Have early menopause What does this mean for my bones and will I need treatment

Whether your early menopause (also called premature menopause) is caused by surgery, is for unknown reasons, or because of cancer treatments, your bones are at risk and you may need treatment.

When you are trying to cope with the treatments for cancer, it's hard to think about your bones and the possibility of developing osteoporosis so early in life. But the fact is that when you stop having your menstrual periods for whatever reason, your risk of bone loss increases. When you experience a natural menopause around the average age of 51, you can expect to lose bone most rapidly in the 4 to 8 years following menopause (starting one year after your last period). There are several reasons why you might experience menopause much earlier than that and, therefore, need to cope with a larger stretch of your life without estrogen, an important hormone for bone growth.

A very small percentage of women (1%) experience natural menopause before the age of 40. It is not known why these people stop having their periods. Idiopathic ovarian insufficiency or premature ovarian failure is a condition that usually occurs in women under the age of 40 and causes menopause. Idiopathic ovarian insufficiency is usually caused by autoimmune and genetic disorders, Addison's disease (disorder of the adrenal glands, which manufacture steroid hormones), or hypothyroidism (an underactive thyroid gland).

Induced menopause is permanent menopause that occurs in women before their natural menopause. It occurs when the ovaries are removed with the uterus and tubes as well (often called a total hysterectomy; the technical term is total hysterectomy with bilateral salpingo-oophorectomy). Once the ovaries are removed, menopause is sudden and the accompanying symptoms of hot flashes, sleep disruptions, and mood changes can be quite severe. The ovaries no longer can secrete estrogen and bone loss may start to occur almost immediately as well.

Idiopathic ovarian insufficiency

The loss of ovarian function (and therefore fertility) in a woman under the age of 40, resulting in menopause. It is usually associated with other health conditions, and can sometimes be temporary. Also called premature ovarian failure.

Induced menopause

Permanent menopause that is not natural; can be caused as a result of surgical removal of the ovaries, chemotherapy, or radiation to the pelvis.

Total hysterectomy

Although technically only refers to removal of the uterus, "total" is sometimes used to refer to removal of the uterus, ovaries, and fallopian tubes.

Salpingo-oophorectomy

Removal of fallopian tube and ovary; bilateral means both fallopian tubes and both ovaries are removed.

If only the uterus is removed, menopause occurs earlier than usual but not abruptly. An earlier menopause is believed to result from the decreased blood supply to the ovaries, which can occur after surgery to remove only the uterus. Many people have the misconception that if the uterus is removed, a woman goes into menopause. However, she only stops having menstrual periods; her ovaries continue to make estrogen. The estrogen will continue to have a protective effect on her bones until her ovaries stop producing estrogen, most likely earlier than the average age of 51. However, she will not be able to gauge exactly when menopause actually occurs because she will not have the usual cessation of her menses for 12 months, the hallmark of menopause.

Surgically-induced menopause (removal of both ovaries) will cause you to lose bone fairly rapidly. It is important for you to prevent bone loss by getting the appropriate amounts of calcium (1,200 to 1,500 mg), Vitamin D (400-800 IU), other necessary nutrients (see Table 6 in Question 54), and exercise. You should also be sure to make lifestyle changes that could improve your bone health, like avoiding heavy alcohol use and stopping smoking. In addition, you and your clinician may want to discuss medications for preventing bone loss. As long as your surgery did not result from cancer and you do not have any contraindications to taking them, you may take any of the medications that are approved for prevention of osteoporosis. If you are experiencing significant symptoms resulting from your induced menopause, a good option for you may be MHT (see Questions 64 and 66). Your clinician may also want to send you for bone mineral density testing to get a baseline reading of your bones.

Induced menopause can also be a result of chemotherapy and radiation used to treat cancers. While surgically induced menopause always causes an abrupt stopping of the production of estrogen by the ovary, chemotherapy and radiation to the pelvis stops ovarian secretion of estrogen but sometimes this occurs over a longer period of time. This often means that women undergoing radiation and chemotherapy will have more time to adjust to the loss of estrogen. But it also means that they will begin to lose bone once the ovaries have stopped making hormones.

While women who have their ovaries removed for reasons unrelated to cancer could use MHT to treat their symptoms and to prevent osteoporosis, breast cancer survivors will have fewer options to treat their symptoms and to prevent bone loss. Few women who experience breast cancer can take estrogen because many cancers are linked to estrogen or are dependent on them for their growth (termed estrogen dependent or estrogen receptor positive cancer). After treatment, some women with estrogen receptor positive cancer will be prescribed tamoxifen, a selective estrogen receptor modulator (SERM), to prevent a recurrence of breast cancer. Tamoxifen is known to increase bone mineral density in the spine by about 1% per year, but it causes bone loss in women who are healthy and pre-menopausal even though it increases bone mineral density in healthy postmenopausal women. Nolvadex (tamoxifen) is not currently approved for the prevention or treatment of osteoporosis. Evista (raloxefene), another SERM, may be an option for breast cancer survivors whose cancers are estrogen receptor positive, but it is not approved for this use currently and there are no studies supporting its use in breast cancer

Estrogen receptor positive cancer

Type of cancer that is estrogen-dependent or has receptors for estrogen.

survivors. Evista is approved for the prevention and treatment of postmenopausal osteoporosis and has the added benefit of helping to prevent breast cancer, at least in healthy postmenopausal women.

