Learning Objectives 1. Define menopause. 2. List 8 responses to estrogen loss that one can feel and 2 responses that one cannot feel. 3. Explain the process of osteoporosis disease. 4. List at least 8 steps a woman can take to prevent osteoporosis. 5. Explain how ERT/HRT can help prevent osteoporosis and identify their risks and benefits. 6. List recommended calcium intake for children, women and men.

Menopause gave me the incentive to eat right and exercise more. I feel so much better, I'd never go back to my old ways.

Menopause was a breeze, so I didn't take estrogen. Now I'm 58 and a bone density test showed that my bone mass is low. I'm going to reassess taking estrogen, which I hope will help my bones.

I couldn't decide about hormone replacement therapy. Since I have some risk factors for osteoporosis, I had a bone density test. That helped me make my decision about HRT.

I'm at risk for osteoporosis and I'm not a candidate for ERT. What can I do?

My mother is quite stooped over from spinal fractures. As a `baby boomer' just turning 50, I'm not going to let that happen to me.

What Is Menopause

The word menopause comes from the Greek words for "month" and "end" and literally means the end of monthly periods. Menopause is a natural transition during which a woman goes from having regular periods to not having any. During this time, the ovaries slow their production of the two female hormones, estrogen and progesterone, and eventually stop producing eggs. Two of the earliest signs of low estrogen are irregular periods and changes in menstrual flow. Although menopause can occur as early as a woman's mid-30's and as late as her mid-50's, the average age is 51. Doctors define menopause as the absence of menstrual periods for one year.

The onset of menopause is associated with increased activation of remodeling sites and a 20% increase in bone resorption. Formation increases to a lesser degree (15%). There is, therefore, an imbalance in remodeling that overall is equivalent to a loss of 40 mg of calcium daily from the body.

Some women pass through menopause without any signs except that their periods stop. In other women, the drop in estrogen produces physical changes, such as hot flashes or sweats. These short-term changes can be mild or severe, and occasionally can lead to poor sleep, anxiety, or depression.

In addition to the changes you can feel, there are other changes taking place that you cannot feel. These can lead to serious, long-term health problems, such as osteoporosis and heart disease, that will affect your future health and well-being.

Responses to estrogen loss that you can feel

    •     Hot flashes

    •     Night sweat

    •     Irregular periods

    •     Insomnia

    •     Anxiety

    •     Vaginal dryness

    •     Painful intercourse

    •     Vaginal and bladder infections

Responses to estrogen loss that you cannot feel

    •     Bone loss (leads to osteoporosis and fractures)

    •     High cholesterol and clogged arteries (leads to heart at tacks and/or strokes)

This chapter focuses on osteoporosis and how it relates to menopause. Many of the suggestions presented here are also good for prevention of heart disease and for your overall health. Be sure to talk to your doctor about these and other health concerns. The Resources listed at the end of this chapter provide more information on long-term health concerns of midlife and older women.

Osteoporosis and Menopause: The Importance of Taking Action Now

Osteoporosis literally means "porous bones." It is a hidden and silent disease that makes bones so thin and fragile that everyday actions like sneezing or lifting a child can cause bones to break.

Osteoporosis is a major public health threat for 25 million Americans, 80% of whom are women. In the United States today, 7-8 million individuals already have the disease and 17 million more have low bone mass, placing them at increased risk for osteoporosis. Each year, this disease causes 1 million fractures of the hip, spine, wrist, and other bones.

At its worst, osteoporosis can result in chronic pain, disability, physical deformity, and loss of independence. Women with advanced osteoporosis say that this is the disease that, overnight, makes them feel frail and vulnerable. The pain and disability, and even the fear of more fractures, cause them to change the way they live. To protect their bones, these women redefine themselves and their lives. Their world becomes smaller and smaller until they are unable to care for their families, have to give up careers, and often can no longer enjoy many of life's pleasures.

If you are like most people, you probably think that osteoporosis is an inevitable part of growing older. But this is not true. Osteoporosis is preventable and treatable, particularly at menopause.

