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Appendix 4 – Osteoporosis

View HRT Guidance Flow Chart

1. Definition

A disease process caused by low bone mass and deterioration of bone achitecture, leading to fragile bones and subsequent increase in fracture risk.

2. Assessment

Osteoporosis can only be accurately demonstrated by bone densitometry (T score less than 2.5). Routine X-rays cannot be used quantitatively.

3. Groups to consider for bone densitometry

High Risk Untreated menopause, premature menopause, steroid and immunosuppressive therapy, atraumatic fractures, family history (especially maternal), history of parental hip fracture, anorexia nervosa, height loss > 5cm, kyphosis, x-ray suspicion of osteoporosis.
Medium Risk Late puberty, prlonged amenorrhoea, liver disease, chronic bedrest, unexplained back pains, chronic arthritis, thyrotoxicosis, thyroxine replacement, coeliac disease/malabsoprtion.
Low Risk Family history of osteoporosis, smokers, alcohol >15 units/week), bone densitometry may help in the decision to prescribe HRT.

4. Treatments Division

See the WHO’s Fracture Risk Assessment Tool (FRAX).

First Choice = HRT in premature menopause patients without contraindications and women recently pre/post-menopausal, bisphosphonates equally effective for established disease.

If HRT is not suitable:

  • Bisphosphonates
  • Raloxifene
  • Denosumah
  • Stronium
  • Calcium + Vitatmin D (most suitable for older women)

Patients are never too old for treatment of osteoporosis.

5. Serum estradiol levels

Serum estradiol measurements are an unreliable guide to serum levels with oral therapy because of the first pass effect in the gut and liver. Estradiol values of 300-500pmol/ℓ are required for protection from osteoporosis. Lower values are adequate for the older women.

Exercise and general lifestyle measures are always important.