Osteoporosis

Women's Health Concern, the patient arm of the British Menopause Society, describes osteoporosis as a thin bone disease that makes bones more fragile and more likely to break. Doctors call the breaks it causes fragility fractures.

The NHS website says it usually causes no pain until a bone breaks, and that broken bones in the spine can lead to a stooped, bent-forward posture.

Bone health covers what happens to bone in the years around the menopause.

Women's Health Concern says the major loss of bone in women comes with the loss of estrogen at the menopause. The NHS website adds that women are at greater risk if the menopause comes early, before 45, or if their ovaries have been removed.

The Pakistan Menopause Society describes the first five or six years after the final period as a time of accelerated bone loss (1.2.7.1). The British Menopause Society adds that South Asian women whose periods stop before 40 may not seek help, which it links to a higher risk of osteoporosis later.

Other risks the NHS names include taking high-dose steroid tablets for more than three months, a family history of osteoporosis (particularly a parent who broke a hip), heavy drinking and smoking.

How doctors check:

• History. The PMS recommendations ask doctors to record past fractures, loss of height, falls, steroid use and a family history of osteoporosis (Table 2).
• A risk score. The NHS website names online tools such as FRAX, which the PMS recommendations use to sort women into low, high and very high risk (6.4).
• A scan. The NHS describes a bone density scan, often called a DEXA or DXA scan, as a short, painless test that measures bone strength. The PMS recommendations suggest one, where available, for women at high risk: after a fragility fracture, with premature or early menopause, after long courses of steroids, with repeated falls or marked height loss (Table 4). In Pakistan, "where available" matters: a scan is not on offer everywhere.

What protects bone, in brief: the PMS recommendations call weight-bearing exercise such as walking essential for bone health, and list strength training alongside it (Table 6). The Menopause Society adds two cautions: exercise cannot reverse osteoporosis, and women who have it, especially after a spine fracture, should avoid lifting or pulling while bending forward or twisting. To prevent falls it names balance, walking and strength exercise such as tai chi, and cutting down, with a doctor, on medicines that make falls more likely, such as some sleeping tablets. For vitamin D and calcium, see vitamin D and calcium.

There are two kinds of medicine.

HRT is one. NICE NG23's table of benefits and risks says "Fragility fracture risk is decreased while taking HRT", and that the benefit holds during treatment and fades once it stops. The PMS recommendations list keeping bones healthy among the main reasons for MHT, their word for HRT (5.1). They also say MHT should not be the first-line treatment or prevention for osteoporosis in women aged 60 and over.

Non-hormonal medicines are the other. The PMS recommendations name several classes, among them bisphosphonates and denosumab, which slow bone loss, and medicines that help build new bone. NICE's osteoporosis guideline, NG259, asks doctors to consider treatment for women past the menopause by fracture risk, for example after a hip or spine fracture or with low bone density (1.7.3). Which medicine, for how long, and whether it suits your kidneys and heart is your doctor's decision with you.

One safety point comes from both The Menopause Society and the European Menopause and Andropause Society (EMAS): denosumab should not be stopped or delayed without another medicine to follow it, because bone can be lost quickly once it stops.

Ask about your bones if you have broken a bone in a minor fall, if you have lost height or noticed your back curving, or if your periods stopped before 45. Do not let a first break pass as bad luck: The Menopause Society names a past fracture as one of the strongest signs of another, with the risk highest in the two years after it.

NICE NG23 asks doctors to discuss bone health at menopause review appointments. If nobody has raised it, you can.

The PMS recommendations name indoor lifestyle and purdah as reasons vitamin D matters so much in Pakistan (Table 5). Covering is a choice of faith, and nothing here asks you to change it. Do tell your doctor, though, because it changes which checks make sense.

A hip fracture in an older mother or grandmother often changes a whole household. If one happened in your family, mention it: family history is part of how risk is worked out.