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Health issues are opposed by the main kind all over the world. The developed world however, seems to deal with the disease and disease related problems in a better planned manner than the less developed countries. Of course, a lot of it is to do with resource availability and technical capacity, but the general level of awareness, education and early diagnosis of the masses plays a significant role in confronting, containing and managing the health threats and risks. Quantification of disease burden caused by different risks and early diagnosis of disease informs prevention by providing an account of health loss different to that provided by a disease-by-disease analysis. One particular disease that needs to be examined and diagnosed in that perspective is the metabolic disease called Osteoporosis that is affecting many millions of people around the world. With aging the prevalence of osteoporosis is continuing to increase. Osteoporosis results in an increase in fractures leads to morbidity, mortality and decreased quality of life.
Osteoporosis, a multifactorial systemic skeletal disease, is considered by low bone mineral density (BMD) and micro-architectural worsening of bone tissue resulting in bone fragility (Sandhu & Hampson 2011).It is a systemic skeletal disorder categorized by decreased bone mineral density and a micro architectural worsening of one tissue, with a resulting increase in bone fragility and vulnerability to fracture (Gass &Dawson-Hughes, 2006).
World Health Organization (WHO) demarcated osteoporosis as the T-score of less or equal to -2.5 measured by DEXA (dual-energy x-ray absorptiometry) (Kanis, 199124; Shuler, Conjeski, Kendall, & Salava, 2012). It shows standard deviation of bone density from healthy 3O years old individual. The lower the score, the weaker bones are:
RELATIONSHIP OF OSTEOPOROSIS WITH MENOPAUSE
There is a direct relationship between the lack of oestrogen after menopause and the development of osteoporosis. After menopause, bone resumption (breakdown) overtakes the building of new bone. Early menopause (before age 40) and any long phases in which the woman has low hormone levels and no or uncommon menstrual periods can cause loss of bone mass. After menopause, with aging many factors cause low BMD. Low calcium is one of the reasons of rapid decrease in bone mass in females after menopause. So decreased calcium intake leads to demineralization and mobilization of calcium from bones which decreases bone mass and results in osteoporosis (Peacock, 1998).Older persons are particularly prone to decreased calcium intake and absorption. In females, estrogens indirectly stimulate calcium absorption from intestine and promote calcium re-absorption from the kidneys. Moreover, estrogens promote mineralization of bone. This is one of the reasons of rapid decrease in bone mass in females after menopause.
TYPES OF OSTEOPOROSIS
There are two main types of osteoporosis:
- Primary osteoporosis
- Secondary osteoporosis
- Idiopathic osteoporosis
Primary Osteoporosis
Primary osteoporosis occurs spontaneously. Secondary osteoporosis is caused by any other disease disorder or by a drug. Primary More than 95% of osteoporosis in women is primary, Most cases occur in postmenopausal wo men and in older men. Lack of oestrogen is the major cause of osteoporosis particularly the rapid decrease that occurs at menopause. So, low oestrogen levels are associated with osteoporosis in both men and women. Men over 50 have higher oestrogen levels than postmenopausal women, but these levels also decline with aging. Oestrogen deficiency increases bone breakdown and results in rapid bone loss and loss of bone is even greater if calcium intake or vitamin D levels are low. Calcium deficiency occurs due to low vitamin D levels and increased activity of the parathyroid glands causes the glands to release too much parathyroid hormone which can also stimulate bone breakdown. For unknown reasons, bone production also decreases. A number of other factors, such as certain drugs, tobacco use, heavy alcohol use, a family history of osteoporosis.
Risk factors for primary Osteoporosis
- Early menopause
- A diet with low Calcium and Vitamin D
- Family members with Osteoporosis
- Sedentary lifestyle
- Thin build
- Cigarette Smoking
- White or Asian race
- Excessive alcohol or caffeine consumption
Secondary Osteoporosis
As compared to primary osteoporosis, among osteoporotic patients, secondary osteoporosis occurs less than 5% in women and about 20% in men . Many medical conditions that may cause secondary osteoporosis are chronic kidney disease and hormonal disorders (especially Cushing disease, hyperparathyroidism, hyperthyroidism, hypogonadism, high levels of prolactin, and diabetes mellitus). multiple myeloma and many other chronic diseases such as rheumatoid arthritis. Many drugs may contribute to osteoporosis such as progesterone, corticosteroids, thyroid hormones, certain chemotherapy drugs, and antiseizure drugs and alcohol or caffeine consumption and cigarette smoking may contribute to osteoporosis.
Idiopathic Osteoporosis
A rare type of osteoporosis is idiopathic osteoporosis. idiopathic simply means that the cause is unknown. It occurs in Pre-menopausal women, in men under age 50, and in children and adolescents who have normal hormone levels, normal vitamin D levels, and no obvious reason to have weak bones.
DIAGNOSTIC METHODS OF OSTEOPOROSIS
When a symptomatic bone fracture results from low-intensity trauma then osteoporosis can be diagnosed on the basis of clinical history alone ( Kanis , Melton , Christiansen , Johnston & Khaltaev , 1994). But imaging tests are needed to identify a decrease in bone mineral density or for diagnosis of osteoporosis in some cases .For diagnosis of osteoporosis BMD is a standard measure. (Johnson & Dawson-Hughes, 1991). There are 2 methods for diagnosis of osteoporosis.
