Top 200: Osteoporosis, Menopause, Oral Contraceptives

Definition: “A skeletal disorder characterized by loss of bone tissue, deterioration of bone architecture, and increased bone fragility leading to increased risk of fractures.”

"Porous bone"

Often a silent disorder

Women 4 times more likely to have

Hips and spine of most concern

Associated with morbidity (disease rate) and mortality (death rate)

Most important risk factors for fractures are low bone mineral density, advanced age, and a history of adult fracture

Reduced quality of life

Chronic pain

Deformity

Disability

Deconditioning

Depression

Nursing Home placement

Death

Primary means there is no known cause.

• Disease related
• Medication induced

• age
• gender
• ethinicity

• White or Asian ethnicity
• Positive family history
• Female sex
• Advanced age
• Small body frame (<127 pounds)
• Smoking
• Inactivity or excessive exercise (need weight
• bearing)
• Excessive alcohol use
• Poor nutrition
• Low calcium and vitamin D intake
• Too much caffeine

• Consume a balanced diet
• Adequate calcium and vitamin D intake
• Avoid smoking
• Limit alcohol and caffeine intake
• Regular weight-bearing exercise
• Take measures to prevent falls
• Talk to your health care provider about bone health
• Have a bone density test and take medication when appropriate

• Skim milk
• Soy milk
• Yogurt
• Cheeses
• Broccoli
• Almonds
• Tofu
• Sardines with bones
• Canned salmon
• Orange juice

• calcium carbonate
• calcium citrate

• Fortified dairy products
• Fatty fish/fish oils
• Cereal

• Ergocalciferol (Vitamin D2)
• Cholecalciferol (Vitamin D3)

Prevent fractures by improving bone strength and reducing risk of falling and injury

Relieve symptoms of fractures and skeletal deformity

Maximize physical function

Bisphosphonates (first line)

SERM (selective estrogen receptor modulators) for POST menopausal women only!!

Monoclonal antibody (RANKL)

Prevention and treatment of osteoporosis

Inhibit osteoclast activity and reduce bone resorption and turnover

Doses vary

Long ½ life

Common side effects: Heartburn, indigestion, jaw bone pain

long half-life

• heartburn
• indigestion
• jaw bone pain

MUST follow proper administration technique

Take first thing in the morning

Take with a full glass of water

Nothing other than water should be taken within 30 minutes

Remain sitting up right or in a standing position for at least 30 minutes

Selective Estrogen Receptor Modulator

Raloxifene (Evista®)

Estrogen like activity on the bones

• Used for a variety of conditions:
• •Osteoporosis
• •Breast Cancer
• •Hormone Replacement Therapy

Common side effects: Hot flashes, night sweats, leg cramps, blood clots

• Calcitonin (Miacalcin®)
• non-FDA approved drugs for osteoporosis

• Indications:
• treatment of osteoporosis
• does not prevent fractures

Nasal spray: report significant nasal irritation immediately; possible anaphylactic shock because derived from salmon, an animal product

Denosumab (Prolia®)

Monoclonal antibody

Blocks osteoclast activation leading to decreased bone resorption

Used for treatment of osteoporosis in postmenopausal women

Twice yearly injection

Common side effects: Stomach upset, muscle pain, infection

Permanent cessation of menses due to the dysfunction of the ovaries

Occurs mainly between ages of 47-53

• Controversy on treatment: Studies differ
• •some show increased breast cancer risks , others show decreased breast cancer risks

• Hot flashes
• Night sweats
• Abnormal uterine bleeding
• Vaginal dryness
• Incontinence
• Sleep disturbances
• Mood changes
• Depression
• Sexual changes
• Problems with concentration
• Problems with Memory

Estrogen derivatives, such as:

• *Premarin® (Conjugated Estrogens)
• - Pregnant Mare Urine

Estrace ® (Estradiol)

Common side effects of estrogen derivatives:

• Vaginal bleeding
• venous thromboembolism
• stroke

In women with a uterus, unopposed estrogen increases risk of endometrial cancer

Estrogen derivatives are contraindicated in women with a history of breast cancer

• Prevent pregnancy
• Regulate menstrual cycles
• Treat acne

• Combined form of progestins and estrogens
• Prevents Ovulation (98-99%)
• Alters endometrium lining

Mostly considered safe (some debate)

No. Does not protect from HIV or other sexually transmitted diseases.

• Upset stomach
• Vomiting
• Stomach cramps/bloating
• Diarrhea /constipation
• Gingivitis (swelling of the gum tissue)
• ↑ or ↓appetite
• Weight gain/weight loss
• Brown or black skin patches
• Acne
• Unusual hair growth
• Intermittent bleeding/spotting
• Changes in menstrual flow
• Painful or missed periods
• Breast tenderness, enlargement, or discharge
• Swelling, redness, irritation, burning, or itching of the vagina
• White vaginal discharge

• Women with pre-existing cardiovascular
• disease or risk:

• DVT (deep vein thrombosis)
• Pulmonary embolism
• Stroke
• Myocardial Infarction (MI)

Higher estrogen containing pills may increase the risk of breast cancer

*Recall that breast cancer is fueled by estrogen!

• PCOS (Polycystic ovarian syndrome) treatment
• Endometriosis treatment
• Dysmenorrhea treatment
• Decreased ovarian cancer risk by 40%
• Decreased endometrial cancer risk by 50%
• Increased breast size (in some patients)

• Hormone imbalance leading to overproduction of follicles each month by the ovaries without producing an egg
• Irregular or no periods
• Depression
• Excessive weight gain
• Acne
• Abnormal hair growth
• Infertility
• Often temporary
• Usually goes hand-in-hand with insulin resistance
• Body begins to make more androgens

• 

• Affects 5.5 million women in North America
• Endometrial tissue develops outside the uterus (commonly in the lining of pelvis, ovaries, or uterus)
• Tissue implants → proliferates → thickens → sheds with each menstrual cycle
• Tissue becomes trapped → scar tissue formation

• pelvic pain
• infertility

LH peaks before ovulation.

