Strategies for the prevention and treatment of osteoporosis during early postmenopause
2006; Elsevier BV; Volume: 194; Issue: 2 Linguagem: Inglês
10.1016/j.ajog.2005.08.049
ISSN1097-6868
Autores Tópico(s)Vitamin D Research Studies
ResumoDuring the perimenopause, both the quantity and quality of bone decline rapidly, resulting in a dramatic increase in the risk of fracture in postmenopausal women. Although many factors are known to be associated with osteoporotic fractures, measures to identify and treat women at risk are underused in clinical practice. Consequently, osteoporosis is frequently not detected until a fracture occurs. Identification of postmenopausal women at high risk of fracture therefore is a priority and is especially important for women in early postmenopause who can benefit from early intervention to maintain or to increase bone mass and, thus, reduce the risk of fracture. Most authorities recommend risk-factor assessment for all postmenopausal women, followed by bone mineral density measurements for women at highest risk (ie, all women aged ≥65 years, postmenopausal women aged <65 years with ≥1 additional risk factors for osteoporosis, and postmenopausal women with fragility fractures). All postmenopausal women can benefit from nonpharmacologic interventions to reduce the risk of fracture, including a balanced diet with adequate intake of calcium and vitamin D, regular exercise, measures to prevent falls or to minimize their impact, smoking cessation, and moderation of alcohol intake. Several pharmacologic agents, including the bisphosphonates (eg, alendronate, risedronate, and ibandronate) and the selective estrogen receptor modulator, raloxifene, have been shown to increase bone mass, to reduce fracture risk, and to have acceptable side-effect profiles. Women who have discontinued hormone therapy are in particular need of monitoring for fracture risk, in light of the accelerated bone loss and increased risk of fracture that occurs after withdrawal of estrogen treatment. During the perimenopause, both the quantity and quality of bone decline rapidly, resulting in a dramatic increase in the risk of fracture in postmenopausal women. Although many factors are known to be associated with osteoporotic fractures, measures to identify and treat women at risk are underused in clinical practice. Consequently, osteoporosis is frequently not detected until a fracture occurs. Identification of postmenopausal women at high risk of fracture therefore is a priority and is especially important for women in early postmenopause who can benefit from early intervention to maintain or to increase bone mass and, thus, reduce the risk of fracture. Most authorities recommend risk-factor assessment for all postmenopausal women, followed by bone mineral density measurements for women at highest risk (ie, all women aged ≥65 years, postmenopausal women aged <65 years with ≥1 additional risk factors for osteoporosis, and postmenopausal women with fragility fractures). All postmenopausal women can benefit from nonpharmacologic interventions to reduce the risk of fracture, including a balanced diet with adequate intake of calcium and vitamin D, regular exercise, measures to prevent falls or to minimize their impact, smoking cessation, and moderation of alcohol intake. Several pharmacologic agents, including the bisphosphonates (eg, alendronate, risedronate, and ibandronate) and the selective estrogen receptor modulator, raloxifene, have been shown to increase bone mass, to reduce fracture risk, and to have acceptable side-effect profiles. Women who have discontinued hormone therapy are in particular need of monitoring for fracture risk, in light of the accelerated bone loss and increased risk of fracture that occurs after withdrawal of estrogen treatment. After peak bone mass is achieved during the third decade of life, bone architecture is maintained by a constant remodeling process. Osteoclasts attach to a specific area of bone, remove old bone (resorption pit), then osteoblasts move in and fill this pit with new bone. The balance between these processes shifts at menopause,1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar, 2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar, 3Brown J.P. Josse R.G. