Transcript Cervical Cancer Prevention in Low

Prof.Emeritus Khunying Kobchitt Limpaphayom
Past President Thai Osteoporosis Foundation (TOPF)
President of Thai Menopause Society (TMS)
Physical sequelae
Height loss…
Back pain…
Limited ventilation…
Narrow abdominal cavity…
Abdominal skin infection…
Problem with gait & balance
Mental sequelae
Poor self esteem…
Social isolation…
Depression…
One year after hip fracture
20% Death…
30% Permanent disability
40% Can’t walk independently
80% Can’t do 1 ordinary activity
Rene Rizzoli, 2006
US (white) Hong Kong Singapore Thailand Malaysia
Male
187
180
164
114
88
Female
535
459
442
269
218
Female/Male Ratio
2.9
2.4
2.6
2.8
2.4
*Adjusted to the 1989 US white population by direct
standardization, and presented with US white incidence data for
1988 -1989.
Asian Osteoporosis Study Group, 1998.
Unable to carry out at
least one independent
activity of daily living
80
80%
Patients (%)
70
60
50
40
30
Permanent
disability
Death within
One year
40%
30%
20
10
Unable to walk
independently
20%
0
Cooper C., Am J Med. 1997;103(2A):12s-19s
1.4
Osteopenia
27.63%
Osteoporosis 19.75%
1.2
1.0
0.847
.8
Osteopenia
0.682
Osteoporosis
.6
.4
.2
30
40
50
60
70
80
90
Age (yrs.)
Limpaphayom K, et al. Menopause 2001; Vol.8., No.1 : 65-69.
1.4
Osteopenia
37.4%
Osteoporosis 13.6%
1.2
1.0
.8
0.716
Osteopenia
.6
0.569
Osteoporosis
.4
.2
30
40
50
60
70
80
90
Age (yrs.)
Limpaphayom K, et al. Menopause 2001; Vol.8., No.1 : 65-69.
National Statistic Office 2003
900
750
600
450
300
150
0
51-54
55-59
60-64
65-69
70-74
>75
Age (yrs)
Phadungkiat S, et al
J Med Assoc Thai 2002;85:565
100000
Total population
Aging population
75181
80000
74188
74029
70975
66511
60000
61399
AP / TP ~ 1 / 3
55595
46718
40000
AP / TP ~ 1 / 12
35745
AP / TP ~ 1 / 20
20000
1715
2527
3716
15827
5338
7205
20131
21981
10765
0
1970
1980
1990
2000
2010
United Nations World Population Prospects, The 1998 Revision, Vol. 1,New York:
Dept. of Economic and Social Affairs, Population Division, 1999.
2020
2030
2040
2050
Estrogen deficiency
Rene Rizzoli, 2006
Osteoclast lineage
Osteoblast lineage
Rene Rizzoli, 2006
RANKL
OPG
Stimulation
Dexametasone
1 α,25-(OH2)D3
PTH
PGE2
17 β-Estradiol
Inhibition
17 β-Estradiol
Hydrocortisone
1 α,25-(OH2)D3
PTH
PGE2
Aubin J., Osteoporosis Int. 2000;11(11):905-13
Estrogen
deficiency
Increased OC formation
Increased OC activity
Increased OC lifespan
Decreased OB lifespan
Decreased O’cyte lifespan
Estrogen
deficiency
Estrogen
therapy
Decreased OC formation
Decreased OC activity
Decreased OC lifespan
Increased OB lifespan
Increased O’cyte lifespan
Osteoporosis is defined as a skeletal disorder characterized
by compromised bone strength predisposing a person to an
increased risk of fracture. Bone strength primarily reflects
the integration of bone density and bone quality.
Normal bone
Osteoporosis
NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95
Normal:
BMD is within +1 or -1 SD of the young adult mean.
Osteopenia (low bone mass):
BMD is between -1 and -2.5 standard deviations below young adult mean.
Osteoporosis:
BMD is -2.5 SD or more than the young adult mean.
Severe (established) osteoporosis:
BMD is more than -2.5 SD and one or more osteoporotic fractures have occurred.
*based on DXA measurement at hip or spine
Bone Strength
NIH Consensus Statement 2000
Bone
Strength
Bone
Quality
and
Bone
Density
Architecture and geometry
Turnover/ remodeling rate
Degree of Mineralization
Damage Accumulation
Properties of collagen/mineral matrix
NIH Consensus Development Panel on Osteoporosis. JAMA 285 (2001): 785-95
1990
2050
3250
(n x1000)
1000
800
600
400
200
0
North
America
Cooper 1992
Europe
Latin America
Asia
Total number of hip fractures 1990 = 1.6 millions
2050 = 6.3 millions
Dietary calcium intake
Vitamin D intake and synthesis
Calcium absorption
Plasma calcium
Estrogen deficiency
 PTH secretion
 Bone turnover and resorption
Low peak
bone mass
Postmenopausal
Bone loss
LOW BONE MASS
Non skeletal
Factors
(propensity to fall)
FRACTURE =
Fall + Low BMD
Age related
bone loss
Other risk
factors
Poor bone
Quality
(architecture)
LOW BMD =  PMB or  Loss
Adapted from Melton LJ & Riggs BL. Osteoporosis : Etiology, Diagnosis and Management
Raven Press, 1988, pp155-179
With socio-economic development in many
Asian countries and rapid ageing of the Asian
population, osteoporosis has become one of the
most prevalent and costly health problems in the
region. Unsurprisingly, Asia is the region
expecting the most dramatic increase in hip
fractures during coming decades; by 2050 one
out of every two hip fractures worldwide will occur
in Asia.
