A prospective population-based longitudinal study of 390 women has now confirmed the assumption that the risk of osteoporosis, osteoporotic fractures and the risk of mortality in the elderly are higher the earlier the menopause begins. This in itself is nothing new, as an early onset of menopause does lead to an early onset of oestrogen decline and thus to premature activation of osteoclasts, the bone resorbing cells. Nevertheless, there are also always studies which come to the conclusion that there is no relationship between the age at onset of menopause and bone density in increased age.
In the recently published study by O. Svejme and his colleagues from the Clinical and Molecular Osteoporosis Unit at University Hospital Skane in Malmö/Sweden, it indicates that women were recruited in 1977 for the study and after 29 and 34 years re-examined. Already at age 48, women with early menopause (menopause at age 42 years) were on average lower by 0.4 standard deviations in bone density than women with late menopause (menopause at age 47 or later). At the age of 77 years 56% of the women with early menopause had osteoporosis while only 30% of women with later menopause did. The comparison between the frequency of fractures and the mortality rate showed a similar picture.
The reasons for the increased risk of suffering fractures cannot be explained by the decreased bone density alone. Rather, other factors, such as the condition of musculature or neuromuscular functions, seem to have an impact. Is the cause really perhaps present much earlier in life?
Osteoporosis not uncommon in young women
Still, osteoporosis is seen primarily as a disease of older women. However, there are also many young women who are affected by this. “In my practice, approximately 60% of patients are post-menopausal women, about 25% are men and 15 to 20% women before menopause”, says Prof. Dr. Reiner Bartl, head of the Osteoporosis Center München am Dom. “The problem for young women with osteoporosis is that there are no approved drugs for treatment. Treatment using bisphosphonates among premenopausal women is off-label, because manufacturers have fear of problems with pregnancy and lactation”, he goes on to explain.
The causes of low bone mass at an early age are diverse: “Girls and women with late menarche, anorexia and disorders of the hormonal system, women with gastrointestinal disorders such as ulcerative colitis often have a decrease in bone density”, Prof. Bartl states with certainty that comes from experience. Equally affected are rheumatism patients who receive cortisone, epileptics who take antiepileptic medications or patients with multiple sclerosis. Then come typical risk factors such as an inadequate supply of vitamin D and calcium, too little physical activity, but also too much activity. Competitive athletes due to disturbances in hormonal balance systems and amenorrhea may also tend toward low bone density.
Heading into pregnancy with vitamin D deficiencies
Pregnancy itself is not really a risk factor for osteoporosis, “but today many women go into pregnancy with calcium and in particular vitamin D deficiencies. If they have to additionally lie down for long periods of time or receive cortisone, pregnancy-associated osteoporosis quickly occurs”, Prof. Bartl says clarifying the relationship. The average bone loss in pregnancy is 2-5%. When followed by a six-month breastfeeding period, the loss rises by a further 1.5-4%. Therefore experts like Prof. Bartl push the idea that at the beginning of pregnancy as part of a process of preparedness vitamin D level also be determined. Alternatively, one can prescribe to pregnant women right at the beginning of pregnancy 1000 international units (IU) of vitamin D, since at this dosage it has no side effects, he adds.
Guidelines for the treatment of young women are lacking
PD Dr. of Medicine Vanadin Seifert Klauss from the interdisciplinary Osteoporosis Center of the Technical University of Munich at the Clinic Rechts der Isar calls, as does his colleague Bartl, for urgent guidelines on diagnosis and treatment of younger female patients. At the same time it is necessary to raise awareness among young women about bone health on the whole. “Every one knows his or her blood pressure and most also know their cholesterol levels. But – bone density”? asks Professor Bartl provokingly. There is no need for extensive bone density screening to identify at-risk people in time. Rather, women with risk factors – be it a family history or other chronic diseases – should also at a young age have bone density measured. In particular gynecologists would be appropriate here as interlocutors, because they have the women regularly in their practice and usually also know of their underlying medical illnesses. In addressing a topic such as the desire to have a child, or being pregnant and the threat of osteoporosis, they would also be the best place.
In young women, osteoporosis is treated only if, in addition to the metrological determination, fractures have occurred. Therapies should then be administered expresses Professor Bartl, since further fractures otherwise inevitably follow. Treatment is usually carried out using the standard medication, bisphosphonates. They inhibit the degradation process in the bone caused by osteoclasts. Administered as a once a year infusion, it is pleasant for patients and more favourable for its effect on bone than is for instance a regular weekly tablet intake. In addition, the intake of vitamin D is recommended.
Men are also affected
Just as with young women, there are also young men affected by osteoporosis. However for them the usual bisphosphonate treatment can be permitted regardless of age. The group of older men with osteoporosis is increasing as well: because men are living longer. The onset of osteoporosis occurs, however, a decade later than in older women. This is because men have a higher peak bone mass, the so-called Peak Bone Measure, and have a larger bone cross-section and no menopause with its relatively abrupt decrease in sex hormone. However, the bone loss in men is treated less often: a study at the University of New South Wales Sydney showed that (only) one third of women in post-menopause and a tenth of the same aged men received osteoporosis treatment after the first fracture.
The German Society for Geriatric Medicince (DGG) and the German Nutrition Society recommend seniors from the age of sixty onward take 800 IU of vitamin D daily as a dietary supplement. Other experts advocate 1000-2000 IU. The ability of the skin to produce Vitamin D3 decreases by a factor of three to four (as compared with a 20-year-old person), so that a deficiency, and thus fractures, become more probable. In a current publication in the New England Journal of Medicine it was shown that seniors who take vitamin D3 walk with more certainty, more rarely fall and suffer fewer fractures. Within the scope of osteoporosis therapy a status of equality among patients is desperately needed: young need to be treated just as well as older people and men just as well as women.