard deviations from the mean.
There are 3 possible results:
T-score: > -1.0 Normal bone density
T-score: > -1.0 to -2.5 Osteopenia ( low bone density but not osteoporosis)
T-score: <-2.5 Osteoporosis
The diagnosis of osteoporosis can be made without a bone density test. A history of a low-trauma fracture in a woman at risk would suffice for the diagnosis of osteoporosis. An example would be a vertebral fracture that resulted from a fall from the standing position vs. falling off a ladder. In most cases, women who have surgery for a broken hip should be treated for osteoporosis.
What is a FRAX Score?
A FRAX score is an assessment tool used to predict the risk of fracture in the next ten years.
The clinical risk factors that are part of the calculation include your age, sex, body mass index, previous fragility fracture, parental hip fracture, current smoking history, use of steroids (more than the equivalent of 5 mg of prednisolone per day for 3 months), alcohol use of more than 3 drinks per day, or other secondary causes of osteoporosis. Results are specific for race and gender. This tool is used to assess those with osteopenia, to determine if other factors increase the fracture risk and to determine if treatment is appropriate.
Generally, if you DXA scan falls into the osteoporosis range, medication is indicated.
If a patient has osteopenia, and her FRAX risk in greater than 20% risk of a major osteoporotic fracture in the next ten years, or a 3% risk of a hip fracture in the next 10 years, medication should be considered.
In the next edition of this series, we will look at treatments for osteoporosis: the pros and cons of medication therapy.
Marilyn Jerome, MD
Foxhall OB-Gyn Associates
The American College of Obstetricians and Gynecologists. Practice Bulletin. Number 129. September 2012. Osteoporosis