Postmenopausal osteoporosis
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■ Overview:
Osteoporosis is a disease in which the risk of fracture increases as the bone mass gradually decreases and structural vulnerability increases. It is divided into osteoporosis without a specific cause and osteoporosis with a clear cause. Most of the uncaused osteoporosis is degenerative osteoporosis.
Degenerative osteoporosis is literally a phenomenon that occurs as we age and can be largely classified into two types (menopausal osteoporosis and senile osteoporosis).
■ Synonym:
Type 1 osteoporosis
■ Definition:
It refers to osteoporosis caused by menopause. Clinically, menopause refers to a state in which menstruation has stopped for 12 months, which occurs because the production of female hormones in the ovaries rapidly decreases. Women have a physiologically clear menopause, but men gradually decrease their androgens, so osteoporosis can progress in a similar way to women, although it is not as clear as in women.
Osteoporosis that progresses due to a decrease in sex hormones is called menopausal osteoporosis or type 1 osteoporosis. Therefore, it often occurs in people aged 51 to 75, and the male to female ratio is about 1:6, which is much more common in women. Since menopause occurs around the age of 50, bone mass decreases rapidly after the age of 50.
Osteoporosis, which occurs frequently in the elderly or in postmenopausal women, is a disease in which calcium metabolism is abnormal, a large amount of calcium and bone matrix are lost from the bones, causing holes in the bones and making the bones weak like corn stalks. When osteoporosis occurs, the bones become weak, which increases the risk of fractures, and symptoms such as back pain, spinal deformation, and height loss follow.
■ Symptoms:
Osteoporosis generally has no symptoms. In the case of high blood pressure or hyperlipidemia, there are usually no symptoms, but when complications occur, specific symptoms appear, and in the case of osteoporosis, symptoms due to fractures are accompanied. Fractures due to osteoporosis can occur even without a large impact, such as falling from a standing position.
Since postmenopausal osteoporosis progresses rapidly at the same time as the rapid decrease in female hormones, women who are the subjects of treatment often visit the hospital with menopausal symptoms and are diagnosed with osteoporosis by chance. In general, bones are composed of cancellous bone with a structure similar to a sponge and dense, hard cortical bone. Among these, the cancellous bone area rapidly decreases as sex hormones decrease, so fractures in areas of bone with a lot of cancellous bone are a characteristic of postmenopausal osteoporosis.
Therefore, areas with a lot of cancellous bone, such as the wrist bones and spine, are prone to fractures in postmenopausal osteoporosis, and those who have experienced fractures due to a light impact are more likely to have osteoporosis.
In the case of spinal fractures, compression fractures mostly occur due to the structure of the bone, so in addition to pain at the fracture site, they also show signs of decreased height. Therefore, if your upper body gradually bends forward, your height decreases by more than 3cm compared to what you knew, or you experience sudden pain, you are likely to have osteoporosis.
■ Cause/Pathophysiology:
Generally, bones accumulate in sufficient quantities during adolescence, and from then on, the process of replacing old bones with new bones continues. Therefore, osteoporosis occurs when a sufficient amount is not accumulated, or when the amount of bone accumulated decreases gradually during replacement.
The process of bone replacement can be easily understood using the house we live in as an analogy. After building a wall, after some time, some of the bricks in the wall break, or the wall maintains its shape but seems like it will fall over easily even with a light impact. In this case, we tear down the weak parts of the wall and repair the wall with new cement and bricks.
This process is similar to bone replacement. The old bones in our body melt away and are replaced with strong bones by workers who create new bones. In this process, if the amount of old bone melting and the amount of new bone forming are equal, the amount of bone will remain the same. However, if the amount of bone melting is large, it is natural for the amount of bone to gradually decrease. When menopause occurs and female hormones decrease, bones begin to melt rapidly. This is because female hormones that have the effect of protecting bones decrease.
During the first 5 to 10 years after menopause, the amount of bone melting increases significantly, and after that, the bone gradually melts. Bones have a structure like a net where vertical and horizontal structures are intertwined. When bones begin to melt, this steel structure gradually becomes thinner and eventually the structural connections are severed. Once the structural connections are severed, it is difficult to maintain the original strength of the bone even with treatment.
Cross-sectional structure of the femur Bone tissue of a normal person Bone tissue of an osteoporosis patient
■ Diagnosis:
First, a medical examination and physical examination are necessary to find risk factors for osteoporosis. The questionnaire includes calcium intake and nutritional status, physical activity level, daily life patterns, smoking, menstrual and reproductive history, and family history of osteoporosis or endocrine and metabolic diseases.
