Menopausal HT may help protect against development of age-related stooped posture

A new North American study found that women who are continuous or remote users menopausal hormone therapy have less evident kyphosis in their mid-eighties as compared to never users. The study is published ahead of print on February 16, 2018, in menopausal society journal Menopause.

Age-related hyperkyphosis is exaggerated anterior curvature of the spine is common in men and post-menopausal women and is associated with increased bone loss, degenerative disc diseases, and vertical compression fractures. It causes difficulty in performing activities of daily living and reduces the quality of life.

The Women’s Health Initiative study has also shown that hormone therapy (HT) reduces the odds of vertebral fractures. Based on the same hypothesis, this study also confirmed the protective effect of HT against the development of kyphosis or dowager’s hump.

The significant decline in estrogen levels after menopause results in accelerated bone loss resulting in the compression fracture of the vertebra. After a woman is put on HT, bone loss increases steadily in 3 years and is maintained by continuous use.

The authors of this study looked at data from nearly 10,000, community-dwelling women aged 65 and older from the landmark Study of Osteoporotic Fractures (SOF) and followed them for a period of 15 years. This study is a multicentric, observational study started in 1986 and closed after 31 years in September 2017.

Kyphosis was measured by mapping the Cobb angle in lateral radiograph spine and correlated with HT use.

The mean age of study participants was 83.7 ± 3.3 years and a mean Cobb angle of 51.3 ± 14.6°. 

Nearly half of the women reported having never used HRT, while 25% reported using it remotely in past, 17% reported that they used HT intermittently while only 12% reported continuous use.

After accounting for confounders, women who used HT in remote past and continuous users had nearly 3.0° less kyphosis compared with never users. Intermittent use did not confer any protection and the women had the same Cobb angle as never users.

The SOF findings also showed that women who lose more than two inches in height have an increased risk for fracture and early death.

NAMS executive director Dr. JoAnn Pinkerton concluded, “Women who reported the early use of HT were less likely to develop age-related kyphosis, and the protective benefits continued even after stopping HT. This supports a benefit of prescribing HT close to menopause.”

Abstract

NAMS press release

Consuming the right amount of Calcium is key to prevent postmenopausal osteoporosis: EMAS guidelines

Courtesy: Washington post 

Intake of right amount of Calcium, preferably from dietary source is the key to manage bone health in postmenopausal women and anything in excessive may not help, and can be harmful, says the new European Menopause and Andropause Society (EMAS) clinical guidelines published in forthcoming issue of Maturitas.

Postmenopausal osteoporosis is rife throughout the world and despite recommendations about diet and lifestyle changes from societies and governmental bodies, many issues remain unresolved. Calcium is drug which is often consumed as either single supplement or in combination with Vitamin D3 and self-dosing is very common.

Different societies have recommended different doses ranging from 700 and 1200 mg/daily and uncertainties prevail about the most appropriate dose.

Excessive intake of calcium beyond 2000mg/day is linked to increases risk cardiovascular events, dementia, urolithiasis and even fractures, but the issue remains unresolved.

To develop the current EMAS guidelines the authors looked at systematic reviews, meta-analyses, and randomized controlled trials from 2007 till present.

The key recommendations by EMAS are:

The guidelines reiterate the role of adequate intake of calcium in preventing postmenopausal osteoporosis and fracture risk.

The recommended calcium intake should be between 700 and 1200 mg per day after menopause.

Diet should be the preferred method for sourcing the daily requirements, as the intake is uniformly distributed throughout day and avoids the calcium peaks in blood.

Higher than recommended amount is not useful, on the contrary it may do possible harm.

If women are not able to take supplements and the diet also does not supply the recommended amount of calcium, they should have regular physical exercise and take Vitamin D to maintain healthy bones.

The EMAS recommendation of 700 to 1200 mg per day differ from US guidelines in terms of daily dosage. The National Osteoporosis Foundation (NOF) and the American Society for Preventive Cardiology (ASPC) the US Institute of Medicine (IOM) Food and Nutrition Board, and the North American Menopause Society(NAMS) recommends 1200 mg of elemental calcium per day.

The National Institutes of Health (NIH) recommended 1500 mg of elemental calcium per day.

But, the study authors opined that the 300-mg difference between European and US guidelines does not matter much as the real problem starts if the daily intake exceeds 2000 mg or more.

The EMAS recommendations does not apply to women receiving antiosteoporotic drugs, which require concomitant supplementation with calcium and vitamin D. 

