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Bone Health Without the Hype

I am at the Australasian Menopause Society meeting and we had a fantastic lecture on Bone Health on Day 2, called, “Everything you need to know about bones - except the boring bits!” Spoiler alert, there were no boring bits. The lecture was given by Dr. Amanda Beech, who is a senior staff specialist in Obstetric Medicine and Endocrinology at the Royal Hospital for Women, where she is director of the Bone Density Unit. I want to summarize my top 10 take-aways for you. Share Osteoporosis is a disease of low bone mass, disruption of bone microarchitecture, and fragility of the skeleton. It is a silent disease…until someone develops a fracture. The diagnosis of osteoporosis is based on either fragility/minimal trauma fractures or a T-score of less than -2.5 on a DXA (Dual-Energy X-ray Absorptiometry) or bone scan. It is important to recognize that about 50% of minimal trauma fractures occur when women have low bone mass (often referred to as osteopenia), but not osteoporosis. This tells us that bone strength is more complicated than a number on a DXA report. I am going to add a little here that wasn’t in the talk (one can only include so much in 25 minutes), as many women might read the above paragraph and think, “Shouldn’t we be treating everyone with low bone mass if this is when 50% of the fractures occur?” Many fractures happen for women with low bone mass because there are so many women with low bone mass –it is a statement about the population on a whole, not about the fracture risk of low bone mass. For you as an individual, bone density is only one component of fracture risk and many women with lower bone mass will not have a significantly elevated fracture risk. This is why individualized risk assessment matters. Subscribe We build bone in our teens and twenties, and by the time we are about thirty we have reached peak bone mass. This is why, when we discuss risk factors for osteoporosis, it is important to consider factors that might have affected us in our teens and twenties when we were actively building bone, such as nutritional restriction/energy imbalance. It is important to ask women about a history of eating disorders, and for those with such a history, getting a bone scan in perimenopause or at age 50 is likely warranted. (This image below isn’t from the talk, but is similar to one that was). Bone mass is relatively stable until about two years before the final menstrual period, and perimenopause marks a time of rapid bone loss for women. Using urinary markers of bone loss we know that the time of significantly accelerated bone loss starts about 1 year before the final period and ends about 2 years after the final period. The Study of Women’s Health Across the Nation (SWAN) shows that over the menopause transition women lose an average of 10.6% of the bone at their lumbar spine and 9.1% at the femoral neck While this wasn’t covered in the lecture, I want to add that the rapid bone loss during perimenopause is clearly related to more than estradiol, because during this time estradiol levels can be erratic and not uniformly low. Bone loss during perimenopause is likely a multi-hormone event. For example, rising FSH (follicle stimulating hormone) tracks with bone loss better than estradiol, and there is evidence that FSH may act directly on bone. While decreased estrogen matters, there is clearly more going on. FSH and bone is an active area of research. Subscribe Screening for osteoporosis was recommended fairly broadly before age 65, and was taken from the “Practitioner’s Toolkit for Managing Menopause,” from Monash University. Here is a screenshot from the toolkit that was used as a slide: I am going to add a little bit more about body weight here for clarification. Low body mass (typically 152.1 lb): 0 points (risk neutral) 60–69 kg (132.3–152.1 lb): 3 points (adds some risk)

Sep 12 • 11:19 PM EDT • Health • vajenda.substack.com