Directive clinique no 422g : Ménopause et ostéoporose.

OBJECTIF: Proposer des stratégies pour améliorer les soins aux femmes en périménopause ou ménopausées d'après les plus récentes données probantes publiées. POPULATION CIBLE: Femmes en périménopause ou ménopausées. BéNéFICES, RISQUES ET COûTS: La population cible bénéficiera des plus récentes données scientifiques publiées que leur communiqueront les fournisseurs de soins de santé. Aucun coût ni préjudice ne sont associés à cette information, car les femmes seront libres de choisir parmi les différentes options thérapeutiques offertes pour la prise en charge des symptômes et morbidités associés à la ménopause, y compris l'abstention thérapeutique. DONNéES PROBANTES: Les auteurs ont interrogé les bases de données PubMed, Medline et Cochrane Library pour extraire des articles publiés entre 2002 et 2020 en utilisant des termes MeSH spécifiques à chacun des sujets abordés dans les 7 chapitres. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Médecins, y compris gynécologues, obstétriciens, médecins de famille, internistes, urgentologues; infirmières, y compris infirmières autorisées et infirmières praticiennes; pharmaciens; stagiaires, y compris étudiants en médecine, résidents, moniteurs cliniques; et autres fournisseurs de soins auprès de la population cible. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

[Fatal outcome of Netherton syndrome due to excessive use of topical corticosteroids in an adult patient]. / Évolution fatale du syndrome de Netherthon due à une utilisation excessive de dermocorticoïdes chez un adulte.

INTRODUCTION: Netherton syndrome (NS) is a rare disease caused by SPINK5 mutations associated with ichthyosis (erythroderma and desquamation), alopecia and atopic manifestations. There are no effective treatments. Topical corticosteroids may be used for a limited period in the event of eczema. Herein we report on a patient with fatal complications related to misuse of topical corticosteroids. PATIENTS AND METHODS: A 38-year-old woman with NS had been using betamethasone for about ten years for severe pruritus. Consumption was estimated at 7.2kg per year. On examination, she had osteoporosis, Cushing's syndrome, corticotropic insufficiency and inframammary, axillary, and intergluteal superinfected intertrigo. During hospitalization for necrotic leg wounds on severe skin atrophy, she sustained a fracture on falling down. The course was marked by the onset of septic shock of unknown etiology, complicated by acute adrenal insufficiency leading to fatal multi-organ failure. DISCUSSION: Many iatrogenic cases related to topical corticosteroids in children have been reported in the literature, including one case of fatal outcome (CMV infection) in an infant. Such iatrogenic cases are rarer in adults and we observed no fatal cases. In NS, the adverse effects of topical corticosteroids are amplified due to the major defect in the skin barrier which enhances the systemic passage of these drugs. In the absence of any effective therapeutic alternative, weaning patients off topical corticosteroids is usually difficult. CONCLUSION: This case illustrates the severity of iatrogenic effects secondary to misuse of topical corticosteroids in NS as well as the need to find effective new treatments for this syndrome.

Methylation of bone SOST impairs SP7, RUNX2, and ERα transactivation in patients with postmenopausal osteoporosis.

Sclerostin (SOST), a glycoprotein predominantly secreted by bone tissue osteocytes, is an important regulator of bone formation, and loss of SOST results in Van Buchem disease. DNA methylation regulates SOST expression in human osteocytes, although the detailed underlying mechanisms remain unknown. In this study, we compared 12 patients with bone fractures and postmenopausal osteoporosis with eight patients without postmenopausal osteoporosis to understand the mechanisms via which SOST methylation affects osteoporosis. Serum and bone SOST expression was reduced in patients with osteoporosis. Bisulfite sequencing polymerase chain reaction revealed that the methylation rate was higher in patients with osteoporosis. We identified osterix (SP7), Runt-related transcription factor 2 (RUNX2), and estrogen receptor α (ERα) as candidate transcription factors activating SOST expression. Increased SOST methylation impaired the transactivation function of SP7, RUNX2, and ERα in MG-63 cells. AzadC treatment and SOST overexpression in MG-63 cells altered cell proliferation and apoptosis. Chromatin immunoprecipitation showed that higher methylation was associated with reduced SP7, RUNX2, and ERα binding to the SOST promoter in patients with osteoporosis. Our studies provide new insight into the role of SOST methylation in osteoporosis.

