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ORIGINAL RESEARCH |
From the Department of Obstetrics and Gynecology and School of Nursing, Medical College of Ohio, Toledo, Ohio.
Address reprint requests to: Louis Weinstein, MD Richard Ruppert Health Center 3120 Glendale Avenue Toledo, OH 43614-5809
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Abstract |
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Methods: We gave a questionnaire we developed for osteoporosis risk factors to 1346 menopausal women who were being screened by bone densitometry at the spine, hip, and femoral neck. Chi-square analysis using the one-tailed test was done on all categoric variables to determine differences or patterns in bone mineral density at specific sites. Multivariate logistic regression analysis was done on each of the three sites scanned to determine which combination of independent variables was a significant predictor of the presence or absence of osteoporosis.
Results: Factors identified that were significant for the presence of osteoporosis were age 61 years or older, weight 165 pounds or less, or lack of any use of estrogen, either oral contraceptives or estrogen replacement therapy.
Conclusion: We devised a simple system to identify which patients should be screened for osteoporosis.
I knew a woman lovely in her bones.—Theodore Roethke, 1958
With the aging of the population, the number of menopausal women is increasing rapidly. The three things that most affect quality of life and independent living in menopausal women are cardiovascular disease, osteoporosis, and cancer. The lifetime risk of death for white women in the United States is 31% for cardiovascular disease, 2.8% for breast cancer, and 2.8% for a hip fracture.1 With improvements in treatment and diagnosis of cardiovascular disease and breast cancer, these numbers are expected to decrease while the increasing age of the population will result in an increase in morbidity and mortality from hip fractures secondary to osteoporosis.
Osteoporosis, predominately a condition of women, is characterized by an increased rate of bone turnover with resultant bone resorption exceeding new bone formation.2 In the United States, osteoporosis results in 1.3 million fractures per year with 250,000 being hip fractures.3 The direct health care costs exceed 10 billion dollars per year and are expected to increase.3,4 The lifetime risk for a woman to experience a hip fracture is 15% with a 12–20% mortality rate in the first year after hip fracture. Another 13% will die in the second year after hip fracture.3,5 Among those who survive, 50% will require assistance with walking and another 15–25% will require long-term care.6
Osteoporosis meets the criteria for a disease to have an appropriate screening program. The condition is common and serious, the natural history of the disease is understood, an excellent screening test, dual-energy x-ray absorptiometry scan, is available, and treatment is excellent. The difficulty has been in identifying which women are at risk and who should be screened with a scan to detect osteoporosis. We developed a questionnaire incorporating the current accepted osteoporosis risk factors to determine whether a simple system could be devised to identify which patients should be screened for osteoporosis.
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Materials and Methods |
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-year period with a questionnaire developed by the senior author. The women presented for osteoporosis evaluation and had a dual-energy x-ray absorptiometry scan of three sites. The questionnaire was administered in person before or during the scan, which was done with a Hologic QDR 1500 densitometer (Hologic Inc., Waltham, MA). The sites evaluated were lumbar spine (L1–4) in the anteroposterior position, total hip, and femoral neck. Quality control was performed daily using a lumbar tissue phantom. The coefficient of variation for bone mineral density measurements during the study interval was 0.25%. All scans were read by the senior author before being aware of the information obtained from the questionnaire. The information was coded into a program developed by one of the authors (BU). Descriptive statistics were done on all demographic and study variables. Analysis was done by using Statistical Package for Social Sciences (SPSS Inc, Chicago, IL). Chi-square analysis using the one-tailed test was calculated for all categoric variables to determine differences or patterns that were present using the areas of spine, hip, and femoral neck. Statistical significance was set at P < .05.
The population was divided into age groups (50 years or younger, 51–55, 56–60, 61–65, 66–70, 71–75, older than 75 years) and weight groups (135 pounds or less, 136–150, 151–165, 166–180, 181–195, more than 195 pounds) with evaluation of the sites affected by osteoporosis. The groups were then combined to determine the number of women in each cell (eg, younger than 51 years and 135 pounds or less) to determine the specific sites affected in each cell and whether any specific group or cell could be identified as being at higher risk of osteoporosis.
Multivariate logistic regression analysis was done on each of the three sites scanned to determine differences in combinations of independent variables as significant predictors for the presence or absence of osteoporosis. Osteoporosis was defined by the criteria of bone mineral density being 2.5 standard deviations below the mean for young adult white women (T score) according to the National Health and Nutrition Examination Survey database.7 In evaluating the spine or hip, the cumulative T score was used, and the femoral neck was analyzed as an individual area.
