OSTEOPOROSIS

A disease which is ignored in our community especially in women’s. After age 65, about 35% of women have osteoporosis, and nearly all of them are unaware of their condition.
Osteoporosis is a classic symptom of aging. What is osteoporosis, it literally means "porous bones". It is the disease of the skeleton in which bones become brittle and prone to fracture. In other words the bone loses its density.
Normally, in the life of a healthy, unremarkable woman, by her late thirties and forties her bones become less dense. By the time she reaches her fifties, she may begin to experience bone loss in her teeth and become more susceptible to wrist fractures.
Gradually, the bones in her spine weaken, fracture, and compress, causing upper back curvature and loss of height, known as "dowager's hump".

Osteoporosis is unfortunately more common in women than in men because when a woman's skeletal growth is completed she typically has 15% lower bone mineral density and 30% less bone mass than a man has of the same age. Studies also shown that women lose more trabecular bone (the inner, spongy part making up the internal support of the bone) at a higher rate then do men.

TYPES OF OSTEOPOROSIS
There are three types of osteoporosis women are prone 2.

1: -POSTMENOPAUSAL
---------------------------- Postmenopausal osteoporosis usually develops roughly ten to fifteen years after the onset of menopause (total natural cessation of menstruation). In this case estrogen decreases. Estrogen may have impact on bone density in different ways:

a) Estrogen's most important effect on osteoporosis appears to be prevention of bone break down. Some research suggests the estrogen may control the life span of osteoclasts, the cells responsible for bone breakdown.
b) One study reported that part of estrogen's beneficial actions may involve maintaining normal levels of vitamin D, an important nutrient in bone protection..

In menopause as estrogen decreases, the loss interferes with calcium absorption and you begin to loss trabecular bone and fractures of the vertebrae, which consist mainly of trabecular bone, are common. The women will also begin to lose parts of cortical (the outer shell of the bone) but not as quickly as the trabecular bone.

2: - SENILE OSTEOPOROSIS
---------------------------------- Senile type effects men and women both, older than age 75 years of age. Here u loss both cortical and trabecular bone because of a decrease in bone cell activity that results from aging. Hip fractures are seen most often with this kind of osteoporosis. The decrease in bone cell activity effects your capacity to rebuild bone in the first place, but it also aggravated by low calcium intake.

3: -SECONDARY OSTEOPOROSIS
---------------------------------------- In which an underlying condition causes bone loss. These conditions include chronic renal failure, hypogonadism (an under activity of the sex glands), hyperthyroidism (an overactive thyroid gland), some form of cancers, gastrectomy (removal of parts of the stomach which interferes with the calcium absorption), glucocorticoid therapy or spontaneous Cushing syndrome’s, malabsorption or malnutrition, multiple myeloma, use of anticonvulsant, and prolonged immobilization, among other things.

WHAT CAUSES BONE LOSS?
Our bones are always regenerating. This process helps to maintain a constant level of calcium in the blood, essential for healthy heart, blood circulation and blood clotting. About 99% of all the body's calcium is in the bones and teeth; when blood calcium drops below a certain level, the body will take calcium from the bones to replenish it. But by the time we reach our late thirties, our bone loss calcium faster than it can be replaced. The pace of bone calcium loss speeds up far "freshly postmenopausal" women who are 3 to 7 years beyond menopause. The pace slows once again, but as we age, the body is less able to absorb calcium from food. One of the most influential factors is estrogen, which we discussed during postmenopausal type of osteoporosis. Estrogen allows maintaining higher level of calcium in our blood. Higher the blood calcium level less chance of losing calcium in bones.In men, testosterone does the same thing for them but unlike women , men never reach a particular age when their testes stop producing testosterone. If they did, they would be just as prone to osteoporosis as women are.

Several physical conditions and external factors help to weaken our bones, contributing to bone loss later in life:

1__Heavy caffeine and alcohol intake. These cause of loss of calcium in urine.
2__Smoking.
3__Women on surgical menopause who are not on Estrogen replacement therapy (ERT).
4__Anatacids containing aluminum and corticosteroids as they interfere with calcium absorption.
5__Diseases of small intestine, liver and pancreas. Preventing body from adequate absorption of calcium from the intestine.
6__ Lymphoma, leukemia and multiple myeloma.
7__ chronic diarrhea from ulcerative colitis or chron's disease.
8__ surgical removal of part of stomach or small intestine.
9__ Hypercalciuria.in which one loss to much calcium through urine.
10_Early menopause before age 45.
11__Lighter complexions. Women with darker pigmentation have roughly 10% more bone mass then women with fairer pigmentation coz the former produces more calcitonin, the harmone that strengthens bones.
12__Low weight. Women with less body fat store less estrogen, which makes the bone less dense to begin with and more vurnebrable to calcium loss.
13__Women with eating disorders (yo-yo dieting, starvation diets, binge/purge eaters)
14__Family history of osteoporosis.
15__High protein diet.
16___Women who had never been pregnant?
17__Amenorrhea in child bearing age.
18___ Athletes
19___ Lactose intolerance
20___Tenage pregnancy.
21___Scoliosis.
22__Being sedentary.

CLINCAL FEATURES:
A) FRACTURES: -
1-- vertebral compression fractures, typically effect T8 to L3 and occur more commonly in women.
2--- Hip fractures, characteristically in the neck and intertrochanteric regions of the femur.
Common in both men and women after age 75.
3---The distal radius and other areas may also be site of fractures.
B) PAIN AND DFORMITY: -
Back pain may persist long after an episode of vertebral fracture because of spinal deformity and alteration of spinal mechanics. Several inches may be lost from height, and sever kyphosis may be the result of multiple vertebral fractures

DIAGNOSIS: -
1--Bone density scan: -
In the past, CAT scans were used but due to high level of radiation during this procedure it’s outdated now. Today a procedure called Absorptiometery is used, which involves the use of radioactive substance. Also called DXA (Dual energy absorptiometry).