Abstract

News from NAMS 2017: “Bisphosphonate drug holiday” not mandatory

A presentation at the North American Menopause Society (NAMS) Annual Meeting in Philadelphia October 11-14, will  present new evidence regarding long term safety and effectiveness of Bisphosphonates and denosumab in treating postmenopausal osteoporosis.

According to International Osteoporosis Foundation, Osteoporosis is estimated to affect 200 million women worldwide - approximately one-tenth of women aged 60, one-fifth of women aged 70, two-fifths of women aged 80 and two-thirds of women aged 90.

Bisphosphonates and denosumab are the most commonly prescribed treatments for osteoporosis. There is no cure for osteoporosis and the effects of these drugs wear-off as treatment ceases, hence prevention is the best bet.

As Bisphosphonates therapy is started, protection from osteoporosis is gained in first few months and persists as long as treatment is continued.

If Bisphosphonate treatment is continued beyond 3 years, increasing risk of unusual or “atypical” fractures of the femur (thigh bone) is observed. The risk increases gradually as patient continue to take the drug beyond 3 years: the risk is 20/100,000 patients at 5 years and 1/1,000 patients at 8-10 years.

If the drug is stopped, protection from fractures is lost gradually in 3-5 years.

This combination of increased risk of atypical fractures on continued treatment and decline in protection from fractures as treatment is stopped led to the confusing concept of a “bisphosphonate holiday.”

The American Society for Bone and Mineral Research (ASBMR) has recently provided clear recommendations about “bisphosphonate holidays.”

ASBMR recommends that, after 3-5 years of treatment with bisphosphonates, a patient risk of fracture should be evaluated. If the patient remains at ‘high risk’ for fracture because of low BMD, previous history of hip, spine, or multiple other fractures, the treatment should not be stopped.

Patient can continue the same treatment or change to some other drugs like denosumab.

Those patients who are at ‘low risk’ for fracture, the treatment can be stopped for 3-4 years, but it is not mandatory.

The concept of ‘drug holiday’ only holds good for Bisphosphonates only, and not for other drugs like raloxifene, teriparatide, and denosumab because beneficial effects of these drugs are lost as soon as they are stopped.

Dr. Michael McClung of the Oregon Osteoporosis Center in Portland, Oregon, who will be presenting his recommendations on long-term osteoporosis therapy at the NAMS Annual Meeting said, “Because protection from fractures disappears quickly if denosumab treatment is stopped, and since there are no currently known safety issues that limit the duration of denosumab therapy, there is no justification for a drug holiday with this treatment.”

“Just as we do not recommend stopping treatment for high blood pressure or diabetes, it is necessary to have a long-term treatment plan for postmenopausal women with osteoporosis if the benefits of our therapies are to be realized,” he further added.

Dr. JoAnn Pinkerton, NAMS executive director said, “Prevention of osteoporosis should be a goal for those treating menopausal women, as up to 20% of bone loss occurs within the first five years of menopause. Once diagnosed with osteoporosis, the goal becomes lowering the risk of fractures as fractures can be life changing or life limiting. This presentation will offer valuable insights about the need for long-term treatment and will change the way health care providers approach long-term osteoporosis management.”

North American Menopause Society (NAMS) video series about important midlife health topics: March 2017.

The North American Menopause Society (NAMS) has started comprehensive video series for clinicians about important midlife health topics. All the interviews in the series are hosted by NAMS Board of Trustees Member and President Dr. Marla Shapiro, a Canadian physician, who led this exciting initiative.

In this monthly series, the latest video is “A Clinician's Guide to Bone Drug Holidays”, Dr. Shapiro interviews Dr. Michael McClung, NAMS Board Member and Founding Director of the Oregon Osteoporosis Center in Portland, Oregon. Dr. McClung discusses the right timing for drug holidays from bisphosphonates for women at low risk and as well as follow-up procedures. He discusses those who should not consider a drug holiday.

                     Dr Michael McClung discusses a clinician's approach to bone drug holidays

Feeding your bones with Calcium and Vitamin D3 does not prevent postmenopausal height loss: WHI post hoc analysis

Clinical Pearls:

1. The current recommendation by Institute of Medicine(IOM) Dietary Reference Intakes is 1200 mg of calcium (total of diet and supplement) and 800 international units of vitamin D daily for most postmenopausal women  for prevention of osteoporosis.
2. The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D₃ and 1000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women. (D recommendation) due to lack of sufficient evidence for its benefits.
3. Post hoc analysis of Women’s Health Initiative study which included 36,282 healthy postmenopausal women who received 1,000 mg of elemental calcium as calcium carbonate with 400 IU of vitamin D3 daily (CaD) did not show any statistically significant benefits in reducing the menopausal height loss or hip/vertebral fracture risk. 

