Menopause & Osteoporosis

Question 1

Definition of menopause?

Answer 1

No more menstrual periods for 1 year

Question 2

Common symptoms of menopause?

Answer 2

• vasomotor sx (VMS): hot flashes
• genitourinary syndrome of menopause (GSM): dryness, UI, UTI etc

Question 3

Types of HRT?

Answer 3

• estrogen only (for those without uterus)
• combi of estrogen & progesterone (for those with uterus): either both continuous or continuous (E) -cyclic (P)
• tibolone

Question 4

Will VSM and GSM improve over time?

Answer 4

VSM yes, GSM no

Question 5

Topical options for VMS?

Answer 5

• Premarin (estrogen) cream
• vagifem (estrogen) tablet for vaginal insert
• lubricants, moisturisers

Question 6

Possible supplements for menopause?

Answer 6

• isoflavones (soy)
• black cohosh
• evening primrose oil
• vitamin E

Question 7

Is progestin-only HRT recommended?

Answer 7

Possible but no long term studies

Question 8

Which progesterone is natural?

Answer 8

utrogestan (micronised progesterone)

Question 9

Advantage of systemic topicals compared to PO?

Answer 9

Bypass hepatic 1st pass effect

Question 10

Can tibolone be used in women with uterus? Need additional progesterone?

Answer 10

Yes, no need progesterone as tibolone sufficiently suppresses endometrial proliferation & estrogen activation

Question 11

Can tibolone protect against bone loss?

Answer 11

Yes

Question 12

Non-hormonal therapy for VMS?

Answer 12

• SSRI: paroxetine, escitalopram
• SNRI: venlafaxine
• gabapentin, pregabalin
• clonidine

Question 13

BMD t-score cut-offs?
- normal
- osteopenia
- osteoporosis

Answer 13

• normal: ≥-1
• osteopenia: -2.5<x<-1
• osteoporosis: ≤-2.5

Question 14

Pathophysiology of osteoporosis?

Answer 14

osteoclastic >osteoblastic

Question 15

How does menopause cause osteoporosis?

Answer 15

reduce estrogen -> more bone resorption, more Ca excretion

Question 16

Meds a/w osteoporosis?

Answer 16

glucocorticoids, PPI, immunosuppressants, ASM

Question 17

What tool to use to screen post-menopausal women for osteoporosis?

Scores for high, medium and low risk and follow-up actions?

Answer 17

osteoporosis self-assessment tool for asians
- low: <0, can defer DXA
- medium: 0-20, consider DXA if have other risk factors
- high: >20, consider DXA

Question 18

What height loss is considered a risk factor for osteoporosis?

Answer 18

> 2cm within 3y

Question 19

How to calculate 10 year probability of having fracture? What is the threshold for major osteoporotic fracture and hip fracture?

Answer 19

FRAX score

• major osteoporotic fracture ≥20%
• hip fracture ≥3%

Question 20

Vitamin D intake requirements for:
- 51-70y
- >70y

Answer 20

• 51-70y: 600 IU/day
• > 70y: 800 IU/day

Question 21

What Z-score suggests that osteoporosis is due to secondary causes?

Answer 21

≤ -2

Question 22

How to diagnose osteoporosis?

Answer 22

either one
- history of fragility fracture
- BMD measurement using DXA hip +/ spine (T score ≤ -2.5)

Question 23

When to start treatment for osteoporosis?

Answer 23

• fragility fracture
• no fragility fracture but BMD ≤ -2.5
• osteopenic with high fracture risk (FRAX ≥3% hip or ≥20% major osteoporotic fracture)

Question 24

Calcium intake requirements per day? Maximum calcium absorption per dose?

Answer 24

800-1000mg

Body can absorb 500mg max, give in divided doses if more than that per dose

Question 25

Nonpharm for osteoporosis?

Answer 25

- exercise (weight bearing, muscle strengthening) - smoking cessation - reduce alcohol, caffeine - eat more calcium rich foods - fall prevention

Question 26

Possible treatment options for osteoporosis?

Answer 26

antiresorptive - bisphosphonates - denosumab (RANK ligand inhibitor) - raloxifene (estrogen agonist/antagonist) - calcitonin anabolic - teriparatide (PTH analog) - romosozumab (sclerostin inhibitor)

Question 27

Calcium percentage content? - calcium carbonate - calcium citrate - calcium acetate

Answer 27

- calcium carbonate: 40% - calcium citrate: 21% - calcium acetate: 25%

Question 28

Is vitamin D water or fat soluble?

Answer 28

Fat soluble

Question 29

Available bisphosphonates and dose?

Answer 29

- alendronate (PO): 70mg Q1w or 10mg OD - risedronate (PO): 35mg Q1w or 150mg Q1m - zoledronic acid (IV): 5mg Q1y as 15min IV infusion

Question 30

Counselling points for PO bisphosphonates? (4)

Answer 30

- take on empty stomach with full glass of PLAIN water (no mineral water -> affect absorption) - wait ≥30min before taking food - space apart from other meds ≥2h - do not lie down after taking med, stay upright for ≥30min

Question 31

Duration of treatment for PO and IV bisphosphonates, and denosumab? Max duration?

Answer 31

PO: 5y (max 10y) IV: 3y (max 6y) Denosumab: up to 10y

Question 32

Rare but serious SE of bisphosphonates?

Answer 32

- atypical femoral fractures (thigh, groin) - osteonecrosis of the jaw

Question 33

CrCl cut off for bisphosphonates?

Answer 33

- <30 for risedronate - <35 for alendronate & zoledronic acid

Question 34

Common SE of bisphosphonates?

Answer 34

- GI: flatulence, heartburn, N/D, abd pain - HA, MSK pain, rash - hypoCa (transient) - IV: flu-like sx

Question 35

MOA of: - bisphosphonates - denosumab - raloxifene - calcitonin - romosozumab - PTH

Answer 35

- bisphosphonates: increase osteoclast death - denosumab: prevent osteoclast development (RANKL inhibitor) - raloxifene: selective estrogen receptor modulator (reduce resorption) - calcitonin: inhibit osteoclast activity - romosozumab: inhibit sclerostin -> anabolic & antiresorptive - PTH: stimulate osteoblast activity

Question 36

Dosing regimen of denosumab? What else should be given to patient while on denosumab?

Answer 36

SC 60mg Q6m, give Ca & vit D

Question 37

Difference between calcium carbonate and calcium citrate?

Answer 37

calcium carbonate must be taken with food, calcium citrate can be taken regardless of food