1. Osteoporosis Dr. Lauren Phillips Sugar Land Women’s Health

2. Osteoporosis- What is it? A common disorder resulting in low bone mass, skeletal fragility, and an increased risk of fracture A common disorder resulting in low bone mass, skeletal fragility, and an increased risk of fracture 15% of women over 50 have osteoporosis 15% of women over 50 have osteoporosis 1.3 million fractures per year in the US 1.3 million fractures per year in the US

3. Bone Remodeling Osteoblasts- bone forming cells Osteoblasts- bone forming cells Osteoclasts- bone destroying cells Osteoclasts- bone destroying cells These cells must cooperate to maintain adequate bone metabolism These cells must cooperate to maintain adequate bone metabolism Regulated by calcium, vitamin D, estrogen, calcitonin, PTH, and inflammatory markers called cytokines Regulated by calcium, vitamin D, estrogen, calcitonin, PTH, and inflammatory markers called cytokines

5. Who is at risk? Postmenopausal women Postmenopausal women Previous fracture Previous fracture Long-term steroid therapy Long-term steroid therapy Low body weight (less than 58 kg [127 lb]) Low body weight (less than 58 kg [127 lb]) Family history Family history Cigarette smoking Cigarette smoking Excess alcohol intake Excess alcohol intake Premature or surgical menopause, malabsorption, chronic liver disease, inflammatory bowel disease Premature or surgical menopause, malabsorption, chronic liver disease, inflammatory bowel disease Caucasian or Asian ethnicity Caucasian or Asian ethnicity

6. Screening for osteoporosis Bone density testing: Bone density testing: Dual energy x ray absorpiometry (DXA)- most useful and reliable test for measuring BMD (bone mineral density). It’s a special type of x ray that gives off little radiation. Dual energy x ray absorpiometry (DXA)- most useful and reliable test for measuring BMD (bone mineral density). It’s a special type of x ray that gives off little radiation.

7. Who should get screened? All women age greater than 65 All women age greater than 65 Postmenopausal women with one or more risk factors Postmenopausal women with one or more risk factors No consensus regarding frequency of screening; most practitioners make individual recommendations for patients based on age and risk factors No consensus regarding frequency of screening; most practitioners make individual recommendations for patients based on age and risk factors Typically every 2-5 years after menopause or yearly if severely osteopenic or osteoporotic Typically every 2-5 years after menopause or yearly if severely osteopenic or osteoporotic

8. Measuring bone mineral density T score: the standard deviation (SD) difference between a patient's BMD and that of a young-adult reference population T score: the standard deviation (SD) difference between a patient's BMD and that of a young-adult reference population Z score: a comparison of the patient's BMD to an age-matched population (less than -2.0 is abnormal) Z score: a comparison of the patient's BMD to an age-matched population (less than -2.0 is abnormal)

9. Diagnosing osteopenia and osteoporosis Measure T scores at spine and hip Measure T scores at spine and hip T score values: T score values: - +1 to -1: normal bone density - -1 to -2.5: osteopenia - -2.5 and lower: osteoporosis

10. Treatment All postmenopausal women with a history of vertebral or hip fracture All postmenopausal women with a history of vertebral or hip fracture Women with a T score of less than -2.5 (osteoporosis) Women with a T score of less than -2.5 (osteoporosis) T-score between -1.0 and -2.5 (osteopenia) with high risk of fracture such as glucocorticoid use or total immobilization. T-score between -1.0 and -2.5 (osteopenia) with high risk of fracture such as glucocorticoid use or total immobilization. Osteopenia plus a 10-year probability of hip fracture ≥3 % or a 10-year probability of any major osteoporosis-related fracture ≥20% based upon the WHO algorithm. Osteopenia plus a 10-year probability of hip fracture ≥3 % or a 10-year probability of any major osteoporosis-related fracture ≥20% based upon the WHO algorithm. www.shef.ac.uk/FRAX www.shef.ac.uk/FRAX

11. Non pharmacologic treatment Calcium and vitamin D intake: 1200 mg/ day calcium and 800 mg vit D per day Calcium and vitamin D intake: 1200 mg/ day calcium and 800 mg vit D per day Exercise: weight bearing exercise for at least 30 min 3 times a week. Exercise: weight bearing exercise for at least 30 min 3 times a week. Smoking cessation Smoking cessation

12. Non Pharmacalogic Therapy Osteostrong.me- a wellness center uses a BioDensity device to build bone mass and promote muscle growth Osteostrong.me- a wellness center uses a BioDensity device to build bone mass and promote muscle growth Weekly visits with improvement each week Weekly visits with improvement each week 4-7% increase in BMD after 12 months 4-7% increase in BMD after 12 months

13. Pharmacologic therapy Bisphosphates: Fosamax, Actonel (taken weekly) Boniva (taken monthly), Reclast (IV once yearly) Bisphosphates: Fosamax, Actonel (taken weekly) Boniva (taken monthly), Reclast (IV once yearly) Causes osteclasts to undergo apoptosis (cell death) Causes osteclasts to undergo apoptosis (cell death) First line therapy- can use safely 5-10 years First line therapy- can use safely 5-10 years Must take on empty stomach and stay sitting up for 30 min Must take on empty stomach and stay sitting up for 30 min Side effects typically mild and include GI upset, flu like symptoms Side effects typically mild and include GI upset, flu like symptoms Osteonecrosis of jaw approx 1/10,000 Osteonecrosis of jaw approx 1/10,000

14. Pharmacolgic therapy Raloxifene (Evista): a selective estrogen receptor modulator. Raloxifene (Evista): a selective estrogen receptor modulator. Increases estrogen absorption in the spine but not other organs. Also decreases risk of breast cancer and LDL cholesterol, but increases risk of DVT slightly Increases estrogen absorption in the spine but not other organs. Also decreases risk of breast cancer and LDL cholesterol, but increases risk of DVT slightly Not as efficatious as bisphosphonates or HRT. Not as efficatious as bisphosphonates or HRT. May increase hot flashes May increase hot flashes

15. Pharmacologic Therapy HRT- estrogen alone or estrogen plus progesterone HRT- estrogen alone or estrogen plus progesterone Effective Effective Due to WHI study in 2002, no longer used solely for the prevention or treatment of osteoporosis. Exceptions include women with persistent menopausal symptoms and those who cannot tolerate the other drugs. Due to WHI study in 2002, no longer used solely for the prevention or treatment of osteoporosis. Exceptions include women with persistent menopausal symptoms and those who cannot tolerate the other drugs.

16. Pharmacologic Therapy Prolia- stops the production of osteoclasts Prolia- stops the production of osteoclasts Injection twice a year Injection twice a year Not first line Not first line Side effects related to injection, hypocalcemia, infections Side effects related to injection, hypocalcemia, infections Not for people who have hypocalcemia, malabsorption, kidney problems, have had thyroid or parathyroid surgery Not for people who have hypocalcemia, malabsorption, kidney problems, have had thyroid or parathyroid surgery

17. Goals of Therapy Introduce/ continue healthy lifestyle habits Introduce/ continue healthy lifestyle habits Prevent fractures! Prevent fractures! Slow or stop progression of bone loss Slow or stop progression of bone loss Improve T scores Improve T scores Re-evaluate every 1-2 years Re-evaluate every 1-2 years

18. Contact information Dr. Lauren Phillips 17510 West Grand Parkway South Suite 430 Sugar Land, TX 77479 713-578-3823www.obgynassociates.comwww.mysugarlandobyn.com