The physical examination should include height measurement and evaluation of spinal diseases. In case of fracture, in addition to general X-ray examination, magnetic resonance imaging (MRI) diagnosis or computed tomography (CT) examination may be necessary if the patient complains of neurological symptoms or a fracture is found in a person with normal bone density.
Laboratory tests may include anemia, blood calcium level, liver function, kidney function, and endocrine tests. In some cases, a detailed examination for a disease suspected of secondary osteoporosis rather than degenerative osteoporosis is also necessary.
One of the important tests is a bone density test. Based on the definition of the World Health Organization, osteoporosis can be diagnosed by measuring bone density before a fracture occurs. The diagnosis rate varies depending on the number of bone density tests, the site of the test, and the timing of the test. There is no consensus on when to test a person, but it is recommended to have a bone density test during menopause. Also, those with a family history or at risk for osteoporosis are eligible for testing. However, many people are still diagnosed only after a fracture occurs.
A bone density test can determine the degree of bone fracture and can be used as a baseline for treatment response. Regardless of the area being measured, it is important to predict fracture risk. Bone density of the spine is important for predicting vertebral fractures, and bone density of the femur is important for predicting femoral fractures. Osteoporotic fractures usually occur in the wrist, spine, and femur, so it is recommended to measure these areas.
However, it is not difficult to predict fracture risk and use these as a treatment standard even if other areas are measured. There are many different methods of measuring bone density, including ultrasound, dual energy X-ray, and computed tomography, all of which are used as methods to predict future fractures.
■ Course/Prognosis:
In the United States, 13-18% of postmenopausal white women have osteoporosis, and 30-50% have low bone density in the femur (the bone connecting the hip and the knee). There are no accurate statistics in Korea, but it is estimated that the same percentage of people have osteoporosis. The most common fractures due to osteoporosis are wrist fractures, spinal fractures, and femoral fractures. These fractures generally occur in old age, and although they can be completely recovered, they can cause chronic pain, aftereffects, and even death.
The most serious problem with femoral fractures is that they have a mortality rate of 10-20% within one year. In addition, 25% require long-term nursing care, and only about 1/3 can live their lives before the fracture. Spinal fractures cause difficulties in daily life due to pain, decreased height, and altered posture, and can also cause loss of self-confidence due to appearance changes. Multiple fractures (Note: multiple fractures) can cause lung disease and also cause constipation, abdominal pain, fullness, and loss of appetite due to abdominal deformation.
According to a study on the rate at which a 50-year-old American white woman will experience a fracture during her average lifespan, the probability of experiencing any of these is over 40%: wrist fractures are 16%, spinal fractures are 15%, and femoral fractures are about 17%. Therefore, it is calculated that 4 out of 10 people will experience a fracture as they age.
The economic loss due to osteoporosis fractures is also enormous. In 1995 alone, 432,000 hospital admissions, 2.5 million doctor visits, and 180,000 admissions to nursing homes in the United States were due to osteoporosis fractures. The direct cost was approximately 16 trillion won, and it is estimated that this will increase further as the aging population increases.
■ Complications:
Wrist fracture
Wrist fractures are fractures of the wrist area, which is mainly composed of cancellous bone like a sponge. They often occur when a person falls with their arms outstretched. In women, wrist fractures begin to increase after the age of 40. Wrist fractures heal well and do not have long-term aftereffects. Women over the age of 40 who have wrist fractures need to be tested for osteoporosis and take appropriate measures in the future.
Vertebral compression fractures
They occur spontaneously or due to light impact and are the most common osteoporotic fractures. The forms of vertebral compression fractures vary; in some patients, fractures occur in only one vertebra, but in many patients, compression fractures occur in multiple vertebrae.
Before these compression fractures occur, significant loss of cancellous bone structure is already observed in the spine. If you take an X-ray of the fracture site, you can observe a mild form that is slightly collapsed, to a form where the entire vertebra collapses. The most common fracture site is the 6th thoracic vertebra (the spine in the chest area) and lower and the upper lumbar vertebra (the spine in the lower back area), so patients complain of back pain. If they complain of pain in the lower lumbar and sacral (the spine in the hip area) areas, it is less likely that the fracture is due to osteoporosis.
A decrease in height can also be a sensitive indicator of a compression fracture. However, a decrease in height
Even without a fracture, a herniated disc can occur due to stenosis of the intervertebral disc or postural deformation. There are 12 thoracic vertebrae, and deformation that occurs in the upper thoracic vertebrae, which corresponds to the 5th to 8th thoracic vertebrae, is common in elderly women and is not necessarily associated with severe compression fractures.