Osteoclast
Established
drugs
Potential
inhibitors
Bisphosphonates
Estrogens
SERMs
Calcitonin
Strontium
Blocking RANKL
system
Cathesin K inhibitor
Mevalonate inhibitor
Other inhibitors &
antagonists
Osteoblast
Established
drugs
Potential
stimulators
PTH
Strontium
PGs
Fluoride
Vitamin D
Sclerostin inhibitors
Androgen (SERMs)
BMP-2
Etc.
Russell RGG, et al. Current Opinion in Rhematology 2006;18:S3-10.
Enhance PBM
Healthy
lifestyle
Prevent bone loss
Avoiding
Health risks
Lifestyle
modification
Fall prevention
Self
improvement
Pharmacological
intervention
Environmental
adaptation
Estrogen
Bisphosphonates
Raloxifene
Calcitonin
Parathyroid hormone
Strontium ranelate
~ 50%
Risk reduction!
Sambrook P, et al. Lancet 2006;367:2010-18.
Fall & balance
Environmental &
family factor!
Physical & mental
strengthening
•
•
•
•
•
•
•
•
•
Age
Impaired gait or balance; lower body muscle weakness
Poor vision; cataracts
Malnutrition; excessive alcohol intake
Certain medical conditions, e.g. arthritis, diabetes, postural
hypotension, cognitive impairment, peripheral neuropathy
Polypharmacy; certain medications, e.g. psychoactive
medications, antihypertensives
Footwear with slippery soles, high heels
Factors in the home, e.g. poor lighting, loose rugs, loose
cabling, uneven or wet surfaces, bathtubs without handrails
or bath mat, clutter at floor level, stepping over pets
Environmental factors, e.g. wet or cracked paving or steps,
ice or snow
1. Lighting : ample, easy switchs, walkways
2. Obstruction
3. Floors & carpets
4. Furniture : chairs, bed height
5. Storage : accessible height
6. Bathroom : grab bars, chairs, toilet seat, nonskid
7. Stairways & halls : handrails, steps, nonskid
8. Human factor : heartfelt care, wheel chair
9. Medication : sedatives
NAMS. Position Statement. Management of Osteoporosis in postmneopausal women 2006.
Menopause 2006;13:340-67.
Kannus P, et al. N Engl J Med 2000;343:1506-13.
100
90
Colles’ fracture
80
% full health
70
60
50
40
30
Road traffic
accident
20
Vertebral
fractures
10
0
0
20
40
Age (years)
60
80
100
NORMAL
HEALTH
OSTEOPOROSIS
Structure / Function
Structure
• bone density
• microarchiecture
Activities / Participation
Mobility
• walking, using transport
Self care
• washing, dressing
FRACTURE
PARTIAL
RECOVERY
FURTHER
FRACTURE
DEATH
Domestic life
• shopping, meals, house
Symptoms
• pain
• loss of movement
Interactions &
relationships
• spousal, family, work
Following first distal forearm fracture
Cuddihy et al Osteoporosis Int 1999
 hip fracture
 vertebral fracture
1.4 fold in women
2.7 fold in men
5.2 fold in women
10.7 fold in men
Prevalent vertebral fracture and new vertebral
fracture in next year Lindsay et al JAMA 2001
 1 prevalent fracture
 1
 2
RR 2.6
RR 5.1
RR 7.3
Prevalent vertebral fracture increases risk of
hip fracture > 2 fold
NORMAL
HEALTH
OSTEOPOROSIS
Direct Costs
Acute care
• hospitalisation
• rehabilitation
Indirect Costs
Attendant care
Social services
FRACTURE
Institutionalisation
PARTIAL
RECOVERY
DEATH
Long term
• primary care
• drugs
• further fractures
Opportunity costs of
family / carers
1. Biology eg., vit D receptor gene, hip axis length
2. Mentality eg., introvert, slow down, peaceful
3. Nutrition eg., semi-vegetarian food
4. Family eg., higher priority, big family
5. Social status eg., privilege, seniority oriented
Perception
HRT should not be used for bone protection because of its
unfavorable safety profile. Official recommendations by
health authorities (EMEA, FDA) limit the use of HRT to a
second-line alternative. HRT could only be considered when
other medications failed, were contraindicated or not
tolerated, or in the very symptomatic woman.
Evidence
For the age group 50-59, HRT is safe and cost-effective.
Overall, HRT is effective in the prevention of all
osteoporosis-related fractures, even in patients at low risk of
fracture.
Roussow J. JAMA 2007;297:1465; Cauley JA. JAMA 2003;290:1729
Jackson RD. J Bone Min Res 2006;21:817
Perception
HRT is not as effective in reducing fracture risk as other
products (bisphosphonated, etc)
Evidence
Although no head-to-head studies have compared HRT to
bisphosphonates in terms of fracture reduction, there is no
evidence to suggest that bisphosphonates or any other
antiresorptive therapy are superior of HRT.
Many people read only headlines or short messages:
For these people, a short take-home message is the following:
The target population for initiation of HRT is usually women up to age
55.
HRT initiated in the early postmenopausal period in healthy women is
safe.
Like all medicines, HRT needs to be used appropriately, but it is
essential that women in early menopause who are suffering
menopausal symptoms should have the option of using HRT.