Reduced miR-144-3p expression in serum and bone mediates osteoporosis pathogenesis by targeting RANK.

Osteoblasts and osteoclasts are responsible for the formation and resorption of bone, respectively. An imbalance between these two processes results in a disease called osteoporosis, in which a decreased level of bone strength increases the risk of a bone fracture. MicroRNAs (miRNAs) are small non-coding RNA molecules of 18-25 nucleotides that have been previously shown to control bone metabolism by regulating osteoblast and osteoclast differentiation. In this study, we detected the expression pattern of 10 miRNAs in serum samples from patients with osteoporosis, and identified the altered expression of 6 miRNAs by comparison with patients without osteoporosis. We selected miR-144-3p for further investigation, and showed that it regulates osteoclastogenesis by targeting RANK, and that it is conserved amongst vertebrates. Disrupted expression of miR-144-3p in CD14+ peripheral blood mononuclear cells changed TRAP activity and the osteoclast-specific genes TRAP, cathepsin K (CTSK), and NFATC. TRAP staining, CCK-8, and flow cytometry analyses revealed that miR-144-3p also affects osteoclast formation, proliferation, and apoptosis. Together, these results indicate that miR-144-3p critically mediates bone homeostasis, and thus, represents a promising novel therapeutic candidate for the treatment of this disease.

Mycobacterial infection influences bone biomarker levels in patients with Crohn's disease.

Patients with Crohn's disease (CD) have higher risk for osteoporosis following decreased level of osteocalcin. We hypothesize that active inflammation following Mycobacterium avium subsp. paratuberculosis (MAP) infection results in elevation of undercarboxylated osteocalcin (ucOC) and downregulation of active osteocalcin in CD patients and cow-disease model (Johne's disease). In this study, we measured ucOC, active osteocalcin, and calcium levels in sera from 42 cattle (21 infected with MAP and 21 healthy cattle), 18 CD patients, and 20 controls. The level of ucOC in MAP+ bovine samples was higher than that in MAP- controls (318 ± 57.2 nmol/mL vs. 289 ± 95.8 nmol/mL, P > 0.05). Consequently, mean calcium level in bovine MAP+ was significantly higher than that in bovine-MAP- samples (9.98 ± 0.998 mg/dL vs. 7.65 ± 2.12 mg/dL, P < 0.05). Also, the level of ucOC was higher in CD-MAP+ than in CD-MAP- (561 ± 23.7 nmol/mL vs. 285 ± 19.6 nmol/mL, P < 0.05). Interestingly, the mean osteocalcin level in MAP+ bovine was lower than that in MAP- bovine (797 ± 162 pg/mL vs. 1190 ± 43 pg/mL) and it was lower in CD-MAP+ than in CD-MAP- infection (1.89 ± 0.184 ng/mL vs. 2.19 ± 0.763 ng/mL) (P < 0.05). The correlation between MAP infection and elevation of sera ucOC, reduction of active osteocalcin and increased calcium supports MAP infection role in CD and complications with osteoporosis.

Chronic alcohol abuse in men alters bone mechanical properties by affecting both tissue mechanical properties and microarchitectural parameters.

