Fracture Risk Linked to Pelvic Organ Prolapse : Collagen deficiencies may explain the presence of prolapse, bone fragility in postmenopausal women.


TORONTO — Women with pelvic organ prolapse may be at more risk for fracture, according to a new analysis of data from the Women's Health Initiative trial.

“As a clinician, if I see a woman who is early postmenopausal with moderate to severe prolapse, it would behoove me to get her bone density assessed to quantify her risk for fracture, because now I believe this woman is more likely to have some form of fragility phenomenon happening,” said principal investigator Dr. Lubna Pal of Albert Einstein College of Medicine, New York.

The study, which she presented as a poster at the annual meeting of the Society for Gynecologic Investigation, was based on the hypothesis that collagen deficiencies may be a unifying explanation for both pelvic organ prolapse (POP) and enhanced fracture risk in postmenopausal women, said Dr. Pal in an interview.

There is a high incidence of both prolapse and fractures in collagen-deficiency disorders such as Marfan syndrome and Ehlers-Danlos syndrome, she said. And the connection is biologically plausible, given that 90% of bone is collagen (thus making deficiency a risk factor for fracture) and that qualitative or quantitative deficiencies of tissue collagen may be more common in women with POP, than in women without.

The cross-sectional analysis included 11,096 postmenopausal women aged 60 years or more who were part of the entire WHI cohort. It found moderate to severe POP in 9% of the subjects and fragility fracture (fracture after age 55 years) in 19%. After adjusting for confounders including age, body mass index, age at menopause, history of osteoporosis, late menarche, hormone replacement and oral contraceptive use, family history of fractures, smoking, nulliparity, and white race, the researchers found a statistically significant association between POP and fracture risk.

Women reporting moderate to severe POP were significantly more likely to have reported ever breaking a bone, compared with women with absent or mild POP (45% vs. 41%), and were also more likely to have reported a fragility fracture (21% vs. 19%), although this association was not statistically significant.

When bone mineral density (BMD) was analyzed in this context, women with moderate to severe prolapse had significantly lower total body and total hip BMD, compared with women who had absent or mild POP. They also had lower lumbar spine BMD—although this difference did not reach significance.

“Maybe as clinicians we should be recognizing this association and focusing on bone health in women who demonstrate genital prolapse,” said Dr. Pal.

“We would first of all tell them they are at risk for fracture; [second,] identify any bone problems [that] are treatable; and [third,] try to optimize their bone collagen or protein content with calcium, vitamin D, weight-bearing exercise, and protein intake,” she suggested.

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