Menopause and Osteoporosis

Menopause

Introduction:

• A woman is born with all of her eggs approximately two million eggs which are stored in her ovaries. 
• The ovaries make the hormones estrogen and progesterone, which control her menstruation and ovulation. Menopause happens when the ovaries no longer release an egg every month and menstruation stops. 
• Once menstrual cycle completely stop for 12 consecutive months, you’ve entered menopause. 
• The average age for onset of menopause is 51. 
• The majority of women stop having periods somewhere between ages 45 to 55. 
• The beginning stages of declining ovary function can start years before that in some women. 
• Others will continue to have menstrual periods into their late 50s.

Definitions:

Perimenopause: 

Begins several years before menopause (2-6 years), it is period of beginning of physiological failure of ovarian function, when ovaries slowly make less estrogen.

Menopause: 

stoppage of menses for one year associated with reduction of circulating estrogen and increased production of gonadotropen

Post menopause: 

the remainder of life after menopause

Types of Menopause:

Physiological: 

Spontaneous progressive decline of ovarian function.

Pathological:

• Premature: premature ovarian failure before age of 40 years. 
• Artificial: permanent cessation of ovarian function due to surgical removal of ovaries or irradiation.
• Delayed : cessation of menstruation above age of 51 years.

Menopausal changes:

Due to reduction of estrogen and progesterone and increase production of gonadotropen

1- Breast changes:

Premenopausal phase👉 increase in subcutaneous fats Menopause👉 fats resorbed, glands atrophied, breast becomes flattened and pendulous.

Before and during menopause, it is common to experience pain or tenderness in breasts (Sore breasts).

Sore breasts, also known as mastalgia, are also very common during menstruation. This is because hormonal changes cause fluid to build up in the breasts, making them feel swollen and tender.

During perimenopause, the hormonal fluctuations are more dramatic. It is also common for breasts to get bigger or smaller or to change in shape during this period.

Lifestyle changes that may help sore breasts include:

• Wearing supportive bras that fit comfortably 
• Exercising regularly 
• Applying a warm compress 
• Avoiding smoking 
• Taking a hot shower 
• Reducing caffeine consumption

2- Psychological changes: 

Irritation, Depressed mood, Sleep disorders (insomnia), 

3- Obesity: 

Hyper function of anterior lobe of pituitary gland leads to increased appetite and decrease in carbohydrate metabolism. 

Estrogen affects where women store fat and how it is burned, causing slow metabolism 

Abdominal fate most common leads to increase risk of cardiovascular disease and diabetes.

Lifestyle changes that may prevent cardiovascular disease and diabetes 

Exercise, prevent (or quit) smoking and eat a healthy, nutritious diet rich in fruits and vegetables

4- Cardiovascular changes: 

• A drop in estrogen raises risk of heart conditions, including atrial fibrillation and high blood pressure.
• High blood pressure: When estrogen levels drop, heart and blood vessels become stiff and less elastic.
• High cholesterol: Lack of estrogen can also cause detrimental changes in cholesterol and blood fats: good cholesterol (high density lipoproteins (HDL)) may go down, and bad cholesterol (low density lipoproteins (LDL)) may go up, Triglycerides increase which increases risks of heart attack and dying from heart disease.

Atrial fibrillation: 

Women may see an increase in abnormal heart rhythms like atrial fibrillation around the time they go through menopause.

Diabetes: 

When women go through menopause, they can also become more resistant to insulin, As a result, “women are more likely to become prediabetic and diabetic as they transition from premenopause to menopause, ” 

All theses disappears over time

5- Vasomotor disturbance: 

hot flushes, sweating, headaches, fainting and palpitation ( increase in pulse rate). 

• Hot flushes and night sweat: 

• Body temperature rise 
• Affects upper chest, neck and face 
• Skin may even turn red in color 
• Women wakened at night soaked in perspiration 
• Each hot flush lasts between 1.5 and 3 minutes with increase in HR 15 beats/minute 
• Hot flashes may come on daily or even multiple times a day. 