Absortiometry is either a single photon or dual photon. These test measures the bone density by counting how much radioactivity the bone, which determines u density, absorbs. The more radiation u absorbed the more bone mass u have urine test known as NTX should also be used, which can measure weather u are peeing out a protein specific to bone loss.

2--Radiography of the spine: -
May revel a decrease in bone density. However, approximately 30% of bone tissue are lost before it becomes to appear on X-ray.Wedge shaped deformities and compression fractures on spinal x-rays are diagnostic for osteoporosis.

3--Biochemical markers of bone formation: -
In osteoporosis, bone turn markers have been suggested to predict the rate of postmenopausal bone loss and the occurrence of osteoportic fractures and may be useful in monitoring the efficacy of treatment, especially antiresponsive therapy e.g. hormone replacement therapy, bisphosphonates and calcitonin. Measurement of bone turn over before treatment might be useful to select the type of treatment and to predict the amplitude of the response estrogen and bisphosphonate treatment, however there is no solid evidence for these two concepts.

TREATMENT OF OSTEOPOROSIS
Prevention of osteoporosis is easier then treatment. Therapeutic agents can slow the rate of bone loss but are less effective in restoring bone mass that has been lost.

A) ESTROGEN: -
An important means of preventing osteoporosis is the administration of estrogen after menopause. Estrogen decreases the accelerated rate of bone loss that occurs following menopause. Obese women have higher estrogen level after menopause, which decreases their risk for osteoporosis.
The decision to use postmenopausal estrogen replacement should be based on the benefits of and risks of estrogen use in each patient.
(1) There is greater risk for osteoporosis ,and therefore greeter potential benefit of estrogen use in an individual who
------ Has a small stature and slender build.
-------Has a family history of osteoporosis.
-------Is white and of northern European ancestry
-------Experienced early menopause.
-------Smokes.
(2) The adverse effects of estrogen , which must be balanced against its benefits are

-------Possible symptoms of nausea, breast tenderness, and fluid retention.
-------A fourfold to eightfold increase in the risk for endometrial cancer if estrogen is taken without progesterone.
-------- Increased risk that unscheduled uterine bleeding may occur and require gynecological investigation.
-------Increased risk of gallbladder disease and hypertension.
-------A possible small increase in the risk of breast cancer.
(3)Other benefits of estrogen therapy, such as relief of menopausal symptoms, must be considered. The most important benefit of estrogen therapy is its effects on blood lipoprotein i.e. it decreases LDL and increases HDL, thereby decreasing the risk of cardiovascular and atherosclerotic diseases.

Once a patient is known to have osteoporosis, the benefit of estrogen therapy clearly outweighs the risk. Estrogen has been showed to decrease the risk of fractures.
Dosage of women depends upon age. Menopausal history, height, weight and countless other factors. Currently most doctors will put u on the most lowest dose, which might be the average of .625mg daily.

B) CALCITONIN: -
Calcitonin supplement is another treatment for osteoporosis. This is a hormone produced in the thyroid gland, which conserves more calcium in the bone, slowing bone loss. It is given as a daily injection, along with 1,500 mg of calcium and 400Ius of vitamin D.It also helps to relieve skeletal pain and increase spinal bone mass.

C) CALCIUM: -
Patients with osteoporosis should at least ingest 1500 mg of elemental Ca daily.

D) BISPHOSPHONATES: -
These are agents that bind to hydroxyapatite in bone and decreases bone resorption. The drugs in this groups are
1---Etidronate (Didronel)
2----Alendronate (Fosamax)

E) CALCITROL: -
Is another form treatment. Its body-working form of vitamin D, which helps to increases calcium absorption in the body.

F) SODIUM FLURIDE: -
Has been found effective in the treatment of osteoporosis in some studies but not in all.

G) VITAMIN D: -
In pharmacological doses more then 1000 units’ daily has not be proven to be effective in treatment of osteoporosis. But physiologic doses, 400- 800 units daily, have decreased the fracture rate in populations of elderly persons who may deficient in vitamin D coz of poor nutrition and lack of sunlight.


Finally, researchers are looking into the use of anabolic steroids to strengthen bones; synthetic parathyroid hormone to maintain balance of calcium in body and thiazides, diuretics that reduce the amount of calcium loss through urine.

PREVENTING OSTEOPOROSIS

-Ingest more calcium and thus increase your bone mass. This boils down to eating right and exercising. It’s not enough to just take calcium supplements or eat high calcium food. You need to cut down on diuretic food such as caffeine and alcohol.
•
Postmenopausal women requires roughly about 1,000 mg of calcium daily and those not taking estrogen roughly 1,500 mg daily.
Food rich in calcium include all dairy products (an 8-ounce glass of milk contains 300 mg), fish, shellfish, oysters, shrimp, sardines salmon, soybeans, tofu, broccoli, dark green vegetables except spinach which contains oxalic acid, preventing calcium absorption.

As for exercise, good activities are walking, running, biking, aerobic dance or cross-country skiing. These are considered good ways to put more stress on the bones, increasing their mass. Carrying weights is a good way to increase bone mass.

By: Dr. Nusrat Shafiq
dr_n@pakistanreview.com