OBJECTIVE OF THE STUDY: Alcohol-induced secondary osteoporosis in men has been characterized by higher fracture prevalence and a modification of bone microarchitecture. Chronic alcohol consumption impairs bone cell activity and results in an increased fragility. A few studies highlighted effects of heavy alcohol consumption on some microarchitectural parameters of trabecular bone. But to date and to our knowledge, micro- and macro-mechanical properties of bone of alcoholic subjects have not been investigated. PATIENTS: In the present study, mechanical properties and microarchitecture of trabecular bone samples from the iliac crest of alcoholic male patients (n=15) were analyzed and compared to a control group (n=8). MATERIALS AND METHODS: Nanoindentation tests were performed to determine the tissue's micromechanical properties, micro-computed tomography was used to measure microarchitectural parameters, and numerical simulations provided the apparent mechanical properties of the samples. RESULTS: Compared to controls, bone tissue from alcoholic patients exhibited an increase of micromechanical properties at tissue scale, a significant decrease of apparent mechanical properties at sample scale, and significant changes in several microarchitectural parameters. In particular, a crucial role of structure model index (SMI) on mechanical properties was identified. CONCLUSIONS: 3D microarchitectural parameters are at least as important as bone volume fraction to predict bone fracture risk in the case of alcoholic patients.

Osteoporosis in Stickler syndrome. A new family case with bone histology study.

The Stickler syndrome (SS) has been described as a "hereditary progressive arthro-ophtalmopathy" by Stickler in 1965, due to mutations on the collagen genes. Currently about 40 different genes have been identified which encode for at least 27 different collagens. The majority of mutations occur in the COL2A1 gene on chromosome 12q13 (SS type I). Mutations in COL11A1 are less frequent (SS type II). More recently, mutations in COL11A2 and in the COL9A1 gene have been reported with particular phenotypes. The main features of this autosomal inherited disease are ocular, auditory with orofacial abnormalities and early-onset osteoarthritis. We report the clinical presentation of an adult and his son, with a particular focus on the bone status of the father, radiography, bone densitometry and transiliac bone biopsy showing that he was suffering from osteoporosis. The lumbar bone mineral density was low with a Z-score at -2.9. Transiliac bone biopsy showed a dramatic decrease of trabecular bone volume (8.6%; Nl: 19.5±4.9%), thin trabeculae and a disorganized trabecular network. A slight increase of osteoid parameters was observed. Bone resorption was markedly increased with an excessive number of active (TRAcP+) osteoclasts. The cortical width was normal, but a slight increase of cortical porosity was found. Osteoporosis has been rarely described in the SS. It might be useful to systematically perform a bone densitometry in all patients with SS and to discuss the indication of a transiliac bone biopsy in severe cases.

[Nurses mobilised in screening for osteoporosis]. / Les infirmières mobilisées dans le dépistage de l'ostéoporose.

The consequences of an osteoporotic fracture are often harmful. The teams of La Roche-sur-Yon general hospital have created a primary and secondary screening programme led by a nurse. Hospitalised female patients between the ages of 50 and 80 are screened for osteoporosis risk factors.

[Management of fractures in the elderly]. / Prise en charge des principales fractures chez les personnes âgées.

Fractures in elderly people are a leading cause of hospitalisation in medical and surgical departments. There may also be a significant increase in associated morbidity and mortality, depending on the site of the fracture and the surgical, medical and paramedical management. The respect of the surgical indications and a multi-disciplinary approach are essential for ensuring high quality care.

[Management of endocrine dysfunctions after allogeneic hematopoietic stem cell transplantation: a report of the SFGM-TC on adrenal insufficiency and osteoporosis]. / Suivi et prise en charge des troubles endocriniens en post-greffe de cellules souches hématopoïétiques: insuffisance corticotrope et ostéoporose.

In the attempt to harmonize clinical practices between different French transplantation centers, the French Society of Bone Marrow Transplantation and Cell Therapy (SFGM-TC) set up the third annual series of workshops which brought together practitioners from all member centers and took place in October 2012 in Lille. Here we report our results and recommendations regarding the management of short and long-term endocrine dysfunction following allogeneic stem cell transplantation. The key aim of this workshop was to give an overview on secondary adrenal insufficiency and osteoporosis post-transplant.

[Osteomicrobiology - Literature Review]. / Osteomikrobiologie ­ aktuelle Literaturübersicht.