Height loss is a common phenomenon associated with aging. Vertebral fractures, changes in spinal curvatures and narrowing of the intervertebral discs are many factors that contribute to this shrinkage. Spinal deterioration combined with muscle loss causes that hunched look we all are familiar with.

A large French study published in Canadian Medical Journal observed a mean loss of nearly two inches since early adulthood in large number of postmenopausal women over the age of 60 years.[1]

On an average people, tend to lose ¼ to ½ inch every 10 years after the age of 50 years, with women losing more than men.[2] A loss of 4 cm or more in height over 10 years seems to be associated with a significant decrease of BMD, and it can be recommended as a clinical marker of osteoporosis.[3]

While it is not entirely possible to prevent the height loss as genetics and ‘how much bone you built when you were young’ plays a very important part.  Feeding your bones with Calcium and Vitamin D (CaD) has been advocated as one of the many ways to prevent osteoporosis and height loss as you age.

The clinical research data and studies show conflicting results when it comes to daily recommendation of CaD for prevention of osteoporosis and fracture risk in postmenopausal women.

The current recommendation by Institute of Medicine(IOM) Dietary Reference Intakes  is 1200 mg of calcium (total of diet and supplement) and 800 international units of vitamin D daily for most postmenopausal women with for prevention of osteoporosis.[4]

In contrast, the U.S. Preventive Services Task Force (USPSTF) recommendation statement on vitamin D and calcium supplementation to prevent fractures in adults were recently published in Annals of Internal Medicine.[5] The USPSTF recommends against daily supplementation with 400 IU or less of vitamin D₃ and 1000 mg or less of calcium for the primary prevention of fractures in noninstitutionalized postmenopausal women. (D recommendation) due to lack of sufficient evidence for its benefits.[6]

The Women's Health Initiative (WHI) CaD trial of 36,282 healthy postmenopausal women with supplementation of 1,000 mg of elemental calcium as calcium carbonate with 400 IU of vitamin D3 daily (CaD) resulted in a small but significant improvement in hip bone density, did not significantly reduce hip fracture.[7] The researchers recommended further trials with larger doses.

Post hoc analysis of the data from the same WHI CaD double blind randomized trial in postmenopausal women at 40 US clinical centers were conducted for prevention of height loss. The study was published in December edition of Menopause journal.[8]

Height was measured every year in 36,282 women with a stadiometer for an average of 6 years. The women were than randomized to receive CaD supplementation or placebo. The average height loss was 1.28 mm/y for women receiving CaD versus 1.26 mm/y for women getting a placebo (P = 0.35).

So, CaD supplementation does not prevent the height loss in postmenopausal women.

So, CaD supplementation does not prevent the height loss or fracture risk in postmenopausal women. The USPSTF stats “Research is needed to determine whether daily supplementation with greater than 400 IU of vitamin D₃ and greater than 1,000 mg of calcium reduces fracture incidence in postmenopausal women or older men”.

Estrogen with or without a progestin as a Hormone Replacement Therapy was effective at preventing bone loss, reducing risk for hip, clinical vertebral and total fractures.

But, it is not solely advocated to promote skeletal health.

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[1] https://www.sciencedaily.com/releases/2010/03/100322121107.htm

[2] http://www.berkeleywellness.com/self-care/preventive-care/article/why-you-shrink-you-age

[3] https://www.ncbi.nlm.nih.gov/pubmed/8088069

[4] Institute of Medicine. Dietary Reference Intakes for Calcium and Vitamin D. Washington, DC: National Academies Press; 2011

[5] http://annals.org/aim/article/1655858/vitamin-d-calcium-supplementation-prevent-fractures-adults-u-s-preventive

[6] https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/vitamin-d-and-calcium-to-prevent-fractures-preventive-medication

[7] http://www.nejm.org/doi/full/10.1056/NEJMoa055218

[8] http://journals.lww.com/menopausejournal/Citation/2016/12000/Calcium_plus_vitamin_D_supplementation_and_height.5.aspx