Estrogen peaks at ovulation.

Ethinyl Estradiol

• Norgestimate
• Drospirenone
• Norelgestromin
• Norethindrone

• Yaz®, Yasmin® *Ocella® (Ethinyl Estradiol/Drosperinone)
• •Anti-mineralcorticoid activity
• •Avoid use in renal/adrenal insufficiency

*TriNessa®, Ortho® Tri-Cyclen® (Lo) (Ethinyl Estradiol/Norgestimate)

• *NuvaRing® (Ethinyl Estradiol/ Etonogestrel)
• •Inserted every 3 wks on day 1 of cycle
• •Use back up if removed > 3hrs

*Loestrin 24 FE®, Necon 7/7/7® (Ethinyl Estradiol/ Norethindrone)

• Triphasil®, Alesse®, Aviane®, Levlen®, Trivora®, Lybrel® etc. (Ethinyl Estradiol/ Levonorgestrel)
• •Menstrual frequency varies, must discuss when menses will begin

• Ortho-Evra® (Ethinyl Estradiol/ Norelgestromin)
• •Contains 60% more estrogen
• •Replace patch weekly
• •Not recommended in pts >90 kg

• Nausea
• breast tenderness
• increased blood pressure
• headache
• melasma (dark skin discoloration on sun-exposed areas of face)

• Early or mid-cycle breakthrough bleeding
• increased spotting
• hypomenorrhea (scanty periods)

• breast tenderness
• headache
• fatigue
• changes in mood

• increased appetite
• weight gain
• acne
• oily skin
• hirsutism
• increased LDL
• decreased HDL

Dosage is 1 tablet daily for 28 consecutive days.

Dose should be taken at the same time each day, either after the evening meal or at bedtime.

Dosing may be started on the first day of menstrual period (Day 1 starter) or on the first Sunday after the onset of the menstrual period (Sunday starter).

Day 1 starter: Dose starts on first day of menstrual cycle taking 1 tablet daily.

Sunday starter: Dose begins on first Sunday after onset of menstruation; if the menstrual period starts on Sunday, take first tablet that very same day. With a Sunday start, an additional method of contraception should be used until after the first 7 days of consecutive administration.

If all doses have been taken on schedule and one menstrual period is missed, continue dosing cycle.

If two consecutive menstrual periods are missed, pregnancy test is required before new dosing cycle is started.

If doses have been missed during the first 3 weeks (the non-sugar pills/non-period week) and the menstrual period is missed, pregnancy should be ruled out prior to continuing treatment.

Missed doses (monophasic formulations) (refer to package insert for complete information):

One dose missed:

Take as soon as remembered or take 2 tablets next day

Two consecutive doses missed in the first 2 weeks:

Take 2 tablets as soon as remembered or 2 tablets next 2 days.

An additional method of contraception should be used for 7 days after missed dose.

Two consecutive doses missed in week 3 or three consecutive doses missed at any time:

An additional method of contraception must be used for 7 days after a missed dose.

Day 1 starter: Current pack should be discarded, and a new pack should be started that same day.

Sunday starter: Continue dose of 1 tablet daily until Sunday, then discard the rest of the pack, and a new pack should be started that same day.

Any number of doses missed in week 4:

Continue taking one pill each day until pack is empty; no back-up method of contraception is needed

• Keep away from moisture (thus, bathroom not the best place)
• Keep away from excessive heat or light

Hormonal birth-control methods can cause spotting. Birth-control pill users can experience spotting if they miss a pill or if the hormone levels in their particular type of pill are not high enough.

Vaginal bleeding: Presentation of irregular, unresolving vaginal bleeding warrants further evaluation including endometrial sampling, if indicated, to rule out malignancy; evaluate hypothalamic-pituitary-function in women with persistent (≥6 months) amenorrhea (especially associated with breast secretion) following discontinuation of therapy.

You don't have to take the sugar pills, but they keep you in the habit of taking your medication every day.

You can also skip the sugar pills and go onto a new pack to completely skip your period. However, this should only be done under the direction of your physician because generally, it is healthy for your body to bleed at least three to four times a year.

One reason people don't skip the sugar pills and go through menstruation is as a confirmation that their birth control is indeed working. (ie, if you stop taking the pill, and you don't have your period, you may be pregnant) While this is not a foolproof way to confirm the efficacy of your birth control, it certainly is practical. (It's actually possible to have your period and still be pregnant, but this very rarely happens.)

It's important to know that you should only skip the inactive pills if you are taking monophasic birth control pills. (This just means that each of the pills that you're taking has an equal amount of the active ingredients in each of them. Some birth control pills work by increasing the estrogen week by week, so you shouldn't skip your period if you're on this type of pill.) Examples of monophasics include Alesse, Brevicon, Demulen, Desogen, Genora, Levlen, Levlite, Loestrin, Lo/Ovral, ModiCon, Necon, Nordette, Norethin, Norinyl, Ortho-Cyclen, Ortho-Novum, Ovcon, Ovral, Portia and Zovia.Check with your doctor to see how long you should/can skip inactive pills.

Some gynocologists recommend taking inactive pills once every 3-4 months (which means you'd have your "period" 3-4 times a year).