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You are here: Home / Articles / Premenopausal Osteoporosis Poses Special Clinical Challenges

Premenopausal Osteoporosis Poses Special Clinical Challenges

March 12, 2020 • By Thomas R. Collins

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A woman being examined for bone density.

A woman being examined for bone density.
GagliardiPhotography / shutterstock.com

ATLANTA—Osteoporosis in premenopausal women is uncommon compared with its frequency in post-menopausal women, but when it is suspected, it poses some difficult questions for clinicians: How should it be diagnosed in this understudied population? If found, should it be treated—and how?

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Elizabeth Shane, MD, professor of medicine at Columbia University and attending physician at New York-Presbyterian/Columbia University Medical Center, who gave the Oscar S. Gluck, MD, Memorial Lecture at the 2019 ACR/ARP Annual Meeting, said that although the data for osteoporosis in premenopausal women are limited, important points can help guide its assessment and management.

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Limits of Bone Density Scores

She cautioned against an overreliance on bone density scores in premenopausal women in their diagnosis.

In women younger than 50 a low bone mineral density (BMD) score could be due to a low peak bone mass or just due to a small stature, Dr. Shane said, and is not necessarily a sign of a problem requiring medical intervention. “It may be that this person just comes from a family with low bone density.”

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And a low BMD in women younger than 50 doesn’t carry the same risk of fracture; young women have more muscle mass than older women and fewer falls, for example.

Dr. Shane

Dr. Shane

What’s more, BMD score cut-off points for a diagnosis of normal bone mass, low bone mass and osteoporosis in post-
menopausal women were “never intended and shouldn’t be used” for diagnosis of premenopausal women, Dr. Shane said.

The International Society for Clinical Densitometry (ISCD) recommends that Z scores, which compare a patient’s bone density to that of a person of the same age and gender, be used in the assessment of premenopausal women instead of T scores, which compare a patient’s bone density to an average 30-year-old adult.

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The ISCD recommendations for diagnosis of osteoporosis in premenopausal women are a BMD Z score of -2.0 or less plus a secondary cause of osteoporosis, or a history of vertebral or non-vertebral low-trauma fractures at a major site, whether or not the BMD is low.

Secondary Causes

The goal of an evaluation in this population is to identify secondary causes of osteo­porosis, particularly causes that are treatable.

“In my opinion, anybody who has a low T or Z score deserves an evaluation to make sure that there’s nothing going on that could be rectified, and perhaps improve their bone density by a targeted inter­vention,” Dr. Shane said. “If I see one hip fracture, that’s it for me.”

Common causes of osteoporosis in premenopausal woman include excessive gluco­corticoid use, premenopausal estrogen deficiency, gastrointestinal disease and effects of other medications, such as anti-epileptic drugs. But many cases are idiopathic, she said.

Tetracycline-labeled transiliac bone biopsy, primarily a research tool, may be indicated in patients who have unexplained low-trauma fractures and can help guide therapy in some cases, Dr. Shane said.

In a cross-sectional study, 64 women with idiopathic premenopausal osteoporosis—some with a fracture history and some with a low BMD—underwent central skeletal quantitative computed tomography (QCT) along with 40 healthy controls. Those with low BMD had a worse volumetric BMD and bone strength compared with controls than those with a fracture history.1

Diagnosis is just the first tricky hurdle, Dr. Shane said. “The dilemma is whether you should treat at all, and then [the next step] if you decide that you must treat—for whatever reason you choose—is to decide how to treat,” she said.

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Filed Under: 2019 ACR/ARP Annual Meeting, Conditions Tagged With: Osteoporosis, premenopauseIssue: March 2020

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