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. For the Scientific Advisory Council of the Osteoporosis Society of Canada.CMAJ. 2002; 167: S1-S34PubMed Google Scholar, 4US Preventive Services Task Force Screening for osteoporosis in postmenopausal women: recommendations and rationale.Ann Intern Med. 2002; 137: 526-528Crossref PubMed Scopus (292) Google Scholar and women typically undergo a rapid phase of bone loss that begins approximately 2 to 3 years before the cessation of menses and continues for up to 5 years postmenopause.5Eastell R. Pathogenesis of postmenopausal osteoporosis.in: Favus M.J. Primer on the metabolic bone diseases and disorders of mineral metabolism. 5th ed. American Society for Bone and Mineral Research, Washington (DC)2003: 314-316Google Scholar, 6Recker R. Lappe J. Davies K. Heaney R. Characterization of perimenopausal bone loss: a prospective study.J Bone Miner Res. 2000; 15: 1965-1973Crossref PubMed Scopus (264) Google Scholar, 7Abrahamsen B. Nissen N. Hermann A.P. Hansen B. Bärenholdt O. Vestergaard P. et al.When should densitometry be repeated in healthy peri- and postmenopausal women?: the Danish Osteoporosis Prevention Study.J Bone Miner Res. 2002; 17: 2061-2067Crossref PubMed Scopus (17) Google Scholar Although the decreased concentrations of circulating estrogen that characterize menopause and the rapid phase of bone loss are chiefly responsible for the process,5Eastell R. Pathogenesis of postmenopausal osteoporosis.in: Favus M.J. Primer on the metabolic bone diseases and disorders of mineral metabolism. 5th ed. American Society for Bone and Mineral Research, Washington (DC)2003: 314-316Google Scholar many other factors are associated with increased fracture risk.8Marshall D. Johnell O. Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures.BMJ. 1996; 312: 1254-1259Crossref PubMed Scopus (2928) Google Scholar These factors include prior fragility fracture, advanced age, a family history of osteoporotic fracture, and the use of certain medications.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar, 3Brown J.P. Josse R.G. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. For the Scientific Advisory Council of the Osteoporosis Society of Canada.CMAJ. 2002; 167: S1-S34PubMed Google Scholar Additional predictors of bone loss and fracture risk in early postmenopause include prolonged low vitamin D and calcium intake and low body weight.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar, 9Picard D. Imbach A. Couturier M. Lepage R. Ste Marie L.-G. Longitudinal study of bone density and its determinants in women in peri- or early menopause.Calcif Tissue Int. 2000; 67: 356-360Crossref PubMed Scopus (16) Google Scholar, 10Ravn P. Cizza G. Bjarnason N.H. Thompson D. Daley M. Wasnich R.D. et al.Low body mass index is an important risk factor for low bone mass and increased bone loss in early postmenopausal women. Early Postmenopausal Intervention Cohort (EPIC) study group.J Bone Miner Res. 1999; 14: 1622-1627Crossref PubMed Scopus (341) Google Scholar Osteoporotic fractures are preventable3Brown J.P. Josse R.G. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. For the Scientific Advisory Council of the Osteoporosis Society of Canada.CMAJ. 2002; 167: S1-S34PubMed Google Scholar; risk-factor assessment and methods to assess bone mass are available for the identification of women at risk, and management of osteoporosis is possible through pharmacologic and nonpharmacologic measures.11Genant H.K. Cooper C. Poor G. Reid I. Ehrlich G. Kanis J. et al.Interim report and recommendations of the World Health Organization task-force for osteoporosis.Osteoporos Int. 1999; 10: 259-264Crossref PubMed Scopus (601) Google Scholar Unfortunately, these measures are often underused, representing missed opportunities for prevention and treatment of osteoporosis.12Andrade S.E. Majumdar S.R. Chan K.A. Buist D.S. Go A.S. Goodman M. et al.Low frequency of treatment of osteoporosis among postmenopausal women following a fracture.Arch Intern Med. 2003; 163: 2052-2057Crossref PubMed Scopus (229) Google Scholar As a result, osteoporosis frequently is not detected until the patient presents with a fracture.