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ปั ญหาทีเ่ กีย
่ วกับสุขภาพ
ทีพ
่ บบ่อยในสตรีวัยทอง
และวิธก
ี ารดูแล (Part II)
By Siraya Kitiyodom
BONE
By Siraya Kitiyodom
Management
• Brain symptoms
• Prevalence
• Mood
• Estrogen as an neuromodulator
• Depression
• Vasomotor symptom
• Definition
• Physiology
• Management
• Bone
• Nonhormonal in menopause
• Hormone replacement therapy
Scope
•Definition
•Pathogenesis
•Evaluate & Diagnosis
•Treatment
Definition
•
Osteoporosis is defined
as a skeletal disorder characterized
by compromised bone strength
predisposing a person to an
increased risk of fracture.
•
Bone strength primary reflects
the integration of
bone density and quality
NIH Concensus Development Panel an Osteoporosis , 2001
Bone Strength
NIH Consensus Statement 2001
Bone
Strength
Bone
Quality
+
Bone
Density
Architecture and geometry
Degree of mineralization
Properties of collagen/mineral matrix
Damage accumulation
Turnover/ remodeling rate
NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95
Scope
•Definition
•Pathogenesis
•Evaluate & Diagnosis
•Treatment
Bone Biology
• TYPE OF BONE
Bone can be divided into 2 major types
• Cortical
- Outer shell of all bones
- 75% of total bone mass
• Trabecular
- Spongy, open architectural structure
- Most of the volume in bone
- 25% of total bone mass
Larger surface area
Higher turn over rate
Show early bone loss
First respond to therapy
ACOG Practice Bulletin. 2004; NO. 50: 203-216
Bone Biology
• Bone mass peaks
at approximately age 30 years
in both men and women
• After reaching peak bone mass,
approximately 0.4% of bone
is lost per year in both sexes
• Women lose approximately
2% of cortical bone and
5% of trabecular bone per year
for the first 5–8 years after menopause
ACOG Practice Bulletin. 2004; NO. 50: 203-216
Osteoblast
Bone formation
Osteoclast
Bone resorption
Osteocyte
Osteoblast that
trap in matrix
OSTEOPOROTIC FRACTURE
Calcium deficiency
Hormone deficiency
Primary Vit D deficiency
Primary 1.25-(OH)2D3
deficiency / resistance
Parathyroid hyperplasia
(estrogen, testosterone,
1.25 (OH)2D3, GH, IGF)
Type I
Type II
Muscle strength 
Sense of balance 
Mental status 
Reflexes 
Mobility 
Secondary
hyperparathyroidism
Low bone mass

Tendency to fall
Bone strength
Fractures
Endocrine
-Cushing
-Thyroid/parathyroid
-hypogonadism
Drug
-glucocorticoid
-heparin, warfarin
-phenytoin, phenobarb
-CA drug
Type II
Systemic disease
-renal disease
-liver disease
-malabsorb
-rheumatoid
-CA
Scope
•Definition
•Pathogenesis
•Evaluate & Diagnosis
•Treatment
Risk factor
• Non modification
- Age > 65
- asian
- early menopause (< 45 year)
- small body built
- Hx fragility fracture
- Family Hx – osteoporosis/osteoporosis Fx
• Modification
- low intake calcium
- sedentary lifestyle
- smoking, alcohol, caffeine
- BMI < 19kg/m2
- estrogen deficiency
Evaluate
• Risk assessment of
osteoporosis fracture (FRAX)
• LAB
• Bone strength assessment
• Biochemical marker of
bone turnover
FRAX
Evaluate
• Risk assessment of
osteoporosis fracture (FRAX)
• LAB
• Bone strength assessment
• Biochemical marker of
bone turnover
LAB
• CBC
• Calcium, phosphate, albumin
• Liver function test
• Renal function
• X-ray – Lateral TL spine or AP hip
(suspected fracture)
Evaluate
• Risk assessment of
osteoporosis fracture (FRAX)
• LAB
• Bone strength assessment
• Biochemical marker of
bone turnover
Bone strength assessment
• Plain X-ray (BMD<30%)
• Semi-quantitative method
(high intra & inter observer)
• Bone mass measurement
-> axial dual energy X-ray
absorptiometry (axial DXA)
Bone mass measurement
• Indication
- Age > 65
- Age < 65 - early menopause
- estrogen deficiency > 1 yr
- on glucocorticoid
- BMI < 19 kg/m2
- parent hip Fx history
- X-ray find osteopenia/vertebral fracture
- fragility fracture
- decrease height
- screening -> high risk – OSTA score
0.2 X (BW – Age)
> -1  low risk
< -1 to > -4  moderate risk
< -4  high risk
Bone mass measurement
WHO Study Group. Osteoporos Int,1994;4:368-381.
Scope
•Definition
•Pathogenesis
•Evaluate & Diagnosis
•Treatment
Stategy
NORMAL
OSTEOPOROSIS
“Prevention”
FRACTURES
“Treatment”
MORTALITY
& MORBIDITY
“Surgery &
Rehabilitation”
Prevention
• Strategy to maximize peak bone mass
• Strategy to prevent bone loss
- weight bearing exercise
- life style modification
- nutrition
– Calcium
Daily intake of calcium.
Women < 50 years : 1,000 mg
Women > 50 years : > 1,200 mg
In dietary  ~ 500-600 mg. calcium/day
Calcium supplement
Divided dose, with meal,
and single dose< 1,000 mg
– Vitamin D (800 iu)
- prevent fall
Treatment
• Indication
- Primary indication
- Menopause – Fragility fracture (vertebrae or hip)
– BMD T score < -2.5
Treatment
• Indication
- Secondary indication
- BMD – 2.5 < T score < -1
with - major fragility Fx e.g. ankle, wrist, pelvis
- use glucocorticoid
- secondary osteoporosis e.g. thyrotoxicosis
- FRAX (no BMD)
10 yr probability of hip Fx > 3%
other Fx > 20%
- clinical risk factor
- parent Hx hip Fx
- Premature menopause
- smoking / alcohol
DRUG
• Hormonal
• Bisphosphonate
• Calcitonin
• Parathyroid hormone
• Strontium ranelate
• Vitamin K2
• New drug
Effects of Medication on Bone Remodeling
Inhibit bone resorption &
Stimulate
bone
formation
Strontium
ranelate
Vitamin k2
Inhibit
HRTbone resorption
Bisphosphonate
SERM
Calcitonin
StimulatePTH
bone formation
www.umich.edu/news/Release/2005/Feb05/bonehtml
DRUG
• Hormonal
• Bisphosphonate
• Calcitonin
• Parathyroid hormone
• Strontium ranelate
• Vitamin K2
• New drug
HRT
• Estrogen therapy (ET)
- prevention of bone loss and fractures in
postmenopausal women with or without
established osteoporosis
- FDA approved only for the prevention of
postmenopausal osteoporosis
- reduce vertebral and non vertebral
fracture
- effect are exerted through estrogen
receptors (present on monocyte lineage
and osteoblasts)
- anti bone resorption
THE END