Preventing fractures in postmenopausal patients

Patients over 65 should have a bone density test or may be considered for earlier screening if they have additional risk factors or a history of long-term steroid use.

Bone health often is overlooked and undertreated in postmenopausal patients, even though appropriate management is critical to lower the risk of fracture and potentially catastrophic falls.

Estrogen protects bones by inhibiting osteoclast cells, which break down bone. With menopause and lower estrogen levels, bone mass starts declining. A person can lose up to 20% of bone in the first five to seven years following menopause.

With decreased bone density comes an increased risk of a fracture. The statistics around fracture after menopause are sobering:

  • Half of assigned females at birth who are over age 50 will break a bone secondary to osteoporosis. After a break, patients are five times more likely to break a second bone within the first year.
  • Risk of breaking a hip in postmenopausal patients is equal to the risk of breast, ovarian, and uterine cancer combined.
  • Mortality, morbidity and loss of independence associated with hip fracture is significant.

The most important thing we as providers can do is focus on prevention — catching patients before the first fracture.

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Bone density tests should be routine

Every patient over 65 should have a bone density test. They may be considered for earlier screening if they have additional risk factors such as a history of a fragility fracture, family history of osteoporosis, a previous history of an eating disorder or have height loss. They should also be screened earlier if they have a history of long-term steroid use.

With menopause, a person can adopt lifestyle choices that improve bone density. This includes limiting alcohol and making sure to have a calcium-rich diet. Weight-bearing exercise also helps. This includes jogging or at least walking at a pace faster than normal, high-impact training, or strength training using resistance bands or weights. Patients should refrain from smoking or quit if they already smoke.

While lifestyle changes can be beneficial, I have a low threshold before considering the use of medication. I think more significant gains are found in the combination of lifestyle changes and prescription drugs.

Medications to slow or restore bone loss

There are two categories of medications to combat bone loss: antiresorptive, which keep bones from breaking down, and anabolic, which stimulate bone growth.

Among medications to treat bone density loss, bisphosphonates are considered first-line treatment and are the most widely used. They come in both oral and IV forms. Alendronate, risedronate, and ibandronate are oral forms, while zoledronic acid is a once-a-year infusion. Another antiresorptive, denosumab, is a monoclonal antibody taken by injection every six months. Much of the decision around which of these to take comes down to patient or provider preference.

Anabolic medications are used to stimulate bone formation. These medications typically are used in more advanced cases of osteoporosis and include teriparatide and abaloparatide. They are daily injections that are used only for two years or less. These medications are well suited for osteoporotic patients who have a current fragility fracture, especially in the spine.

A newer medication, the monoclonal antibody drug romosozumab, has a dual effect, working as both anabolic and antiresorptive.

The number of patients who experience hip fractures shows we have a long way to go when it comes to recognizing the fracture risk among postmenopausal individuals. As health care providers, we need to do a better job screening patients who may be at risk and treating them to minimize their risk of bone loss.

Robin G. Curry, M.D., is an orthopedic and sports medicine physician with Norton Orthopedic Institute.

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