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar Moreover, even those patients who do experience a fracture often do not receive subsequent treatment for osteoporosis, leaving them at high risk for future fractures.12Andrade S.E. Majumdar S.R. Chan K.A. Buist D.S. Go A.S. Goodman M. et al.Low frequency of treatment of osteoporosis among postmenopausal women following a fracture.Arch Intern Med. 2003; 163: 2052-2057Crossref PubMed Scopus (229) Google Scholar, 13Panneman M.J.M. Lips P. Sen S.S. Herings R.M.C. Undertreatment with anti-osteoporotic drugs after hospitalization for fracture.Osteoporos Int. 2004; 15: 120-124Crossref PubMed Scopus (128) Google Scholar There are many factors that contribute to the less than optimal identification and treatment of these patients; the difference between best practice and clinical practice with respect to the management of osteoporosis are diverse. Women at risk of osteoporotic fracture may fall into a health care gap between the obstetricians, gynecologists, internists, and others, who are in a position to detect and treat osteoporosis, thereby preventing fractures, and the orthopedists who are responsible for treating the fractures.12Andrade S.E. Majumdar S.R. Chan K.A. Buist D.S. Go A.S. Goodman M. et al.Low frequency of treatment of osteoporosis among postmenopausal women following a fracture.Arch Intern Med. 2003; 163: 2052-2057Crossref PubMed Scopus (229) Google Scholar, 14Freedman K.B. Kaplan F.S. Bilker W.B. Strom B.L. Lowe R.A. Treatment of osteoporosis: are physicians missing an opportunity?.J Bone Joint Surg Am. 2000; 82: 1063-1070PubMed Google Scholar, 15Simonelli C. Killeen K. Mehle S. Swanson L. Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons.Mayo Clin Proc. 2002; 77: 334-338Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar Alternatively, some women may fall victim to the failure of health care providers to initiate or alter intervention strategies, despite changes in the patient's health status that would seemingly justify such action.12Andrade S.E. Majumdar S.R. Chan K.A. Buist D.S. Go A.S. Goodman M. et al.Low frequency of treatment of osteoporosis among postmenopausal women following a fracture.Arch Intern Med. 2003; 163: 2052-2057Crossref PubMed Scopus (229) Google Scholar To prevent the progression of osteoporosis and the occurrence and recurrence of fracture in postmenopausal women, primary health care providers must recognize osteoporosis as a risk factor for fracture, just as hypertension is a risk factor for stroke1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar and accordingly intervene as early as possible to maximize the retention and the enhancement of bone mass and the structural integrity of the skeleton.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar, 3Brown J.P. Josse R.G. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. For the Scientific Advisory Council of the Osteoporosis Society of Canada.CMAJ. 2002; 167: S1-S34PubMed Google Scholar This article will review current strategies for the prevention and treatment of bone loss during perimenopause and early postmenopause to reduce the risk of osteoporotic fracture. Most authorities recommend risk-factor assessment for all postmenopausal women, followed by bone mineral density (BMD) testing for those women at highest risk for osteopenia, osteoporosis, and fractures.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar, 2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar, 3Brown J.P. Josse R.G. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. For the Scientific Advisory Council of the Osteoporosis Society of Canada.CMAJ. 2002; 167: S1-S34PubMed Google Scholar, 4US Preventive Services Task Force Screening for osteoporosis in postmenopausal women: recommendations and rationale.Ann Intern Med. 2002; 137: 526-528Crossref PubMed Scopus (292) Google Scholar The National Osteoporosis Foundation (NOF) recommends that the following women undergo BMD testing:•All women aged 65 years or older, regardless of other risk factors for osteoporosis;•Postmenopausal women younger than 65 years with 1 or more risk factors for osteoporosis (other than being white, postmenopausal, and female); and•All postmenopausal women who have had a fragility fracture.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar The recommendations of the North American Menopause Society (NAMS), the American Association of Clinical Endocrinologists (AACE), and the American College of Obstetricians and Gynecologists (ACOG) regarding BMD measurements generally parallel those of the NOF.2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar, 3Brown J.P. Josse R.G. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. For the Scientific Advisory Council of the Osteoporosis Society of Canada.CMAJ. 2002; 167: S1-S34PubMed Google Scholar, 16American College of Obstetricians and Gynecologists Clinical management guidelines for obstetrician-gynecologists, ACOG practice bulletin 50.Obstet Gynecol. 