Study variables included past or current use of steroids, thyroid replacement, heparin, oral contraceptives, estrogen replacement therapy, alcohol (none = 0, mild = 1, moderate = 2, excessive = 3), caffeine intake (0–3), exercise (0–3), dietary calcium intake (< 500 mg = 0, 500–1000 mg = 1, 1000–1500 mg = 2, > 1500 mg = 3), calcium supplementation (0–3), past or present smoking, presence or absence of uterus or ovaries, and family history of osteoporosis. Smoking history, oral contraceptive use, and estrogen replacement therapy were considered positive if use was 6 months or longer.
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Results |
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Osteoporosis was absent at all three sites in 873 women (64.8%), present in 473 women at one or more sites (35.2%), with 127 women having osteoporosis at all three sites. Of the total population evaluated, osteoporosis of the spine was present in 321 women, in the hip in 249 women, and in the femoral neck in 289 women, with the sole site affected being spine in 126, hip in 33, and femoral neck in 55 women.
Multivariate logistic regression analysis to determine which combination of independent variables was related to osteoporosis of the spine, hip, and femoral neck found increasing age to be a positive predictor P < .001 and increasing weight a negative predictor P < .001. Table 1
shows the number of patients in each weight group with the number and percentage of women in whom each site was affected. Similar data for age groups are given in Table 2.
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Discussion |
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Several impediments to screening large numbers of women have been cost and lack of access to dual-energy x-ray absorptiometry scanners. By carefully selecting the patients who are at the highest risk and are most likely to have osteoporosis, each scan center can better apportion the limited resources of equipment and dollars. This approach should appeal to managed care groups or capitated health care systems and allow them to offer this service to their at-risk female members. Current suggested risk factors alone have not proved useful in identifying women with low vertebral bone mass, and bone densitometry is critical in assessing low bone mass.10 Age is directly related to bone loss, with accelerated loss in the hip in women over 65 years old.11,12 Weight has been shown to be inversely related to bone mass and fractures in the hip and needs to be considered when establishing a screening program.13
Our current data support the direct relationship of age and the inverse relationship of weight to decreased bone mineral density. Also, never using estrogen in any oral form for more than 6 months is statistically associated with low bone mineral density and osteoporosis.
We suggest that women 61 years old or older who weight 165 pounds or less be screened; if they have never used oral estrogens, either the age or weight criterion can be used alone to determine the need for screening. By using these criteria for screening, patients with osteoporosis or osteopenia can be detected early and preventive measures or treatment can be initiated to decrease the profound morbidity and mortality from osteoporosis.
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Footnotes |
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Received August 3, 1998. Received in revised form October 22, 1998. Accepted October 29, 1998.
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References |
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2. Riggs BL, Melton LI. Involutional osteoporosis. N Engl J Med 1986;314:1676–86.[Medline]
3. National Osteoporosis Foundation. Boneing up on osteoporosis. A guide to prevention and treatment. Washington, DC: The National Osteoporosis Foundation, 1991.
4. Barrett-Connor E. The economic and human costs of osteoporotic fracture. Am J Med 1995;98(Suppl 2A):3S–8S.[Medline]
5. White BL, Fisher WD, Lacerin CD. Rate of mortality for elderly patients after fracture of hip in the 1980s. J Bone Joint Surg 1987;69A:1335–40.
6. Filer WD, Filer RB. Transdermal estrogen and prevention of osteoporosis. Am Fam Physician 1994;49:1639–44.[Medline]
7. Looker AC, Johnston CC Jr, Wahner HW, Dunn WL, Calvo MS, Harris TB, et al. Prevalence of low femoral bone density in older US women from NHANES III. J Bone Miner Res 1995;10:796–802.[Medline]
8. Lindsay R, Tohme J, Kanders B. The effect of oral contraceptive use on vertebral bone mass in pre- and post-menopausal women. Contraception 1986;34:333–40.[Medline]
9. Kleerekoper M, Brienza RC, Schultz L, Johnston CC. Oral contraceptive use protects against low bone mass. Arch Intern Med 1991;151:1971–6.[Abstract]
10. Ribot C, Pouilles JM, Bonneau M, Tremollieres F. Assessment of the risk of post-menopausal osteoporosis using clinical factors. Clin Endocrinol 1992;36:225–8.[Medline]
11. Black DM. Screening and treatment in the elderly to reduce osteoporotic fracture risk. Br J Obstet Gynaecol 1996;103:2–8.
12. Ensrud KE, Palermo L, Black DM, Cauley J, Jergun M, Orwoll ES, et al. Hip and calcaneal bone loss increase with advancing age: Longitudinal results from the study of osteoporotic fractures. J Bone Miner Res 1995;10:1778–87.[Medline]
13. Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM, Ensrud KE, et al. Risk factors for hip fracture in white women. N Engl J Med 1995;332:767–73.
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