Osteomicrobiology - Literature Review Abstract. Abtract: Several in vivo studies show interesting correlations between microbiota and bone remodeling. The microbiota model and stimulate the immune system, which exerts a direct effect on the bone. The first clinical studies confirm these results and open new perspectives for the prevention of osteoporosis.

[A Distal Radius Fracture Is Not Simply a Distal Radius Fracture]. / Eine distale Radiusfraktur ist nicht einfach eine distale Radiusfraktur.

A Distal Radius Fracture Is Not Simply a Distal Radius Fracture Abstract. We report on a 57-year-old female patient with a distal extra-articular radius fracture. The family doctor's suspicion was an osteoporosis-associated fracture, and an interdisciplinary investigation was initiated. In addition to DXA measurement differential diagnoses for secondary osteoporosis were considered. In our case, secondary osteoporosis was diagnosed as part of Graves' disease and insufficiency of vitamin D leading to a radius fracture.

The effects of Pilates on health-related outcomes in individuals with increased risk of fracture: a systematic review.

This systematic review examined the effect of Pilates on health-related outcomes in individuals with increased fracture risk to inform the 2021 Clinical Practice Guidelines for Management of Osteoporosis and Fracture Prevention in Canada. Seven electronic databases were searched to December 2020. Studies of Pilates in men and postmenopausal women aged ≥50 years with low bone mineral density (BMD), history of fragility fracture, or moderate-high risk of fragility fracture were included. Two reviewers independently screened studies and performed risk of bias assessment. Of 7286 records and 504 full-text articles, 5 studies were included, encompassing data from 143 participants (99% female). Data were insufficient for meta-analyses. There is low-certainty evidence that Pilates improved physical functioning and health-related quality of life. The effect of Pilates on falls and BMD is uncertain. No evidence was available for the effect of Pilates on mortality, fractures, or adverse events. Overall, Pilates may improve physical functioning and quality of life. Evidence of benefits relative to harms of Pilates in people with increased fracture risk, particularly males, is limited. PROSPERO registration: CRD42019122685. Novelty: Pilates may improve physical functioning and quality of life in women with osteoporosis. Evidence of the effect of Pilates on BMD, falls, fractures, or adverse events is limited.

Risk Factors, Screening, Diagnosis, and Treatment of Osteoporosis in HIV-Infected Adults in an HIV Primary Care Clinic.

Background: The population of people living with HIV is aging, and with aging come emergent comorbidities, including osteoporosis, for which screening and treatment are becoming increasingly important. Osteoporosis prevalence among those living with HIV is 3 times greater than among HIV-uninfected controls. Objective: To assess and describe osteoporosis risk factors, screening, diagnosis, and treatment for people 50 years of age or older living with HIV and receiving care at a multidisciplinary HIV primary care clinic. Methods: A retrospective chart review of people 50 years of age or older living with HIV was conducted at the John Ruedy Clinic in Vancouver, British Columbia, between June 1, 2016, and June 1, 2019. Patients who had had fewer than 2 yearly follow-up appointments were excluded. Results: A total of 146 patients were included in the analysis; most were male (n = 134, 92%), and the median age was 55 years. Patients had a median of 3 osteoporosis risk factors (in addition to age and HIV infection), and 145 patients had at least 1 risk factor. All screening for osteoporosis was conducted by dual-energy X-ray absorptiometry (DXA). Thirty-nine (27%) of the patients were screened with DXA, 92 (63%) were not screened, and 15 (10%) already had a diagnosis of osteoporosis. The DXA screening identified osteoporosis in an additional 10 patients and osteopenia in 22 patients. Treatments for patients with osteoporosis included bisphosphonates (n = 15, 60%) and vitamin D or calcium (or both), without any other medications (n = 4, 16%). In the overall study population, 32 (22%) of the patients were taking calcium and 46 (32%) were taking vitamin D. Conclusions: Many patients aged 50 years or older and receiving HIV care at the John Ruedy Clinic had or were at risk for osteoporosis. An opportunity exists to increase screening and treatment of these individuals. A multidisciplinary team may be crucial in achieving this goal.