A few techniques may help reduce hot flashes :

• Avoid triggers like spicy foods, caffeine, or alcohol. Smoking may also make hot flashes worse. 
• Use a fan at work or in home to help cool down. 
• Do breathing exercises during a hot flash to try to minimize it. 
• Medications that may help reduce hot flash symptoms such as birth control pills, hormone therapy

6- Female genital organs:

• Ovaries: decrease in size, become non functional. 
• Uterus and tubes: atrophied. 
• Ureters: mucosa atrophied leads to urethritis. 
• Pelvic floor muscles: lose their tone, elasticity prolapse and stress incontinence can be developed.
• Vaginal soreness and atrophic vaginitis: 

1. Vaginal and cervical secretions decreased 
2. Vaginal lining become thin, dry and less elastic , vaginal become more prone to infection, soreness, irritation, burning and discharges 
3. Dyspareunia 

Theses symptoms response well to administration of estrogen

Osteoporosis

Is defines as systemic skeletal disorder characterized by low bone mass with increase in bone fragility and susceptibility to fracture due to decreased level of estrogen. 

The greatest rate of bone loss or reduction in bone mineral density occurs in the first 3 years after menopause 

Three main factors involves in the development of osteoporosis: 

• Irreversible damage of microreactor of bone (a decrease in bone quality) 
• Decreased bone mass 
• Increased tendency to fall

Bone turnover is a balance of bone metabolism whereby bone resorption (osteoclast) equal bone formation (osteoblasts) 

Accelerated bone loss postmenopausal associated with increased osteoclast activity ( bone resorption occurs at greater rate than bone formation) 

Estrogen receptors present in osteoclasts and both estrogen and androgen receptors have been found in osteoblasts this suggests disruption of bone metabolism postmenopausal 

It affects vertebrae( trabecular bone) then the axial skeleton( cortical bone.

Features: 

• Bone pain especially back pain. 
• Fractures (most commonly proximal femur, distal radius, vertebral body) 
• loss of height. 
• Deformities of vertebral column → angular or round kyphosis

Risk factors for osteoporosis: 

1- Low calcium intake (Calcium helps build bone) adults require 1,000 mg per day (preferably through diet) which increases to 1,500 mg per day for women over 50 and men over 70 

2- Low vitamin D level (maintaining bone strength) - a lack of sun exposure can mean you are not getting enough vitamin D your body needs to absorb calcium

3- Corticosteroids - commonly used for asthma, rheumatoid arthritis and other inflammatory conditions 

4-Thyroid conditions - over active thyroid or parathyroid 

5- Some medicines for breast cancer, prostate cancer, epilepsy and some antidepressants 6- Lifestyle factors 

7- Low levels of physical activity (An inactive lifestyle) 

8- Smoking 

9- Excessive caffeine and alcohol intake 

10-Weight - thin body build or excessive weight 

11-Ethnicity (people who are Caucasian or of Asian descent have the greatest risk) 

12- Menopause or hysterectomy

Diagnosis of osteoporosis:  

1- Bone densitometry using DEXA ( dual energy X ray absorptiometry) scanner measures bone mineral content at the hip and lumber spine and compare it with that of healthy young adults and age matched controls. 

2- Calcaneal ultrasound for assessing bone density

Treatment: 

Aim: 

• Alleviate patients symptoms 
• Reduce risk for fracture 

Methods: 

• Drugs to reduce bone loss 
• Any secondary cause should be treated ( endocrine disorder. Rheumatological conditions) 
• Assess dietary deficiencies 
• Corticosteroids should be undertaken 
• Old persons should be subjected to sunlight 

If foot and ankle fracture is present 

• Rest 
• Decrease activity 
• Mechanical support 

Pain relief through:  

• Analgesic drugs 
• TENS 
• hydrotherapy 
• Pain clinic 

Reduction of fracture site risk through: 

• Wearing shock absorbing protectors 
• Prevent falling ( using appropriate walking aid, environmental changes) 

Management of Menopausal changes

1- General treatment: 

Proper explanation about this changes Improve general health Diet control 

2- Hormonal treatment: 

Estrogen and estrogen with progestogen 

3- Medical treatment 

Sedative drugs , calcium intake 

4- Preventive treatment: 

Regular exercise include both aerobic and resistance training to prevent or minimize many of these problems 

Low repetition exercise with moderate resistance more effective than high repetitions with low loading

Exercise for cardiovascular disorders: 

Regular aerobic exercise improves cardiorespiratory endurance and reduce risk of cardiovascular disease. 30 minutes 3 times / week 60% of VO2 max.

