Women's Health Medicine最新文献

Women and bone: self-appraisal

This contribution assesses who is at risk of osteoporosis, by delineating the key risk factors involved in the condition. Osteoporosis represents a major public health problem through its association with fragility fractures, primarily of the hip, spine and distal forearm. Some risk factors for fragility fracture act through bone mineral density (BMD), for example female gender, asian or Caucasian race, premature menopause, primary or secondary amenorrhoea, primary and secondary hypogonadism in men, prolongued immobilisation, low dietary calcium intake, vitamin D deficiency. However, a number of others contribute significantly to fracture risk over and above their association with BMD (age, high bone turnover, poor visual acuity, neuromuscular disorders, previous fragility fracture, glucocorticoid therapy, family history of hip fracture, low body weight, cigarette smoking, excess alcohol consumption).

Patient information

This contribution assesses the incidence, aetiology, classifications, diagnosis, intracapsular and extracapsular fractures, postoperative management and prognosis associated with fractures of the hip. A hip fracture or proximal femoral fracture refers to any fracture of the proximal femur down to a level of about five centimetres below the lower border of the lesser trochanter. Fractures of the femoral head involving the articular surface are, strictly speaking, included in this definition. A hip fracture is the most common reason for an elderly person to be admitted to an acute orthopaedic ward. There has been a continued increase in hip fractures in the last 50 years.

The aims of treatment of established osteoporosis are the alleviation of symptoms and reduction of the risk of further fractures. Currently available drugs are used to prevent further bone loss and can reduce the risk of further fractures by up to 50%. Drugs to increase bone mass inhibit bone resorption or stimulate bone formation. Most drugs approved for use in osteoporosis inhibit bone resorption, but some of these (e.g. hormone replacement therapy (HRT), bisphosphonates) increase BMD by 5–10% over the first 2 years of treatment. However, this contribution notes that drug treatments should be monitored by BMD, because some patients fail to respond to certain drugs. There is also evidence that the rate of bone loss is accelerated once treatment is stopped; it is therefore important to measure BMD or bone turnover markers after stopping treatment.

It is important to identify secondary causes of osteoporosis, as treatment often tends to partial recovery of bone mass. This short contribution offers two case studies. The first case study is a 62-year-old widow, who was a regular attender at her family practitioner's surgery, complaining of back pain and diarrhoea. The second case study is a 72-year-old white woman with a 20-year history of rheumatoid arthritis presenting with a 2-week history of mid-thoracic back pain of spontaneous onset. A discussion of the cases is reported, followed by a clinical diagnosis.

It is commonly believed that diet composition is important throughout life for optimizing bone health and reducing osteoporotic fracture risk. This contribution offers a critical overview of the main dietary components which are reported to be important. There is evidence to suggest that peak bone mass and later fracture risk are influenced by nutritional exposures in utero, in infancy and during childhood and adolescence. There are also particular concerns that individuals with a low calcium intake or vitamin D status may be at an increased risk, particularly at vulnerable periods during growth, and at times of high requirement (e.g. during pregnancy and lactation). Several other nutrients may play a key role in bone health, including vitamin K, phosphorus, potassium, magnesium, protein and sodium. In addition to specific nutrients, food groups (e.g. fruit and vegetables, pulses) may also have a positive effect on bone health.

Despite the high number of osteoporotic fractures sustained in the UK per annum there remains uncertainty in the cost associated with each fracture type, with literature estimates either conflicting, being non-existent or dated. With prescribing policies more frequently driven by health economic analyses errors in the estimated costs of fracture will lead to inefficient use of the healthcare budget. We present the estimated costs for each fracture type using a common methodology. UK data has been used wherever possible, however where this did not exist, or was inapplicable, data from Sweden was used as a proxy. Where both UK and Swedish data were available it was seen that in comparison costs are greater in the UK and thus our values are likely to be conservative. The average lengths of stay per fracture and cost per bed-day have been used to calculate the inpatient costs incurred by those admitted to hospital. Ratios of inpatient to out-patient costs from Sweden have been used to estimate the cost of out-patient care, which was also assumed equal to the costs incurred by patients with a clinical fracture where hospitalisation was not required. Whilst fractures at the hip, pelvis and other femoral sites incur the largest costs, it is seen that the costs of fractures at the tibia, fibula, spine, proximal humerus and humerus shaft are far from insignificant and should be included in all health-economic analyses of osteoporosis interventions.

Offering a patient's perspective, Julia Clough tells how she was finally diagnosed with PCOS in December 2001, aged 31. The diagnosis was a result of numerous visits to her GP regarding sleeplessness, anxiety and depression which she suffered for up to five days, every month or every other month. Julia had also put on approximately four stone in the previous four years with no apparent explanation. The scan confirmed Julia's GP's suspicions and PCOS was diagnosed. Julia followed her doctor's advice (based at the Endocrinology department at St Mary's Hospital) and managed to lose three stone, unfortunately some of that weight has crept back on but she is back losing weight again and exercises regularly. Julia's symptoms have improved through healthy eating, exercise and stress management. Julia has also found that sleeping tablets prescribed by the GP help with her insomnia which she now suffers very irregularly.

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