Women whose breast cancers are not estrogen receptor positive generally are not treated with either SERM. And most clinicians will not prescribe MHT to breast cancer patients even if the cancer is not estrogen dependent. Regardless of the type of breast cancer, any woman with chemotherapy-induced menopause will be at risk for losing bone. If you have a test that shows osteoporosis, your treatment options include the bis-phosphonates and calcitonin (see Questions 57-59, and 63). Because many tumor cells secrete a substance related to parathyroid hormone, it is not clear if Forteo (teriparatide, a synthetic parathyroid hormone) would be an option for treatment in breast cancer survivors. Other treatment options are under study. For example, the bisphosphonate Zometa (zoledronate) is being evaluated for osteoporosis treatment in breast cancer survivors. So far, there is strong evidence that the bone density of the women taking Zometa has increased, but further study is needed to confirm the improvement and to document the long-term effects (see Question 99). Several options are also available to prevent osteoporosis in women who have had chemotherapy, such as the bis-phosphonates and SERMs, as well as lifestyle changes that include calcium supplementation, Vitamin D, exercise, diet modifications, and smoking cessation.

Chemotherapy or pelvic radiation used to treat cancer can also induce menopause and the bone loss that follows the loss of estrogen. Although men don't experience menopause, they can have significant bone loss and fragility fractures when treated with GnRH agonists for prostate cancer. GnRH agonists such as Lupron are also used to treat endometriosis in women. Bone loss is one of the major side effects of Lupron.

Advanced breast cancer, advanced prostate cancer, and a cancer called multiple myeloma are all associated with bone metastases. The spread of cancer cells to the bone causes loss of strength of the bone, significant pain, and an increased risk of fracture. So those with cancer can have considerable bone loss and a significant increase in fractures, which result from the treatments for the cancer and the spread of the cancer itself.

71. Are there any complementary or alternative therapies that are effective for osteoporosis or osteopenia? Can I have a massage, or will that hurt my bones?

Complementary therapies are therapies that are used in addition to conventional (sometimes called "Western") medical treatments or interventions. Alternative therapies are therapies that are used in place of conventional medical treatments. The use of these therapies has increased dramatically over the years. In fact, a recent study of Americans found that, when prayer is included as a complementary and alternative medicine (CAM) therapy, 62% of Americans used CAM therapies in the preceding 12 months. But large clinical studies that compare a CAM therapy with a placebo or with a conventional treatment have rarely been funded, so making a case in support of using CAM therapies to prevent or treat osteoporosis is difficult.

Complementary therapies

Therapies that are used in addition to conventional, Western medical treatments or interventions.

Alternative therapies

Therapies that are used in place of conventional Western medical therapies; includes massage, visualization, naturopathic medicine, and acupuncture, among others.

The National Center for Complementary and Alternative Medicine (NCCAM), a division of the National Institutes of Health, divides CAM into the following categories:

  • Alternative medical systems such as acupuncture and naturopathic medicine.
  • Mind-body interventions such as prayer and guided imagery.
  • Biologically based therapies such as dietary supplements and phytoestrogens.
  • Manipulative therapies such as acupressure and massage.
  • Energy-based therapies such as magnet therapy and Therapeutic Touch.

Practitioners of chiropractic, the CAM practice that involves manipulating and aligning bones and surrounding tissues correctly, are educated about ways to modify manipulation techniques to avoid fractures of weak bones. Some chiropractors do not manipulate or align any bones in patients with osteoporosis. They may prefer instead to play a teaching role in counseling patients about appropriate calcium and Vitamin D intake, healthy diet, and particularly how to avoid fracturing their bones when exercising. They may also help patients to learn appropriate strengthening exercises, targeting specific muscles.

In some studies of acupuncture, results have been mixed. For the treatment of osteoporosis, acupuncture is more commonly used with herbs in the practice of traditional Chinese medicine (TCM). According to TCM, the kidneys govern the bones, so TCM therapies target strengthening the kidney. Herbs that may be used to treat or prevent osteoporosis include those that boost estrogen levels, such as black cohosh, cypress, sage, ginseng, and licorice, and those that enhance mineral use by the body, such as horsetail, stinging nettle, and knotweed. Before using herbs to prevent or treat osteoporosis, you should consult your clinician and a licensed herbalist. Many of the above herbs can interact or interfere with your existing medications.

While not all of the CAM therapies would be appropriate to consider for the management or prevention of osteoporosis, some therapies may help in the management of pain from fractures. For example, hypnotherapy and guided imagery might be helpful. When pain causes stress, there are a number of CAM therapies that would be appropriate for stress management, including massage, aromatherapy, mindfulness, and yoga, to name a few (see Question 82).

Massage is gaining popularity not only because it is relaxing, but because many in the massage field believe that human touch can help all conditions. Massage has been shown to improve pain levels, particularly in people with arthritis, cancer, and low back pain. Most practitioners of massage will take a history from you, and you should be sure to mention that you have osteoporosis if you're not asked specifically. If you are having a chair massage, it is important to refrain from bending your spine forward, as this potentially may cause compression fractures of your spine.

Massages while you're lying down are definitely appropriate and can be beneficial to your stress level. Because it can ease the pain associated with many conditions, massage is a useful adjunct to self-healing. Some believe that massage can help to increase bone mass, at least indirectly, because it can relieve pain, which in turn can make exercise more manageable, and because it can help muscles become more flexible, making exercise more effective for bone health. If they are made aware of any vertebral fractures, massage therapists would be careful to avoid directly manipulating the tissue near the bones in the back. Massage increases blood flow to all areas of the body, improving your circulation, which can boost healing and reduce pain.

PART FOUR

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