Contexte: La population des personnes vivant avec le VIH vieillit et, avec le vieillissement, des comorbidités émergent, dont l'ostéoporose, pour laquelle le dépistage et le traitement sont de plus en plus importants. La prévalence de l'ostéoporose chez les personnes vivant avec le VIH est 3 fois plus élevée que chez les témoins non infectés. Objectif: Évaluer et décrire les facteurs de risque, le dépistage, le diagnostic et le traitement de l'ostéoporose chez les personnes d'au moins 50 ans vivant avec le VIH et qui reçoivent des soins dans une clinique pluridisciplinaire de soins primaires pour le VIH. Méthodes: Un examen rétrospectif des dossiers des personnes d'au moins 50 ans vivant avec le VIH a été effectué à la clinique John Ruedy à Vancouver (Colombie-Britannique) entre le 1er juin 2016 et le 1er juin 2019. Les patients qui avaient eu moins de 2 rendez-vous de suivi annuels ont été exclus de l'étude. Résultats: Au total, 146 patients ont été inclus dans l'analyse; la plupart étaient des hommes (n = 134, 92 %) et l'âge médian était de 55 ans. Les patients avaient une médiane de 3 facteurs de risque d'ostéoporose (en plus de l'âge et de l'infection par le VIH), et 145 patients avaient au moins 1 facteur de risque. Tous les dépistages de l'ostéoporose ont été réalisés par absorption biphotonique à rayons X (DXA). Trente-neuf patients (27 %) ont été dépistés par DXA, 92 (63 %) ne l'ont pas été et 15 (10 %) avaient déjà un diagnostic d'ostéoporose. Le dépistage par DXA a permis d'identifier l'ostéoporose chez 10 patients supplémentaires et l'ostéopénie chez 22 patients. Le traitement des patients atteints d'ostéoporose comprenait des bisphosphonates (n = 15, 60 %) et de la vitamine D ou du calcium (ou les deux) sans autre médicament (n = 4, 16 %). Dans la population générale de l'étude, 32 patients (22 %) prenaient du calcium et 46 (32 %) prenaient de la vitamine D. Conclusions: De nombreux patients d'au moins 50 ans recevant des soins pour le VIH à la clinique John Ruedy présentaient un risque d'ostéoporose ou l'avaient déjà développée. Il est possible d'accroître leur dépistage et leur traitement, et une équipe multidisciplinaire peut être cruciale pour atteindre cet objectif.

A retrospective study on the etiological exploration of osteoporosis in aging men in a French geriatric setting.

INTRODUCTION: Osteoporosis in older men is common and causes significant mortality and morbidity. Some data suggest that conditions leading to bone fragility, including osteoporosis, are under-identified and undertreated in men. Additionally, 50% of the causes of osteoporosis are secondary in men. The latest Endocrine Society and different Rheumatology Societies Guidelines recommend additional laboratory investigations in men with osteoporosis so as to treat them more efficiently. MAIN GOAL OF THE STUDY: Our aim was to determine whether men managed in our geriatrics center, diagnosed with osteoporosis, underwent investigations to determine the aetiology of osteoporosis and other bone fragility conditions and what the secondary causes were. MATERIALS AND METHOD: We conducted a monocentric, retrospective study including all men seen at the geriatric consult in 2016 diagnosed with osteoporosis. For each patient, we evaluated our clinical practice, whether common secondary causes were sought-after and what these aetiologies were. RESULTS: Among the 121 men with a diagnosis of osteoporosis seen at the geriatric consult at the Lille University Hospital in 2016, only 51 had undergone further investigations. Among the 3 major secondary causes were identified: 17.6% glucocorticoid induced, 13.7% treatment induced hypogonadism, 11.7% late onset hypogonadism. CONCLUSIONS: A more efficient etiological assessment of osteoporosis in older men could be achieved and would improve management for our patients. This can be achieved by a better knowledge of the recommendations for etiological assessment of bone fragility and osteoporosis and a dedicated consultation within the geriatric sector.

Endocrinology of bone mineralization: An update.

