Bone Loss During the Perimenopausal Transition Should a clinician be concerned about bone loss and consider interventions

during the perimenopausal years? Some studies have concluded that calcium supplementation of perimenopausal women retards metacarpal and lumbar bone loss.480, 481 However, the amount of perimenopausal bone loss is small unless estrogen levels are below normal. 482, 483 and 484 Healthy women (exercisers and nonexercisers) who are anovulatory or who have inadequate luteal phase function (and thus are exposed to less progesterone) do not have an increase in bone loss. 485, 486 Interventions and treatments to prevent future osteoporosis are not necessary in women who have adequate estrogen levels and who are eating normally. Signs and Symptoms The osteoporotic disabilities sustained by the castrate or postmenopausal woman include back pain, decreased height and mobility, and fractures of the vertebral body, humerus, upper femur, distal forearm, and ribs. Back pain is a major clinical symptom of vertebral compression fractures. The pain with a fracture is acute, and then it subsides over 23 months, but lingers as chronic low back pain due to increasing lumbar lordosis. The pain will subside within 6 months unless multiple fractures produce a picture of constant pain. Epidemiologic studies have revealed the following: 487 1. Spinal (vertebral) compression fracture. Symptomatic spinal osteoporosis, causing pain, loss of height, postural deformities (the kyphotic Dowager's hump) with consequent pulmonary, gastrointestinal, and bladder dysfunction, is 5 times more common in white women than men. Approximately 50% of women over 65 years of age have spinal compression fractures; about two-thirds are clinically unrecognized. Each complete compression fracture causes the loss of approximately 1 cm in height. The average non-treated postmenopausal white woman can expect to shrink 2.5 inches (6.4 cm). The most common sites for vertebral fractures are the 12th thoracic and the first 3 lumbar vertebrae. These physical changes also have a negative impact on body image and self esteem. 2. Colles' fracture. There is a 10-fold increase in distal forearm fractures in white women as they progress from age 35 to 60 years. A white woman has approximately a 15% lifetime risk of a forearm fracture. Colles' fractures are the most common fractures among white women until age 75, when hip fractures become more common. 3. Head of femur fracture. The incidence of hip fractures increases with age in white women, rising from 0.3/1000 to 20/1000 from 45 to 85 years. Eighty percent of all hip fractures are associated with osteoporosis. White women have approximately a 16% lifetime risk of having a hip fracture. This fracture carries an increased risk of morbidity and mortality. Between 1520% of patients with hip fracture die due to the fracture or its complications (surgical, embolic, cardiopulmonary) within 3 months, and Beals found that only half of hip fracture victims in Portland, Oregon, survived for 1 year. 488 However, most of this increase in mortality is due to underlying conditions and prevention of these fractures would have only a minor impact on longevity. 489 Nevertheless, the survivors are frequently severely disabled and may become permanent invalids. Hip fractures alone occur in more than 300,000 women per year in the U.S. with a mortality of 40,000 annually and an associated cost of billions of dollars. 4. Tooth Loss. Oral alveolar bone loss (which can lead to loss of teeth) is strongly correlated with osteoporosis, and the salutary effect of estrogen on skeletal

bone mass is also manifested on oral bone. 490 Even in women without osteoporosis, there is a correlation