2004; 103: 203-216PubMed Google Scholar, 17AACE Guidelines American Association of Clinical Endocrinologists (AACE) medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003.Endocr Pract. 2003; 9: 544-564Crossref PubMed Scopus (360) Google Scholar Two different scoring methods—the T-score and the Z-score—are commonly used by device manufacturers in scoring dual-energy x-ray absorptiometry (DXA) scans, both of which compare a woman's BMD value with the average value expected based on population norms, to gauge the presence or absence of osteoporosis and to determine the risk for fracture. The T-score quantifies the difference between an individual's BMD value and the norm for "young normal" adults of the same sex and ethnicity at peak bone mass. This difference is expressed as standard deviations (SDs) above or below the mean. A postmenopausal woman is considered to have a normal BMD value if her T-score is −1.0 or above (no lower than 1.0 SD below the BMD norm for "young normal" women). A diagnosis of low bone mass, or osteopenia, is assigned to women whose T-scores fall between −1.0 and −2.5 SDs (between 1.0 and 2.5 SDs below that of "young normal" women). A woman is diagnosed with osteoporosis if her T-score is −2.5 or lower (at least 2.5 SDs lower than the norm for "young normal" women).18World Health Organization Study Group Assessment of fracture risk and its application to screening for postmenopausal osteoporosis.World Health Organ Tech Rep Ser. 1994; 843: 1-129PubMed Google Scholar The Z-score quantifies the difference between an individual's BMD value and the norm for sex- and age-matched people.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar It should not be used for the diagnosis of postmenopausal osteoporosis but may be appropriate for determining whether additional screening is necessary for secondary osteoporosis.19Lindsay R. Cosman F. Osteoporosis.in: Braunwald E. Fauci A.S. Kasper D.L. Hauser S.L. Longo D.L. Jameson J.L. Harrison's Principles of Internal Medicine. 15th ed. McGraw-Hill, New York2001: 2226-2237Google Scholar All women, regardless of menopausal status, should be made aware of their risk of osteoporosis and of ways in which they can reduce their risk of bone loss and fracture. Communicating the value of bone health to minimize fracture risk may motivate patients to make and maintain lifestyle changes. Clinicians should discuss, in appropriate detail, the range of nonpharmacologic approaches to maintain bone health and to prevent osteoporotic fracture with their patients (Table I). Ideally, the clinician's involvement at this important stage of a woman's life will motivate her to make and sustain lifestyle changes relating to diet, exercise, tobacco and alcohol use, and approaches to fall prevention.Table IRecommended nonpharmacologic interventions for the prevention of osteoporotic fracture1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar, 2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar, 21Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board Institute of Medicine Calcium and related nutrients: overview and methods.in: Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. National Academy Press, Washington (DC)2003: 38-53Google ScholarInterventionObjectiveBalanced diet including adequate protein, calcium 1200 mg/d, and vitamin D 400-600 IU/dSupport bone health, provide substrateExerciseSupports bone formationWeight-bearing∗Non–weight-bearing exercise (eg, swimming) is of unknown benefit. activitiesReduce risk of falls via improved gaitMuscle-strengthening activitiesSmoking cessationEliminate detrimental effects on BMDReduction of excessive alcohol intakeEliminate detrimental effects on BMDReduce risk of fallsVision correctionReduce risk of falls via improved visual perception of hazardsHousehold/workplace managementReduce risk of falls via elimination of tripping hazardsMedication review to identify current medications that may be associated with dizziness or balance problemsReduce risk of falls∗ Non–weight-bearing exercise (eg, swimming) is of unknown benefit. Open table in a new tab Probably the easiest, least costly, and safest lifestyle modification to achieve is adequate intake of calcium and vitamin D.1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar, 2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar Although dietary sources of these nutrients are optimal,1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar supplements should be used if diet alone cannot provide the recommended daily intake. The NOF recommends at least 1200 mg of dietary calcium and 400 to 800 IU of vitamin D each day,1National Osteoporosis Foundation Physician's guide to prevention and treatment of osteoporosis. National Osteoporosis Foundation, Washington (DC)2003Google Scholar based on levels of intake demonstrated in clinical trials to preserve calcium in the skeleton.20Dawson-Hughes B. Vitamin D and calcium: recommended intake for bone health.Osteoporos Int. 1998; 8: S30-S34Crossref PubMed Google Scholar Similarly, the National Academy of Sciences considers 1200 mg of calcium and 400 to 600 IU of vitamin D as adequate daily intakes of these nutrients for women aged 51 years or older.21Standing Committee on the Scientific Evaluation of Dietary Reference Intakes Food and Nutrition Board Institute of Medicine Calcium and related nutrients: overview and methods.in: Dietary reference intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. National Academy Press, Washington (DC)2003: 38-53Google Scholar All postmenopausal women should be counseled regarding the benefits of regular physical exercise to achieve several objectives, including maintenance of muscle and bone strength through adulthood, reduction in the risk of fragility fractures, promotion of overall fitness, and improvement of quality of life.22South-Paul J.E. Osteoporosis: part II, nonpharmacologic and pharmacologic treatment.Am Fam Physician. 2001; 63: 1121-1128PubMed Google Scholar, 23Sinaki M. Nonpharmacologic interventions: exercise, fall prevention, and role of physical medicine.Clin Geriatr Med. 2003; 19: 337-359Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar, 24Lloyd T. Beck T.J. Lin H.-M. Tulchinsky M. Eggli D.F. Oreskovic T.L. et al.Modifiable determinants of bone status in young women.Bone. 2002; 30: 416-421Abstract Full Text Full Text PDF PubMed Scopus (52) Google Scholar The skeletal benefits of weight-bearing exercise have been well documented in a multitude of randomized controlled trials.25Ernst E. Exercise for female osteoporosis: a systematic review of randomised clinical trials.Sports Med. 1998; 25: 359-368Crossref PubMed Scopus (71) Google Scholar, 26Feskanich D. Willett W. Colditz G. Walking and leisure-time activity and risk of hip fracture in postmenopausal women.JAMA. 2002; 288: 2300-2306Crossref PubMed Scopus (367) Google Scholar, 27Kemmler W. Engelke K. Lauber D. Weineck J. Hensen J. Kalender W.A. Exercise effects on fitness and bone mineral density in early postmenopausal women: 1-year EFOPS results.Med Sci Sports Exerc. 2002; 34: 2115-2123Crossref PubMed Scopus (92) Google Scholar For example, the results of a prospective cohort study of more than 60,000 postmenopausal women (aged 40-77 years) showed that women who engaged in walking and other leisure-time activities were 55% less likely to suffer a hip fracture than sedentary women.26Feskanich D. Willett W. Colditz G. Walking and leisure-time activity and risk of hip fracture in postmenopausal women.JAMA. 2002; 288: 2300-2306Crossref PubMed Scopus (367) Google Scholar In addition, The Erlangen Fitness Osteoporosis Prevention Study showed that aerobic, weight-bearing, strength training, and stretching exercises increased lumbar spine BMD by 1.3% over 14 months in postmenopausal women (up to 8 years postmenopause) who were receiving calcium and vitamin D supplementation compared with a 1.2% decrease in the control group.27Kemmler W. Engelke K. Lauber D. Weineck J. Hensen J. Kalender W.A. Exercise effects on fitness and bone mineral density in early postmenopausal women: 1-year EFOPS results.Med Sci Sports Exerc. 2002; 34: 2115-2123Crossref PubMed Scopus (92) Google Scholar After 26 months, lumbar spine BMD was still higher in the exercise group (+0.7%) compared with an even further decrease in the control group (−2.3%).28Kemmler W. Lauber D. Weineck J. Hensen J. Kalender W. Engelke K. Benefits of 2 years of intense exercise on bone density, physical fitness, and blood lipids in early postmenopausal osteopenic women: results of the Erlangen Fitness Osteoporosis Prevention Study (EFOPS).Arch Intern Med. 2004; 164: 1084-1091Crossref PubMed Scopus (221) Google Scholar Although any increase in physical activity may be an improvement for currently sedentary women, the average older woman is not likely to exercise to the level needed to actually build bone. However, exercise is critical to strengthen muscles, improve balance, prevent falls, and a weekly exercise program ideally should incorporate at least 3 sessions lasting from 30 to 60 minutes each. The relationship between exercise and hormone therapy (HT) on BMD in younger postmenopausal women was recently evaluated in the Bone, Estrogen, and Strength Training study.29Going S. Lohman T. Houtkooper L. Metcalfe L. Flint-Wagner H. Blew R. et al.Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy.Osteoporos Int. 2003; 14: 637-643Crossref PubMed Scopus (120) Google Scholar In this 12-month study, 320 women, who were 3 to 11 years postmenopausal (surgical or natural) and who were, on average, aged 56 years, were prospectively randomized within groups (HT or no HT) to participate in a supervised weight-bearing, weight-lifting program, or to continue their current level of physical activity.29Going S. Lohman T. Houtkooper L. Metcalfe L. Flint-Wagner H. Blew R. et al.Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy.Osteoporos Int. 2003; 14: 637-643Crossref PubMed Scopus (120) Google Scholar All women received calcium citrate 800 mg/d.29Going S. Lohman T. Houtkooper L. Metcalfe L. Flint-Wagner H. Blew R. et al.Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy.Osteoporos Int. 2003; 14: 637-643Crossref PubMed Scopus (120) Google Scholar After 12 months, women who exercised experienced significant (P < .01) mean increases in trochanter BMD (1.2%-2.1%) regardless of HT use, whereas women who received HT experienced significant (P < .01) increases in BMD at the lumbar spine (0.7%-0.8%) and total body (0.4%) regardless of exercise status.29Going S. Lohman T. Houtkooper L. Metcalfe L. Flint-Wagner H. Blew R. et al.Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy.Osteoporos Int. 2003; 14: 637-643Crossref PubMed Scopus (120) Google Scholar Women who neither exercised nor received HT generally lost BMD at all sites evaluated.29Going S. Lohman T. Houtkooper L. Metcalfe L. Flint-Wagner H. Blew R. et al.Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy.Osteoporos Int. 2003; 14: 637-643Crossref PubMed Scopus (120) Google Scholar Overall, these results suggest independent benefits of exercise and HT in early postmenopausal women receiving adequate calcium.29Going S. Lohman T. Houtkooper L. Metcalfe L. Flint-Wagner H. Blew R. et al.Effects of exercise on bone mineral density in calcium-replete postmenopausal women with and without hormone replacement therapy.Osteoporos Int. 2003; 14: 637-643Crossref PubMed Scopus (120) Google Scholar Although younger postmenopausal women are at lower risk for falls and fall-related fracture than older postmenopausal women, fall prevention is an important consideration for all postmenopausal women. Therefore, NAMS recommends annual evaluation of a woman's risk for falls.2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar Several factors are correlated with increased fall risk, including poor vision, muscle weakness or poor muscle coordination, dizziness, balance problems, and a personal history of falls, fainting, or loss of consciousness.2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar Vitamin D deficiency, a common feature in postmenopausal women, is associated with increased body sway and a consequent increased risk of falls and fall-related fractures.30Pfeifer M. Begerow B. Minne H.W. Schlotthauer T. Pospeschill M. Scholz M. et al.Vitamin D status, trunk muscle strength, body sway, falls, and fractures among 237 postmenopausal women with osteoporosis.Exp Clin Endocrinol Diabetes. 2001; 109: 87-92Crossref PubMed Scopus (188) Google Scholar Supplementation with vitamin D and calcium has been shown to reduce the risk of falling in elderly women (aged 85.3 years), possibly via improved musculoskeletal function.31Bischoff H.A. Stahelin H.B. Dick W. Akos R. Knecht M. Salis C. et al.Effects of vitamin D and calcium supplementation on falls: a randomized controlled trial.J Bone Miner Res. 2003; 18: 343-351Crossref PubMed Scopus (777) Google Scholar The use of a wide variety of medications, including sedatives, narcotic analgesics, antidepressants, anticholinergics, and antihypertensive agents, should be viewed as an additional risk factor for falls.2North American Menopause Society Management of postmenopausal osteoporosis: position statement of the North American Menopause Society.Menopause. 2002; 9: 84-101PubMed Google Scholar In addition, safety hazards in the
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