Postmenopausal Women

Hip Fracture Rates in Postmenopausal Women: Diabetes Sufferers Show Increased Risks

Although research has shown that type 1 (juvenile onset) diabetics have decreased bone mass compared to people without this disease, experts have not reached consensus regarding the effects of type 2 diabetes on bone mass.

Few studies have investigated this relationship in postmenopausal women, who are at the greatest risk for hip fractures.

This study investigated the relation between both types of diabetes to hip fractures in thousands of women. The investigators sent a mail survey to 99,609 women in Iowa, ages 55 to 69. The survey contained questions regarding diabetes status and risk factors. After 11 years, hip fracture incidents were recorded from a follow-up survey. Subjects were classified with type 1 diabetes if they developed it at age 30 or younger, and with type 2 diabetes if developed after age 30.

Results: Over 32,000 respondents were included in the analysis after ineligible surveys were excluded. Women with type 1 diabetes were 12.25 times more likely to suffer hip fracture than women without diabetes; type 2 diabetic women were 1.7 times more likely to experience hip fracture. Length of time since being diagnosed with type 2 diabetes, insulin use, and diabetes medication use were all positively associated with higher incidence rates. Women who initially did not have diabetes, but developed it over the 11 year time period, were 1.6 times more likely to develop a hip fracture than women who never had diabetes. 

Conclusion: The authors speculate that it is possible that hip fracture risks in diabetic women may be increased due to increased risk of falling, as opposed to reduced bone mass. These results should be considered when providing care to women with diabetes. 

TAKE NOTE: Hip fractures are disabling and have a great impact on the normal activities of patients, particularly older patients who do not heal quickly. Strategies to make patients� homes safer to prevent falls may be a good method to bring prevention into your practice.

Diabetes in Postmenopausal Women: Exercise May Lower Risk

The incidence of type II diabetes has risen substantially in the United States in recent years. Physical inactivity and obesity have been proposed as potentially modifiable risk factors for the disease, although few studies have investigated this relationship in a population of older women.

In January 1986, a questionnaire about diet and lifestyle was mailed to 99,826 postmenopausal women (55-69 years of age) as part of a study designed to evaluate the influence of physical activity on diabetes risk.

Subsequent questionnaires mailed, completed and returned over a 12-year period provided data on new diagnoses of diabetes during that time. A total of 41,836 women completed the questionnaire.

Greater leisure-time physical activity was associated with a reduced risk of type II diabetes. This association was stronger with increasing levels of activity, such that the most active women had approximately half the risk of acquiring diabetes as the least active women. Results were maintained after accounting for potential factors such as age, smoking status, alcohol intake, estrogen replacement therapy and family history of the disease. 

Conclusion: The authors suggest that "...physical activity is important for type II diabetes prevention among older women."

Hidden Vitamin D Deficiency and Fractures in Postmenopausal Women

Hip fractures, one of the most devastating and costly osteoporotic fractures, are said to be increasing worldwide. Vitamin D is associated with calcium absorption and normal bone mineralization, two factors known to prevent bone loss and reduce fracture risk.

While vitamin D can be found in many foods and is produced internally by exposure to sunlight, an alarming number of postmenopausal women present with occult vitamin D deficiency. This may be associated with the natural decrease in vitamin D intake and skin activation associated with aging, as well as reduced exposure to the sun. 

In a hospital setting, postmenopausal women were categorized into two groups in a study designed to evaluate this potential association between vitamin D intake and fracture rates. Women with hip fractures and scheduled for joint replacement comprised the first group; women without osteoporosis but admitted for elective joint replacement comprised the second group.

Results showed that 50% of the women admitted with acute hip fractures had vitamin D deficiency, as evidenced by low circulating calcium and phosphate levels. Overall, the women with hip fractures had lower levels than women admitted for elective joint replacement. These findings suggest that adequate vitamin D intake, by way of supplement, sun exposure and proper nutrition, may help reduce the risk of fractures in postmenopausal women.

Hormone Replacement Therapy: When Less Means More

Many women receive hormone replacement therapy (HRT) after menopause, when estrogen levels decline considerably. Maintaining adequate hormone levels can help prevent or delay osteoporosis, but the side effects associated with HRT suggest that modifications in this type of therapy may require consideration.

A study of 128 Caucasian women (> 65 years old) with low bone mass (defined as spinal bone mineral density of 0.90 g/cm2 or less) investigated whether low-level hormone replacement could reduce side effects while still positively influencing bone mass.

Women received either hormone replacement (in the form of estrogen and medroxprogesterone) or a placebo for 3.5 years, during which time bone mineral density (BMD) of the spine, hip, forearm and total body was measured at six-month intervals. Calcium and vitamin D supplements were also given to both groups during the study period.

Results: Bone mineral density of the spine, forearm and total body increased significantly in the HRT group compared to the placebo group. The symptoms normally related to HRT, such as weight gain, pelvic discomfort, breast tenderness, mood changes and spotting, were generally mild and short-lived, often disappearing within six months.

The authors conclude that "continuous low-dose HRT with conjugated equine estrogen and oral medroxyprogesterone, combined with adequate vitamin D and calcium, provides a bone-sparing effect that is similar or superior to that provided by other, higher-dose HRT regimens in elderly women. This combination is well-tolerated by most patients."

More Data on the Pathological Effects of Hormone Imbalance

Many women take hormone replacement following menopause to compensate for declining hormone levels. These decreased levels of sex hormones present in the blood may influence the risk of hip and vertebral fracture.

A study of 9,704 postmenopausal women (65 years of age and older) investigated this potential relationship by evaluating the effects of naturally occurring hormone levels on hip and vertebral fracture rates. Blood samples were drawn and stored, lateral x-rays of the thoracic and lumbar spine obtained, and bone mineral density of the heal measured by absorptiometry. Four-month mailings assessed health status and the occurrence of fractures.

Women age 65 and older with detectable estrogen serum levels had a 60% lower risk of hip fracture compared to women with low (undetectable) levels. For women with higher levels of sex hormone-binding globulin (a hormone that does not allow estrogen to function), the risk of fracture was even higher. 

A third category of women, those with very low estrogen levels and high levels of the hormone-binding globulin, had the highest rates of hip and vertebral fractures. Chiropractors should be mindful of the potential risks associated with declining sex hormones and discuss these risks with postmenopausal patients.