Ultrasonography
DEXA scan and ultrasonography are the tools for diagnosis of osteoporosis on the basis of BMD, In many studies significant correlations between BMD values for both techniques have been reported (Falcin, Bindi , Ermini, Galluzzi, Poggi,& Rossi, 2000; Massie , Reid & Porter, 1993). Worldwide, gold standard test for the diagnosis and quantification of osteoporosis is DEXA scan and is the most acceptable modality. In Kashmir it is not available and in Pakistan, it is expensive and not widely available. Hence population screening of all high-risk women is not possible in Pakistan. To predict osteoporosis in performance characteristics of BMD are at least as good as blood pressure to predict stroke (Genant, 1999). Major cause of fragility fractures in elderly population is low bone mass.
The standard diagnostic classification for osteoporosis is constructed on the T-score (according to WHO criteria), which is defined as the number of standard deviations from the young adult population-based reference value for peak BMD (Kanis ,2002; Kanis & Gluer , 2000). As described earlier the T-score represents the number of SD from normal young adult mean values and the Z-score represents the number of SD from the normal mean value for age-, sex- and gender-matched control subjects. For secondary osteoporosis low Z-score may be considered a cause. DEXA scan generally takes 10 to 20 minutes. It is on-invasive and painless procedure, and the amount of radiation patient get from the X-rays the scan uses is low. Unlike some other types of tests, like MRIs or CT scans, patient wont have to lie inside a closed tunnel or ring. Instead, patient will lie on an open X-ray table and try to stay still as the scanner passes over your body. When the test is over, patient will be able to go home.
MENO-PAUSE AND ITS IMPACT ON BONES
Increased risk of sudden and unexpected fractures is caused by osteoporosis, a silent disease that weakens bones. The disease habitually progresses without any symptoms or pain. Primary osteoporosis mainly occurs in women 1015 years after menopause and in elderly men around 7580 years old as BMD decreases with age. Normal menopause is at least 12 uninterrupted months of amenorrhea not due to physiologic and pathologic causes as defines by WHO. The mean age of natural menopause is 51 years in developed nations, compared to 48 years in poor and non-developed nations as shown in statistical data (Sapre & Thakur, 2014). In some countries menopause age is 45 years and in some countries of Asia mean age of menopause is 40 years. With the average life span protracted to 70 years, most women will spend more than one third of their life time beyond the menopausal changeover. Besides, the proportion of menopausal women is rising since the aging population is expanding rapidly. As a consequence, the menopausal women health becomes a leading concern worldwide. Menopause is a natural physiological phenomenon resulting from primary ovarian failure secondary to apoptosis or programmed cell death. Ovarian function decays with age. The beginning of menopause structures the decreasing production of estradiol, as well as increasing levels of follicle-stimulating hormone (FSH).
In menopausal women Osteoporosis is the most prevalent disease and is sturdily related with low quality of life and we concentrate on postmenopausal osteoporosis in this review. BMD decreases with age, thus primary osteoporosis mainly occurs in women 10 to 15 years after menopause and elderly men around 75 to 80 years old. With an intensifying aging population, osteoporosis and osteoporosis-related fractures are debauched becoming important public health issues that result in a considerable economic burden on health service resources.
Two phases of bone loss in women occurs. The first occurs predominantly in trabecular bone and starting at menopause and results from oestrogen deficiency and leads to a disproportionate increase in bone desorption as compared with formation. This phase is demarcated as menopause related loss of bone.. After 4 to 8 years, the second phase exhibits a persistent, slower loss of both trabecular and cortical bone, and is mainly attributed to reduced bone formation (Rogers, Saleh, Hannon, Greenfield & Eastell, 2002). This is age related bone loss, which is the only phase that also happens in men. During the menopausal transition period, the average reduction in BMD is about 10%. Approximately half of women are losing bone even more rapidly, perhaps as much as 10% to 20% in those 5 to 6 years around menopause.
IMPACT OF OESTROGEN ON BONES
About 25% of postmenopausal women can be classified as fast bone losers and they could be discovered by the measurement of bone loss and bone desorption markers (Garnero, Sornay-Rendu, Duboeuf & Delmas ,1999).Osteoporosis is a major cause of fracture in postmenopausal women. Nowadays, a large number of studies have proven that oestrogen is effective in the prevention of osteoporosis and hormone therapy can still be considered a first line choice for postmenopausal women.
From osteoporosis, globally 200 million women suffer resulting in pain, disability, costly rehabilitation, poor quality of life and premature death (Sultan, Khan, Mushtaq & Hassan, 2006). There is a direct relation of osteoporosis and post-menopausal women because the hormones levels are low and menstrual periods are absent can cause loss of bone mass. A decrease in bone density is directly related to low level of oestrogen that is a natural consequence of menopause. Because no oestrogen or very little is secreted by ovaries after menopause thats why the post-menopausal females are at a greater risk of developing Osteoporosis. This low oestrogen level in the body results in increased bone loss and frequency of osteoporosis increases with increasing age so osteoporosis is a major and growing public health problem in postmenopausal women (Spencer, 2007; Khawaja, Nasir & Mithani, 2006). The incidence of fractures due to osteoporosis increases exponentially with advancing age. Osteoporosis fractures are a major cause of morbidity and disability in older people and can lead to premature death. Such fractures impose a significant economic load on health services.
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