UPDATE: MENOPAUSE
We’re learning more about the long-term risks and benefits of hormone therapy, how to assess and treat osteoporosis, and the need for vitamin D
IN THIS ARTICLE
This updated guidance from NAMS emphasizes that BMD need not be assessed in women younger than 65 years unless they have specific risk factors. FRAX evaluation also makes it possible to estimate the 10-year risk of fracture in women who have low bone mass but who do not meet criteria for osteoporosis. FRAX evaluation indicates that prescription therapy is rarely required for women in their 50s or 60s who have low bone mass (but not osteoporosis). For women in their 70s or 80s who have low bone mass (but not osteoporosis), however, FRAX evaluation often leads to a recommendation to initiate prescription antifracture treatment.
Many postmenopausal women who are in their 50s or 60s and who have T-scores of –1.0 to –2.5 are given bisphosphonates, despite being at low risk of fracture. Adherence to the NAMS guidelines will help prevent unnecessary assessment and treatment. In particular, the NAMS recommendations for follow-up BMD assessment—i.e., one-time evaluation 1 to 2 years after initiating therapy and no further assessment in women found to have stable BMD at the first follow-up DXA—should simplify clinical management in this setting.
Hold off on ordering DXA testing until women meet criteria for BMD assessment. In women who do not have osteoporosis, limit use of bisphosphonates to those who have an elevated 10-year risk of fracture, as assessed using the FRAX tool.
Our menopausal patients should be taking more vitamin D supplements
Bischoff-Ferrari H. Vitamin D: what is an adequate vitamin D level and how much supplementation is necessary? Best Pract Res Clin Rheumatol. 2009;23(6):789.
Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, et al. Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ. 2009;339:b3692.
Stewart JW, Alekel DL, Ritland LM, et al. Serum 25-hydroxyvitamin D is related to indicators of overall physical fitness in healthy postmenopausal women. Menopause. 2009;16(6):1093–1101.
Office of Dietary Supplements. Dietary Supplement Fact Sheet: Vitamin D. National Institutes of Health Web site. https://dietary-supplements.info.nih.gov/factsheets/vitamind.asp. Updated November 13, 2009. Accessed April 2, 2010.
We have long recognized the important role vitamin D plays in promoting calcium absorption from the gut and maintaining adequate serum calcium and phosphate concentrations to enable normal bone mineralization. Now, studies reveal that the vitamin also helps prevent falls and promotes overall fitness in menopausal women. It has also become clear that traditional targets for vitamin D supplementation are inadequate.
Two recent meta-analyses of double-blind, randomized trials concluded that vitamin D reduces the risk of falls in a dose-dependent manner. Dr. Heike Bischoff-Ferrari, a Swiss scientist and a leading vitamin D researcher, points out that 1) a minimum of 700 to 1,000 IU of vitamin D supplementation daily is appropriate in menopausal women and 2) a higher amount is indicated for those who are obese or deficient in vitamin D.
Compare the current recommended dietary allowance (RDA) for adults 51 to 70 years old: 400 IU daily. The federal Food and Nutrition Board is expected to update the vitamin D RDA this spring. The 2010 NAMS statement on osteoporosis recommends a daily vitamin D intake of 800 to 1,000 IU for menopausal women.
Ask your patient to add up the aggregate daily amount of vitamin D she ingests with her multivitamin and calcium and vitamin D supplements. If it is less than 800 IU, have her purchase over-the-counter vitamin D supplements (available in 400, 1,000, and 2,000 IU capsules). Obese patients and those known to be deficient may need to ingest higher daily amounts of vitamin D.
