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Healthy Bones After Menopause: What Has to Be Done?

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Pre-Menopause, Menopause and Beyond

Part of the book series: ISGE Series ((ISGE))

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Abstract

Osteoporosis leads to weakness of the skeleton and increased risk of fracture. The World Health Organisation (WHO) has defined Osteoporosis as a systemic skeletal disease characterised by low bone mass and micro architectural deterioration of bone tissue, with a consequent increase in bone fragility and susceptibility to fracture.

The likelihood of a major fracture at any of the four major sites (spine, femoral neck, wrist, proximal humerus) is 40% or more in developed countries, a figure close to the probability of coronary heart disease. In a woman at the menopause, the remaining lifetime probability after a fracture at any one of these sites is less favourable that the one after breast cancer. All preventive measures must be individualized and tailored according to the personal risk profile including personal and family history and the results of relevant investigations as well as to the woman’s preferences and expectations. Prescription of MHT or SERMs for primary prevention of fragility fractures should be part of an overall strategy including lifestyle recommendations regarding diet, a sufficient daily intake calcium and proteins, adequate Vit. D levels, exercise, smoking cessation and safe levels of alcohol consumption. The evidence presented by the WHI study does not support the restrictions placed on MHT as a bone-specific drug. Healthy women younger than 60 years and/or less than 10 years from menopause should not be unduly concerned about the safety profile of a correctly indicated MHT.

Nitrogen-containing bisphosphonates have been proven in numerous randomized, controlled outcome trials (RCTs) in postmenopausal osteoporosis to reduce significantly the incidence of fragility fractures. They are suitable first-line treatments for elderly women after the age of 60 years with postmenopausal osteoporosis. In women with low fracture risk, a “drug holiday” after 5–10 years of bisphosphonate treatment has been recommended. Serious adverse effects such as atypical subtrochanteric fracture and osteonecrosis of the jaw are very rare in women receiving bisphosphonates for fracture prevention in presence of postmenopausal osteoporosis, and not for oncological indications.

Adherence may be insufficient in some patients treated by oral drugs. In these patients, the administration of non-oral bisphosphonates or denusomab are recommended. Denosumab is a humanized monoclonal antibody that works by decreasing the activity of the receptor activator of nuclear factor kappa B ligand. In contrast to bisphophonates, denosumab has a short half-life so that its antiresorptive effects as well as its adverse effects are rapidly reversible. Denosumab reduces median bone formation rate to zero after 2-3 years use. Continuous use of denosumab to 8 years maintains the reduced fracture rates. The relative risk of serious adverse events is low. Again, osteonecrosis of the jaw has only been seen in cancer patients receiving very high doses of denosumab. EMA recommended in 2014 that strontium ranelate should only be used for the treatment of severe osteoporosis in postmenopausal women at high risk of fracture.

Parathyroid hormone (PTH[1-84]) and human recombinant PTH[1-34] (Teriparatide) are the only anabolic agents available today. They reduce the risk of new vertebral and non-vertebral fractures in postmenopausal women with and without prior fractures. With sequential PTH treatment, BMD gain is maintained or increased by alendronate or raloxifene, but lost if parathyroid hormone or teriparatide is not followed by an antiresorptive agent.

In conclusion, MHT is the first choice for fracture prevention in women < 60 years and/or less than 10 years from menopause. In women with a simultaneously increased breast cancer risk, SERMs should be preferred. In women aged 60 years or more, non-hormonal anti-resorptive therapies such as bisphosphonates or denosumab are the first choice. For economic reasons, teriparatide is reserved for the treatment of severe osteoporosis. If costs are considered without taking into account adherence, to-day, some older bisphosphonates have the best cost-benefit ratio. Following the recommendation of EMA, Strontium ranelate should only be used for the treatment of severe osteoporosis in postmenopausal women at high risk of fracture.

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  1. Martin Birkhaeuser

    Present address: , Gartenstrasse 67, CH-4052, Basel, Switzerland

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  1. Professor emeritus for Gynaecological Endocrinology and Reproductive Medicine, University of Bern, Bern, Switzerland

    Martin Birkhaeuser

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  1. Professor emeritus for Gynaecological Endocrinology and Reproductive Medicine, University of Bern, Bern, Switzerland

    Martin Birkhaeuser

  2. International Society of Gynecological Endocrinology, Pisa, Italy

    Andrea R. Genazzani

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Birkhaeuser, M. (2018). Healthy Bones After Menopause: What Has to Be Done?. In: Birkhaeuser, M., Genazzani, A. (eds) Pre-Menopause, Menopause and Beyond. ISGE Series. Springer, Cham. https://doi.org/10.1007/978-3-319-63540-8_14

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  • DOI: https://doi.org/10.1007/978-3-319-63540-8_14

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