Throughout the world, millions of people suffer from fragilizing osteopathies such as osteomalacia and osteoporosis. Osteomalacia is a rare disorder, corresponding to mineralization abnormalities in adult bone, as opposed to rickets in children. Renal phosphate loss and hypophosphatasia are the main causes of vitamin-resistant osteomalacia. Diagnosis is based on clinical history, phosphocalcic metabolism assessment and, if necessary, molecular characterization, and must be rapid in order to initiate the most appropriate treatment and consider new treatments such as burosumab if necessary. Osteoporosis is characterized by reduced bone mass and strength, which increases the risk of fragility fracture. Fracture-related burden is expected to increase over the coming decades linked to the aging of population and a treatment gap. In order to reduce this treatment gap, it is important to develop two strategies: improvement of screening and of treatment. Systematic screening using the FRAX® fracture risk assessment tool could be useful to increase anti-osteoporosis medical treatment and reduce fracture rates. The question of treatment sequencing in osteoporosis is another challenge, notably after denosumab cessation, complicated by a decrease in bone mineral density and increased risk of fracture. New treatments are also available, including romosozumab, a humanized monoclonal antibody, which promotes bone formation and inhibits bone resorption by inhibiting sclerostin. Romosozumab is approved in several countries, including France, for treating severe osteoporosis in postmenopausal women at high risk of fracture and free of cardiovascular comorbidity. Endocrinologists need to be aware of these fragilizing osteopathies in order to improve both diagnosis and treatment.

Association Between Parental Type 1 and Type 2 Diabetes Diagnosis and Major Osteoporotic Fracture Risk in Adult Offspring: A Population-Based Cohort Study.

OBJECTIVES: Previous research suggests an intergenerational influence of diabetes on bone health. We examined the association between parental diabetes and major osteoporotic fracture (MOF) risk in offspring. METHODS: This population-based cohort study used de-identified administrative health data from Manitoba, Canada, which capture population-level records of hospitalizations, physician visits and drug dispensations. The cohort included individuals ≥40 years of age with at least 1 parent identified in the data between 1997 and 2015. The exposure was parental diagnosis of diabetes since 1970; the outcome was offspring incident MOF diagnosis of the hip, forearm, spine or humerus. Both measures were identified from hospital and physician visit records using validated case definitions. Multivariable Cox proportional hazards regression models tested the association of parental diabetes and offspring MOF risk. RESULTS: The cohort included 279,085 offspring; 48.5% were females and 86.8% were ≤44 years of age. Both parents were identified for 89.4% of the cohort; 36.7% had a parental diabetes diagnosis. During a median follow up of 12.0 (interquartile range, 6.0 to 18.0) years, 8,762 offspring had an MOF diagnosis. After adjusting for fracture risk factors, parental diabetes diagnosis was not associated with MOF risk, whether diagnosed in fathers (adjusted hazard ratio [aHR], 1.02; 95% confidence interval [CI], 0.97 to 1.08), mothers (aHR, 1.02; 95% CI, 0.97 to 1.07) or both parents (aHR, 1.01; 95% CI, 0.93 to 1.11). The results remained consistent in a stratified analysis by offspring sex, secondary analysis based on MOF site and sensitivity analyses. CONCLUSIONS: The results indicate parental diabetes is not associated with offspring MOF risk.

Effect of yoga on health-related outcomes in people at risk of fractures: a systematic review.

We summarized the effects of yoga on health-related outcomes and adverse events in men and postmenopausal women ≥50 years-old at increased risk of fracture, to inform the updated Osteoporosis Canada clinical practice guidelines. Six databases were searched for observational studies, randomized controlled trials and case series. Certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation handbook. Nine studies were included and reported using narrative syntheses due to the limited available evidence. Overall, the available evidence was of very low certainty. There was no effect of yoga on health-related quality of life in randomized trials. Effects on other health-related outcomes were mixed or not available in the literature. Five studies reported no adverse events directly related to the study intervention, and 2 studies did not report whether adverse events occurred. However, 2 case series reported vertebral fractures related to yoga participation, possibly due to excessive spinal flexion. Due to the limited and very low certainty evidence, guideline developers will need to draw indirect evidence from yoga studies among middle aged or older adults that are not at fracture risk. PROSPERO: CRD42019124898. Novelty: Evidence in general was of very low certainty. Yoga had no effect on health-related quality of life in randomized trials. Evidence was mixed or unavailable for other outcomes. Case studies reported yoga poses involving spinal flexion coincided with incidents of vertebral compression fracture among older adults with increased fracture risk.

