Clinical Evidence Concise

A Publication of BMJ Publishing Group

Fracture Prevention in Postmenopausal Women

Am Fam Physician. 2008 May 15;77(10):1447-1448.

This clinical content conforms to AAFP criteria for evidence-based continuing medical education (EB CME). See Clinical Quiz on page 1367.

The lifetime risk of fracture in white women is 20 percent for the spine, 15 percent for the wrist, and 18 percent for the hip; there is an exponential increase in risk after 50 years of age.

  • About 13 percent of persons die in the year after a hip fracture, and most survivors lose some or all of their previous independence.

Alendronate, risedronate, and parathyroid hormone reduce vertebral and nonvertebral fractures compared with placebo.

  • Etidronate, ibandronate, pamidronate, and raloxifene reduce vertebral fractures, but have not been shown to reduce nonvertebral fractures.

  • Raloxifene protects against breast cancer, but increases venous thromboembolic events and stroke compared with placebo.

  • Strontium ranelate reduces vertebral and, to some extent, nonvertebral fractures.

  • Calcitonin may reduce vertebral fractures over one to five years, but has not been shown to reduce nonvertebral fractures.

  • Clodronate has been shown in one large randomized controlled trial (RCT) to reduce nonvertebral, but not vertebral, fracture risk. One small RCT showed a decrease in vertebral, but not nonvertebral, fracture risk.

Caution: Hormone therapy may reduce fractures, but it increases the risk of breast cancer and cardiovascular events.

Combined calcium plus vitamin D, or vitamin D analogues alone, may reduce vertebral and nonvertebral fractures, but studies have had inconclusive results.

  • Monotherapy with calcium or vitamin D has not been shown to reduce fractures.

We do not know whether multifactorial nonpharmacologic interventions, including environmental manipulation or regular exercise, reduce the risk of fractures.

  • Hip protectors may reduce the risk of hip fractures in nursing home residents, but compliance tends to be low.

Clinical Question

What are the effects of treatments to prevent fractures in postmenopausal women?

Beneficial

Alendronate

Parathyroid hormone

Risedronate

Strontium ranelate

Likely to be beneficial

Calcitonin

Calcium plus vitamin D

Clodronate

Etidronate

Hip protectors

Ibandronate

Pamidronate

Vitamin D analogues (alfacalcidol or calcitriol)

Trade-off between benefits and harms

Raloxifene

Unknown effectiveness

Exercise

Multifactorial nonpharmacologic interventions

Unlikely to be beneficial

Calcium alone

Vitamin D alone

Likely to be ineffective or harmful

Hormone therapy

Clinical Question

View Table

Clinical Question

What are the effects of treatments to prevent fractures in postmenopausal women?

Beneficial

Alendronate

Parathyroid hormone

Risedronate

Strontium ranelate

Likely to be beneficial

Calcitonin

Calcium plus vitamin D

Clodronate

Etidronate

Hip protectors

Ibandronate

Pamidronate

Vitamin D analogues (alfacalcidol or calcitriol)

Trade-off between benefits and harms

Raloxifene

Unknown effectiveness

Exercise

Multifactorial nonpharmacologic interventions

Unlikely to be beneficial

Calcium alone

Vitamin D alone

Likely to be ineffective or harmful

Hormone therapy

Definition

This review covers interventions to prevent fractures in postmenopausal women. A fracture is a break or disruption of bone or cartilage that may be symptomatic or asymptomatic. Symptoms and signs may include immobility, pain, tenderness, numbness, bruising, joint deformity, joint swelling, limb deformity, and limb shortening.

Diagnosis. Fracture is usually diagnosed on the basis of a typical clinical picture combined with results from an appropriate imaging technique. Usually, in trials evaluating osteoporosis, menopause is considered to be present 12 months after the last menstruation.

Incidence

The lifetime risk of fracture in white women is 20 percent for the spine, 15 percent for the wrist, and 18 percent for the hip. The incidence of postmenopausal fracture increases with age. Observational studies found that age-specific incidence rates for postmenopausal fracture of the hip increased exponentially after 50 years of age. The incidence of fractures varies by ethnic group. The incidence of hip fractures is highest in white persons, and then decreases successively in Hispanic, Asian, and black persons.

Etiology and Risk Factors

A fracture arises when the load to the bone exceeds the bone biomechanical competence (strength). Fractures are usually caused by trauma, but may occur without an apparent injury. Risk factors are those factors that increase the risk of trauma and decrease bone biomechanical competence. An increased risk of trauma exists when the risk of falls is increased, such as in persons with impaired vision, decreased postural balance, or neurologic disorders (e.g., ataxia, stroke, epilepsy). Factors that decrease bone biomechanical competence, and therefore induce osteoporosis, include increasing age, low body mass index or weight, genetic predisposition, diseases (e.g., hyperthyroidism, hyperparathyroidism, rheumatoid arthritis), drugs (e.g., corticosteroids), and environmental factors (e.g., smoking). Postmenopausal women are at an increased risk of fracture compared with premenopausal women and men of all ages because of hormone-related bone loss.

Prognosis

Fractures may result in pain, short- or long-term disability, hemorrhage, thromboembolic disease (thromboembolism), shock, and death. Vertebral fractures are associated with pain, physical impairment, muscular atrophy, changes in body shape, loss of physical function, and a decreased quality of life. About 13 percent of persons die in the first year after a hip fracture, representing a doubling of mortality compared with persons of similar age and no hip fracture. One half of all older women who have previously been independent become partly dependent after hip fracture, and one third become totally dependent.

editor's note: Alfacalcidol, clodronate, and strontium ranelate are not available in the United States. Parathyroid hormone is available as teriparatide (Forteo) in the United States.

search date: January 2007

 

Author disclosure: Leif Mosekilde has received reimbursement from several pharmaceutical companies for attending conferences, fees for speaking, and a research grant from a private noncommercial foundation.

Peter Vestergaard has received reimbursement from several pharmaceutical companies for attending conferences, fees for speaking, and is the author of two references cited in the full review.

Bente Langdahl has received reimbursement from several pharmaceutical companies for attending conferences and fees for speaking and consulting.

Adapted with permission from Mosekilde L, Vestergaard P, Langdahl B. Fracture prevention in postmenopausal women. Clin Evid Handbook. December 2007:364–365. Please visit http://www.clinicalevidence.bmj.com for full text and references.

 

This is one in a series of chapters excerpted from the Clinical Evidence Handbook, published by the BMJ Publishing Group, London, U.K. The medical information contained herein is the most accurate available at the date of publication. More updated and comprehensive information on this topic may be available in future print editions of the Clinical Evidence Handbook, as well as online at http://www.clinicalevidence.bmj.com (subscription required). Those who receive a complimentary print copy of the Clinical Evidence Handbook from United Health Foundation can gain complimentary online access by registering on the Web site using the ISBN number of their book.


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