Postmenopausal Bone Metabolism

and Structural Changes

DR. dr. H. Joserizal Serudji, SpOG-K

Obstetrics and Gynecology Department
Faculty of Medicine of Andalas University
 Definitions
Menopause: a point in time that follow 1 year after
the cessation of menstruatioin
Postmenopause: those years following this point.
The average age of FMP (final menstruation periode):
51.1 yrs the cessation of mensis due ovarian
failure may occur at any age.
Premature ovarian failure: cessation of menses
before age 40 and is associated with an elevated FSH
level.
 Perimenopause or climacteric: the time period in the
late reproductive years, usually late 40s to early 50s
characteristically: it begins with menstrual cycle
irregularity and extends to 1 year after permanent
cessation of menses.
The more correct terminology: menaopausal
transition typically develops over a span 4 to 7 yrs,
and the average age at its onset is 47 yrs.
 Influential factors
Environmental, genetic, surgical influences
may alter ovarian aging
Smoking: advances the age of menopause
Chemotherapy, pelvic radiation, ovarian
surgery: lead to earlier age of menopause
 Hypothalamus-PituitaryOvarian Axis Changes

Ovarian failure ovarian steroid release

ceases, and negative feedeback is opened
GnRH is released at maximal frequency and
amplitude FSH and LH levels rise up (4x).
 Ovarian Changes
The process of atresia of the non dominant
cohort of follicles, largely independent of
menstrual cyclicity, is the prime event that
leads to the eventual loss of ovarian activity
and menopause
 Bone Metabolism and Structural Changes

Normal bone: dynamic, living tissue that is in a

continuous process of destruction and rebuilding
(remodelling)
This remodelling (or bone turnover): allows adaptation
to mechanical changes in weigh bearing and other
physical activities
Process of remodelling involves: a constant resorption
of bone (by osteoclasts) and a concurrent process of
bone formation (by osteoblasts)
During menopause: the rate of bone mass decline
increases to 2 5 % per year for the first 5 10 year
 Osteopenia and Osteoporosis
Bone disorders: characterized by a progressive
reduction in bone mass (typically: trabecular
bone) and predispose to fractures in the spine,
hips, and other sites.
Fracture: the most debilitating and costly
consequence of osteoporosis associated with
significant morbidity and mortality, and the risk
of dying 2 x higher.
Only 40 % of those who sustain a hip fracture are
capable of returning to their prefracture level of
independence
 Pathophysiology
Osteoporosis: a skeletal disease in which bone strength
is compromise, resulting in an increased risk for
fracture
A major proportion of bone strength is determined by
bone mineral density (BMD)
Primary osteoporosis: bone loss associated with aging
and menopausal estrogen deficiency ec estrogen
regulatory effect on bone resorption is losts most
rapid in the early postmenopausal years.
Secondary osteoporosis: caused by other diseases or
medication.
 Pathophysiology, contd
Aging and a loss of estrogen: lead to significant
increase in osteoclastic activity
Ca intake or impaired of Ca: serum level of
ionized Ca PTH level stimulates
production of vit. D serum Ca level
In menopausal woman: estrogen
responsiveness of bone to PTH more Ca
removed from bones serum Ca level
lowers PTH level and vit D level
 Diagnosis of Osteoporosis
Standard: BMD reported as T-score
T-score of -2.0 means: the BMD is 2 SDs below
the average peak bone mass for a young
woman
Criteria for Interpretation of BMD table.
 Prevention
The most important predictive factors: bone
density in combination with age, fracture
history, ethnicity, various drug treatments,
weight loss, and physical fitness.
The presence of a key risk factor should alert a
clinician to the need for further assessment
and possibly active intervention, such as
calcium therapy coupled with weight-bearing
exercise or pharmacologic therapy.
 Treatment
Primary goal: fracture prevention in low BMD
women the aim: to stabilize or increase BMD.
Treatment: lifestyle changes or pharmacotherapy
Therapeutic options:
Hormonal th/ for prevention
Biphosphonates and selective estrogen reseptor
modulator (SERM) for prevention and treatment
Calcitonin and injectable hPTH for treatment
 Treatment contd
Nonpharmacologic therapy
Calcium
Vitamin D
Diet : protein supplementation
Physical activity: aerobic exercise
 Fall-Prevention Strategies
Falls: responsible for >90% hip fractures
Minimize falls by: reducing clutter and
implementing nonslip tiles, rug with nonskid
backing, night lights.
Hip protector padding