[Different Perspectives of Drug Holiday and Combination Therapies When Treating Osteoporosis]. / Verschiedene Perspektiven von Therapiepausen und Kombinations-therapien bei Osteoporose.

Different Perspectives of Drug Holiday and Combination Therapies When Treating Osteoporosis Abstract. Sequential and combined therapy for osteoporosis is challenging because of the many options, and difficult because robust fracture data are not available, especially for combination therapies, mostly because the studies are too small. The principle of sequential and combined therapy for osteoporosis is that osteoanabolic therapy (teriparatide [TPTD]), whether sequential or combined, leads to an increase in bone mineral density (BMD), especially in the lumbar spine. The only exception is the sequence of TPTD after denosumab (Dmab), which leads to a loss (transient) of BMD in both the lumbar spine and the hip; for this reason, this sequence should be avoided at all costs. A second principle is that the stronger and longer the antiresorptive pretreatment was, the more delayed and reduced the effect of osteoanabolic therapy (TPTD). A third principle is the need for antiresorptive retreatment after therapies with TPTD and Dmab or their combination to prevent vertebral fractures (Dmab) and maintain bone density (TPTD). An effect of osteoanabolic therapy with TPTD on BMD of the hip is expected only in combination with antiresorptive therapy (bisphosphonates, Dmab). If the antiresorptive therapy is not continued, there is a transient loss in the first months of osteoanabolic monotherapy, the more so the stronger the antiresorptive pretreatment was.

[Menopause, menopause hormone therapy and osteoporosis. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]. / Ménopause, traitement hormonal de ménopause et ostéoporose. RPC Les femmes ménopausées du CNGOF et du GEMVi.

Postmenopausal osteoporosis is a frequent clinical condition, which affects nearly 1 in 3 women. Estrogen deficiency leads to rapid bone loss, which is maximal within the first years after the menopause transition and can be prevented by menopause hormone therapy (MHT). Assessment of the individual risk of osteoporosis is primarily based on the measurement of bone mineral density (BMD) at the spine and femur by DXA. Clinical risk factors (CRFs) for fractures taken either alone or in combination in the FRAX score were shown not to reliably predict fractures and/or osteoporosis (as defined by a T-score<-2.5) in early postmenopausal women. If DXA measurement is indicated in all women with CRFs for fractures, it can be proposed on a case-by-case basis, when knowledge of BMD is likely to condition the management of women at the beginning of menopause, particularly the benefit-risk balance of MHT. MHT prevents both bone loss and degradation of the bone microarchitecture in early menopause. It significantly reduces the risk of fracture at all bone sites by 20 to 40% regardless of basal level of risk with an estrogen-dependent dose-effect. Given the inter-individual variability in bone response, individual monitoring of the bone effect of MHT is warranted when prescribed for the prevention of osteoporosis. This monitoring is based on repeated measurement of lumbar and femoral BMD (on the same DXA measurement system) after 2years of MHT, the response criterion being no significant bone loss. Discontinuation of treatment is associated with a resumption of transient bone loss although there is a large variability in the rate of bone loss among women. Basically, there is a return to the level of fracture risk comparable to that of in untreated woman of the same age within 2 to 5years. Therefore, when MHT is prescribed for the prevention of osteoporosis in women with an increased risk at the beginning of menopause, measurement of BMD is recommended when MHT is stopped in order to consider further management of the risk of fracture whenever necessary (with possibly another anti-osteoporotic treatment).