In the years before menopause, estrogen levels can vary, causing irregular menstrual periods. Some bone loss may occur at this time. In the years following menopause, estrogen production ceases. This results in even greater bone loss. Women who begin menopause with low bone mass, or who have rapid or severe bone loss after menopause, are more likely to develop osteoporosis. (Bone mass is the calcium-rich material that makes bones strong.) Menopause is a good time for you to take steps to protect your bone health so you can live a full and independent life well into the future. Remember, the time to find out about osteoporosis is before your bones begin to break. 

What Causes Osteoporosis

Once you reach your adult height, you may think that your skeleton is complete and will not change for the rest of your life. Actually, bone is constantly changing.

Bone is considered a "tissue" that is continually "renewed" throughout life. During this renewal process, old bone tissue is removed and is replaced with new bone tissue. During youth, bones grow in size and strength because more bone tissue is laid down than is removed. Around age 30, bone removal starts to overtake replacement and both men and women lose bone. However, women have less bone mass than men and the rate of loss is generally greater in women than in men, especially at the time of menopause.

Osteoporosis occurs when too little bone is formed, when too much bone is lost or a combination of both. With osteoporosis, there is not enough bone tissue and the normal "architecture" or structure of the bone is poor so that bones are weak and break easily.

Bone loss is an asymptomatic process. A good analogy for bone mass, osteoporosis, and fracture is blood pressure, hypertension, and stroke. The pathologic processes that change bone mass or blood pressure have no symptoms as osteoporosis or hypertension develop. It is only through careful monitoring that the existence of these two processes can be ascertained. However, if they are not detected, the result can be catastrophic in the form of either fracture or stroke.

Osteoporosis is a complex disease and although we do not know all of its causes, we do know that certain risk factors are associated with it. For women, an important risk factor is the loss of estrogen. Estrogen has an important role in the control of the bone renewal process. In many women, but not all, the sharp decline in estrogen production after menopause leads to rapid bone removal.

Below are photos of the inside of a bone. As you can see, bone is not solid. The photo on the left is normal bone, with large amounts of bone tissue that look like a honeycomb. The bone tissue forms connections that give bone its strength. The photo on the right is osteoporotic bone. Notice that there is less bone tissue and the spaces are bigger. Some of the connective structure is missing, further weakening the bone. (The arrow in the lower left of the photo points to a broken connection.) Once the connections are broken, they cannot be rebuilt.

Clinical Features

The following clinical features characterize the two primary fractures seen in osteoporotic postmenopausal women:

Vertebral Fracture

    •     Often asymptomatic

    •     When pain is present:

    •     Acute with a sudden onset

    •     Localized to vertebrae

    •     Local tenderness

    •     Radiates bilateral1y

    •     May cause ileus because of bulging periosteal capsule (perhaps secondary to painful bowel irritation and compression)

    •     Pain subsides over 2 to 6 weeks

    •     Kyphosis often not seen acutely on the first fracture, al- though it gradually becomes obvious

    •     Possible modest to moderate scoliosis, especially if the fracture occurs at T2 to T11

    •     Chronic pain in the paraspinal muscles that may be localized to the lumbar area of the spine even when    the fractures occur in the thoracic area

Hip Fracture

    •     History of a fall, especially for intertrochanteric fracture

    •     Pain localized

    •     Inability to bear weight

How Strong Are Your Bones?

The best way to find out how strong or weak your bones are before a bone breaks is to have a Bone Mineral Density (BMD) test. These safe and painless tests can determine your bone density, which is a measure of bone strength, and can predict your chances of fracturing in the future. They use very low amounts of radiation and are much more sensitive than standard x-rays.

Risk factors help identify some of the people who will develop osteoporosis, but not all. Only a BMD test can detect low bone density and diagnose osteoporosis. The results from this test can help you and your doctor decide whether osteoporosis prevention or treatment steps are necessary for you at this time.

Act Now to Prevent Osteoporosis

Menopause is a good time to take action to prevent osteoporosis. Here are some steps you can take now:

    •     Review the osteoporosis risk factors. Do any of them apply to you? If so, change the ones you can.

    •     Pay special attention to medications that affect bone health. • Talk to your doctor about having a BMD test.

    •     Discuss with your doctor whether you are a candidate for estrogen replacement therapy to prevent osteoporosis.

    •     Make sure to get adequate calcium, vitamin D, and exercise to promote bone health and overall fitness.

    •     If you already have osteoporosis, ask your doctor about avail- able treatments.

    •     Don't smoke. Limit alcoholic beverages.

    •     Seek out more information about menopause and osteoporosis.

Estrogen Replacement Therapy

One of the most important decisions a woman faces at menopause is whether or not to take estrogen replacement therapy (ERT). ERT is medication that replaces or supplements the body's falling level of estrogen. ERT is available in the form of pills, a skin patch, or vaginal cream.

In the short term, ERT has been shown to relieve hot flashes, vaginal dryness, and other effects of estrogen loss. The vaginal cream, which may be used for vaginal dryness, is not effective for osteoporosis prevention or treatment.

In the long term, ERT helps keep calcium in the bones and maintains bone density, thereby preventing osteoporosis. Studies have shown that ERT can increase bone density and cut in half the number of spinal and hip fractures that women suffer. Recent research findings indicate that ERT may also protect women against heart disease. There are several kinds and doses of ERT that are FDA-approved specifically for osteoporosis prevention and treatment. Pills and patches are equally effective.

However, ERT is not for everyone. There are medical reasons why some women should not take estrogen, such as a personal history of breast or endometrial cancer, unexplained vaginal bleeding, blood clots, chronic liver disease, stroke, or uncontrolled, severe high blood pressure. Also, estrogen can make some conditions worse, such as lupus, migraine headaches, and gall bladder disease.

Estrogen also causes overgrowth of the lining of the uterus, increasing the risk of endometrial cancer. For this reason, women who still have a uterus are generally prescribed another hormone, progesterone, to prevent this overgrowth and eliminate the increased risk of endometrial cancer. Like estrogen, progesterone (also known as progestin) is a hormone, produced by the ovaries, that declines at menopause.

Estrogen and progestin taken together is called hormone replacement therapy (HRT). HRT may be prescribed in one of two ways, cyclic HRT or continuous HRT. With cyclic HRT, estrogen is taken daily or from days 1 through 25 of the month. Progestin is added for the last 2 weeks of each month. With this pattern, you may bleed every month, similar to a menstrual period. With continuous HRT, estrogen and progestin are taken every day, 365 days a year. After several months of treatment on continuous therapy, you are much less likely to have a monthly period. Researchers are studying other patterns of HRT use. You should talk with your doctor about which approach is right for you.

There may be an increased risk of developing breast cancer; however, the question of whether estrogen therapy increases the risk of breast cancer—and by how much—is still being studied by medical experts. The decision to start ERT or HRT should only be made after discussing the risks and benefits with your doctor, taking into account your personal medical history, your current situation, and your future health risks and concerns.

All women should do monthly breast self-exams and have manual breast exams by their doctor at least once a year. In addition, women should have a mammogram before starting ERT/HRT, and every year thereafter.

Other Approaches to Healthy Bones

Calcium, vitamin D, and exercise are essential for healthy bones and should be part of every osteoporosis prevention program. Keep in mind, however, that calcium, vitamin D, and exercise alone cannot prevent rapid bone loss that occurs with a drop in estrogen.

    •     To increase your daily intake of calcium, select low-or non-fat dairy products, soybeans, tofu, dark green vegetables, and calcium fortified foods and juices.

    •     Avoid excessive amounts of protein, sodium, alcohol, and caffeine in your diet, as they can cause you to lose calcium.

    •     Use calcium supplements as a "safety net" if you cannot get enough calcium from food.

    •     Eat a balanced diet with a variety of fruits, vegetables, whole grains and low or non-fat calcium-rich foods.

Recommended Vitamin D Intake

Adult Women and Men:

400 - 800 IU daily

    •     Vitamin D is formed by the body from sunlight. It is also found in tuna, sardines, liver, egg yolks, and fortified milk.

    •     Older people and people who are housebound may need a supplement.

    •     Massive doses of vitamin D can be harmful.

Recommended Exercises

    •     Walking, running, aerobics, cross-country skiing, strength training, and tennis are all examples of "weight bearing" exercises—the kind that force your bones and muscles to work against gravity.

    •     You don't need to become an athlete—just make weight- bearing activity part of your everyday life.

    •     Exercise also helps with muscle tone, weight control, balance, and overall fitness.

    •     Even if you already have osteoporosis, an exercise program can help you. Ask your doctor about safe exercises.

Treatment for Postmenopausal Osteoporosis

Women who already have osteoporosis can choose from several FDA approved treatments. ERT/HRT can be used as a treatment to slow or stop additional bone loss. ERT/HRT has been shown to be effective for postmenopausal women of any age.

For women with osteoporosis who cannot or choose not to take estrogen, a doctor might recommend a medication called calcitonin, which slows bone loss.

Another medication used to treat osteoporosis is alendronate. Alendronate, from the class of drugs called bisphosphonates, has been shown to increase bone density and prevent fractures.

Other medications are also being developed for the prevention and treatment of osteoporosis. These may soon expand the options available to patients. Among the drugs being investigated are selective estrogen receptor modulators, sodium fluoride, parathyroid hormone, and vitamin D metabolites.

Questions to Ask Your Doctor

Even though you may sail through menopause with few problems, you should talk with your doctor about your long-term health needs. The prevention of osteoporosis should be at the top of your list. Here are some questions to ask your doctor:

    •     Do I have risk factors for osteoporosis?

    •     Should I have a BMD test?

    •     How is osteoporosis prevented and/or treated?

    •     What are the pros and cons of ERT/HRT?

    •     Are there alternatives to ERT/HRT?

    •     What are safe exercises if I already have some bone loss?

    •     What kind of calcium should I be taking?

    •     What other health concerns should I be aware of at this time?

Make Choices for a Healthy Future

Remember, each woman experiences menopause differently, but all women at menopause face choices that will make a difference for their future health and well-being.

Every woman should try to:

o Be informed about health concerns that are linked to de- creased estrogen levels, especially osteoporosis and heart disease

o Eat a healthy diet rich in calcium.

o Exercise regularly.

o Don't smoke, and limit alcohol intake.

o Consult a health care professional about specific steps you can take to ensure a healthy future.

o Learn the latest facts about osteoporosis by joining the National Osteoporosis Foundation. Complete the attached membership form (inside back cover) and mail it today.

Resources

Keeping up to date on research concerning menopause will help you through this important passage in your life and help you make informed decisions concerning your health care. The following organizations are good resources for this kind of information.

National Osteoporosis Foundation
1150 17th Street, N. W., Suite 506
Washington D.C., 20036                                                                                       

800-223 -9994

American College of Obstetricians and Gynecologists
409 12th Street, SW
Washington, DC 20024

American Dietetic Association
216 West Jackson Blvd.
Chicago, IL 60606312-899-0040

American Heart Association                                                                                         7320 Greenville Ave.                                                                                                        Dallas, TX 75231 

214-373-6300                                                                                                                 

Help for Incontinent People                                                                                           P.O. Box 544 A                                                                                                         Union, SC 29379

803 -579-7900

HERS Foundation Hysterectomy                                                                          Educational Resources and Services                                                                               422 Bryn Mawr Ave.                                                                                                       Bala Cynwyd, PA 19004                                                                                            

215-667-7757

Melpomene Institute for Women's Health Research                                                       1010 University Ave.                                                                                                       St. Paul, MN 55104                                                                                                            

612-642-1951

National Institute on Aging Information Center                                                                    P O. Box 8057                                                                                                 Gaithersburg, MD 20989                                                                                       

301-496-1752

North American Menopause Society                                                                                c/o University Hospital's Department of Ob/Gyn                                                           2074 Abington Road                                                                                                     Cleveland, OH 44106                                                                                       

216-844-3334

Older Women's League                                                                                                  666 Eleventh Street, N.W., Suite 700                                                                Washington, D.C. 20001 

202-783 -6686

Osteoporosis and Related Bone Diseases Center                                                       National Resource Center                                                                                                1150 17th Street, N.W., Suite 500                                                                    Washington, D.C. 20036 

202-223 -0344

Resources for Midlife and Older Women, Inc.                                                                 226 East 70th St. Suite 1C                                                                                                 New York, NY 10021 

212-439-1913

Source: National Osteoporosis Foundation

Reprinted with permission