Hip joint (hip joint) fracture (hip clinic link)
Clinically, it occurs in the elderly, so it was thought to be a clinical manifestation of senile osteoporosis, but since the two diseases are not separate diseases, classification is not very meaningful. Hip fractures are common in people over 70 years of age, so they are one of the causes of death in the elderly. Generally, a femur fracture refers to a fracture of the femoral neck (the neck of the femur) and the greater trochanter (the large protrusion at the top of the femur). As you get older, the amount of bone decreases continuously and the number of falls increases, so the number of fractures also increases.
Hip fractures require surgical treatment, so they are expensive, and they have a mortality rate of 5-20% due to complications that occur before and after surgery. Many elderly patients have difficulty maintaining their preoperative activity level after hip fractures and require long-term care at nursing homes. Secondary hip fractures in other areas may occur, so diagnostic tests are required and prevention is important.
Areas where fractures are likely to occur
■ Treatment:
Osteoporosis is a preventable disease, and it is not easy to treat in advanced cases, so prevention is the best option. It is advisable to discover risk factors, start treatment early, and provide long-term treatment. Treatment can be broadly divided into drug and non-drug methods.
Diet
All patients need an appropriate amount of calcium (at least 1,200 milligrams per day), and those at risk of deficiency are advised to take an additional 400-800 units of vitamin D per day. An appropriate amount of calcium intake is necessary both during the period when bones are at their strongest during the growth period and to maintain healthy bones thereafter. Since bones account for 99% of the total calcium in our body, if calcium intake is insufficient, calcium is released from the bones to maintain calcium in the blood.
Calcium is most effectively consumed through dairy products such as milk, cheese, and yogurt. Smoking worsens osteoporosis and is recently considered a risk factor for hip fractures, so it is recommended to avoid it. Excessive drinking also worsens osteoporosis. You should try to eliminate the habit of eating salty foods in your regular diet and eat all foods evenly.
Regular weight-bearing exercise (exercise prescription clinic link)
Weight-bearing exercise (e.g. walking, jogging, climbing stairs, dancing, tennis, etc.) and strength training can suppress aging and improve physical strength and balance, reducing the risk of falling. It also has a slight bone density increase effect, so it is highly recommended.
Drug therapy
It can be broadly classified into drugs that prevent bone fracture and drugs that increase new bone production, but drugs that prevent fracture are mainly used for treatment because they are more effective and safe, and research on drugs that increase bone production is continuing. Female hormones are effective in preventing and treating osteoporosis, and they have other effects as well, making them the most effective treatment method. In addition, alendronate, calcitonin, raloxifene, activated vitamin D, and ipriflavone are being used clinically.
■ Prevention:
Consume sufficient amounts of calcium.
It is recommended that adults, not just teenagers, consume at least 1,200 milligrams of calcium every day to maintain healthy bones. The average calcium intake of Koreans is about 500-600 milligrams, which is far from the recommended amount for preventing osteoporosis.
Perform continuous weight-bearing exercise. It is recommended to do weight-bearing exercise such as walking, jogging, climbing stairs, dancing, tennis, etc. for more than 30 minutes a day at least 3 times a week.
Postmenopausal women should supplement female hormones.
Even if menopause is appropriate for your age, female hormones are effective in preventing osteoporosis and other menopausal diseases, so it is recommended for those without special contraindications to supplement hormones.
Be careful not to fall.
Since bones with osteoporosis are easily broken by impact, it is recommended to protect the bones from impact. Wearing comfortable shoes, turning on indoor lighting, making the floor of the bathroom non-slip, and improving structures in the living room and bedroom that can cause tripping are also ways to protect the bones. People taking sleeping pills or tranquilizers should be more careful, and it is recommended to avoid excessive bending of the waist as an exercise for osteoporosis.
Treat risk factors for osteoporosis early. If you have a family history of osteoporosis, have early menopause in women, or are taking other diseases or medications that cause osteoporosis, you should consult a specialist and receive active treatment if there is a risk.
If you are diagnosed with osteoporosis, continuous treatment is required.
Just as chronic diseases such as high blood pressure or diabetes require continuous treatment, osteoporosis also requires continuous treatment.
■ When to see a doctor:
People with risk factors for osteoporosis should consult a specialist early to prevent osteoporosis.
People who have experienced a fracture due to a minor impact as an adult
If a family member has experienced a femur fracture due to a minor impact
If you smoke
If you have a thin body type
If you are over 65 years old
If you are a woman
If you have female hormone deficiency, menopause, early menopause, ovarian surgery, amenorrhea
If you have low calcium intake
If you mainly live indoors
If you have alcoholism
If you are taking medications: steroid hormones, thyroid medications, anticonvulsants, medications that affect menstruation
If you have diseases associated with osteoporosis: hyperthyroidism, rheumatoid arthritis, parathyroid disease, liver disease, diseases with absorption disorders, diabetes, chronic lung disease, adrenal disease, hormone deficiency diseases, etc.