Exercise for obesity: 

Aerobic exercise more effectively lose fate in post menopause than dieting results from several mechanisms including energy expenditure, metabolic rate and altered body composition 

Recommended exercise: 

walking or jogging and light resistance exercise for 60 minutes / day 3 times / week 50% of VO2 max.

Exercise for osteoporosis: 

• Weight bearing exercise in form of walking, jogging and climbing stairs. 
• Non weight bearing exercises in form of bicycle, swimming and specific exercise for spine Recommended exercise: to provide protection against bone loss is 30 minutes / day 3 times / week 60% of VO2 max.

BENEFITS OF EXERCISE :

• Exercise increases the cardiorespiratory function. If done regularly, it reduces the metabolic risks associated with declining estrogen. It increases HDL, reduces LDL, triglycerides and fibrinogen. There is an additional benefit of a reduced risk of high blood pressure, heart attacks, and strokes. 
• Exercise can help create a calorie deficit and minimize midlife weight gain. 
• It increases the bone mass. Strength training and impact activities (like walking or running) can help to offset the decline of bone mineral density and prevent osteoporosis. 
• It also reduces low back pain. 
• It is proven to help reduce stress and improve the mood. 
• It may help to reduce hot flashes

VARIETIES OF EXERCISES:

• Exercises that can help in building and maintaining the bone density and mass are as follows: 
• Weight bearing, high impact exercises: Includes dancing, high impact aerobics, running / jogging, jumping rope, stair climbing, and sports like tennis, basketball, volleyball or gymnastics. These are best for those who are not osteoporotic, not have low bone mass, and are not frail. 
• Weight bearing, low impact exercises: Are walking (treadmill/outside), elliptical training machines, stair step machines, and low impact aerobics. This group of exercises may be optained to build bones, by women who cannot do high impact exercises. 
• Weight or strength training or resistance training exercises: Include lifting weights, using elastic bands or weight machines for exercise, using simple functional movements such as standing or lifting the own body weight. 
• Nonweight bearing, nonimpact activities: Are cycling, swimming, stretching, and flexibility exercises. These should be included as components of a comprehensive exercise program. Alone these do not help building up the bones. 
• NonImpact exercises: Involve exercises that help in the balance posture and attitude, for example, T’ai Chi.

Menopause friendly exercise prescription:

The exercise program for postmenopausal women should include, endurance exercise (aerobic), strength exercise, and balance exercise. Out of these aerobics, weight bearing, and resistance exercises are all effective in increasing the bone mineral density of the spine in postmenopausal women. 

An effective exercise prescription may be resistance and weight bearing exercise three days a week (on alternate days). Care should be taken to do the exercise for all the muscle groups by rotation preferably with a trainer. Brisk walking at the speed of five to six kilometres per hour, cycling, treadmill, gardening or dancing may be done on the remaining days of the week. 

Warming up beforehand can help to reduce exercise related injuries and pain following exercise. One should aim for two hours and 30 minutes of moderate aerobic activity each week. Other deep breathing, yoga, and stretching exercises can help to manage the stress of life and menopause-related symptoms.

Electrotherapy for prevention of osteoporosis:

1-Electromagnetic field: PEMFs with 10 micro volt/cm , frequency 50-150 Hz on hour /day slowing down the loss of bone mass 

2- Pulsed Ultrasound: Frequency 1.5 MHz intensity 0.5-2 W/Cm 2 for 10 minutes/day increase bone regeneration 

3- Electrical Stimulation: