Treatment of postmenopausal osteoporosis. How to treat postmenopausal osteoporosis? What is postmenopausal osteoporosis

The goal of the treatment of postmenopausal osteoporosis is to block the processes of bone tissue resorption and activate the processes of bone remodeling (formation).

Non-pharmacological treatment of postmenopausal osteoporosis

The diet should include foods high in calcium (fish, seafood, milk), as well as exclude alcohol, coffee and quit smoking.

Drug therapy for postmenopausal osteoporosis

In postmenopausal osteoporosis, pathogenetic systemic hormone replacement therapy is carried out. Also used drugs of other groups.

• Calcitonin 50 IU subcutaneously or intramuscularly after 1 day or 50 IU intranasally 2 times a day, a course of 3 weeks to 3 months with minimal symptoms of osteoporosis or as maintenance therapy. In severe osteoporosis and vertebral fractures, it is recommended to increase the dosage to 100 IU per day subcutaneously or intramuscularly 1 time per day for 1 week, then 50 IU daily or every other day for 2-3 weeks.
• Bisphosphonates (etidronic acid) 5–7 mg/kg body weight for 2 weeks every 3 months.
• Alendronic acid 1 capsule 1 time per week.
• Calcium carbonate (1000 mg) in combination with colecalciferol (800 IU). The drug is indicated both for the prevention of osteoporosis and fractures, and for the complex therapy of osteoporosis in combination with calcitonin or bisphosphonate. Reception of calcium carbonate with cholecalciferol is indicated for life.
• Tamoxifen or raloxifene 1 tablet once a day for no more than 5 years is usually prescribed for breast cancer and osteoporosis. The drugs do not have antiestrogenic properties, but have an estrogen-like effect on bone tissue, resulting in an increase in BMD.

Surgical treatment of postmenopausal osteoporosis

Do not use for this disease.

Patient education

It is necessary to explain to the patient that it is more difficult to restore bone tissue than to preserve it. Maximum bone mass is reached at the age of 20–30 years, and 3 main protective factors: physical activity, good nutrition and normal levels of sex hormones are a necessary condition for its preservation.

Further management of the patient

Therapy for postmenopausal osteoporosis is long-term. BMD should be monitored by bone densitometry once a year.

For a dynamic assessment of the effectiveness of treatment, it is recommended to determine the markers of bone tissue formation:

• serum osteocalcin;
• alkaline phosphatase isoenzyme;
• procollagen peptides.

One of the most important health problems worldwide is osteoporosis, a disease that occurs more frequently in women than in men. The urgency of the problem is caused by both social and some economic consequences that occur after osteoporotic fractures, their negative impact on the quality of human life.

Postmenopausal osteoporosis is the most common age-dependent form of the disease. The disease is characterized by a significant loss of bone mass in every third woman after the cessation of menstruation.

Specialist studies show that as a result of the onset of menopause (for the first 4–5 years), bone loss can reach 1/3 of the total bone mass. During the postmenopausal period, a third of all women have osteoporosis, and more than half have osteopenia.

Main risk groups

Are more likely to get sick:

• women with premature (35-38 years) or early (39-43 years) menopause;
• patients diagnosed with infertility or oligomenorrhea at childbearing age;
• many women giving birth, long-term breastfeeding (more than 2 years);
• genetic predisposition plays an important role;
• the presence of chronic diseases (diabetes mellitus, kidney disease, liver disease, low or overweight);
• bad habits;
• Caucasian race;
• the lowest mineralization of bone tissue.

Causes leading to illness

The main reason for the development of the disease, in which there is a maximum loss of bone tissue, is a deficiency of hormones. The onset of menopause leads to the progression of resorption (destruction) of bone mass.

The essence of the pathology is that in women in the period of menopause (after 40-45 years), the level of female sex hormones - estrogen - sharply decreases. Under the influence of hormone deficiency, the body loses the ability to absorb calcium, protein and other trace elements. Against this background, osteoblasts are activated, which destroy bone tissue, and this leads to irreversible consequences.

Comprehensive diagnostics will determine the severity of the pathology

Characteristic species

These factors play an important role in the development and course of the disease: the amount of bone mass in a woman before menopause, the rate at which bone loss occurs. Experts divide bone loss in postmenopausal women into 3 phases:

• Rapid loss - observed in the first 5 years of postmenopause. In this period, the annual loss of bone mass of the spine is 3%.
• Slow - the beginning of the phase occurs at about 55 years of age. The loss is approximately 0.5–1% per year (depending on the area of ​​the skeleton).
• Normal Loss - Bone loss occurs consistently at a rate of 1-2% per year.

Manifestations and symptoms

For a sufficiently long period from the onset of menopause, osteoporosis proceeds without any obvious clinical manifestations, so already sick people do not seek medical help. Only when there is already a significant loss of bone mass in the body, the following symptoms begin to appear:

• pain in the back, which tends to increase when turning the body, when walking fast, when lifting a slight weight, after a long stay on the legs, pain is especially pronounced in the lumbosacral region;
• rapid general weakness, fatigue;
• feeling of stiffness, heaviness and aching pain between the shoulder blades;
• hunched back, protruding belly and shortness of breath after exercise;
• increased pain symptoms in the spine and pelvic bones as the disease progresses;
• fractures of the vertebral bodies, distal radius and femurs;
• gradual flattening and deformation of the anterior walls of the vertebrae;
• weakening of the muscular corset of the back, which leads to the formation of a characteristic posture (stoop, kyphosis);
• gradual decline in growth;
• violation of the functions of internal organs.

Diagnostic methods

During the examination, the specialist pays special attention to the presence of changes in posture, impaired movements and gait, and a pronounced deformity of the chest. To clarify the diagnosis, radiography, computed tomography, and dual-energy X-ray densitometry (DEXA) are performed.

With age, the severity of the pathological process is aggravated

Medical treatments for postmenopausal osteoporosis

The primary importance and main task of a specialist is the correct choice of an effective treatment regimen. The method of treating the disease depends entirely on the individual tolerance and sensitivity of the body to the drug, risk factors, the effectiveness of drugs and the occurrence of side effects.

Modern doctors treat postmenopausal osteoporosis according to individually developed methods. These developments include a combination of anti-osteoporotic drugs and non-pharmacological methods.

Widely applied:

• biophosphonates (Etidronate, Clodronate, Tiludronate, Aledronate, Risedronate) - drugs have a pronounced effect on reducing resorption and remodeling (destruction) of bones by osteoclasts, reduce the risk of fracture by 40-50%;
• anabolic steroids (Tibolone) maximize bone mineral density;
• recombinant human paratrohormones (Teriparatide, HPTH 1-34) the use of drugs leads to an optimal increase in the level of mineralization of the bone tissue of the lumbar spine, is used in the treatment of especially severe forms of the disease;
• vitamin preparations (calcium preparations, vitamin D) - drugs used in combination reduce the risk of fractures.

If necessary, specialists use hormonal therapy (estrogens, androgens), painkillers, drugs that relieve tension and muscle spasm (muscle relaxants).

Antiresorptive therapy is especially popular among specialists. The technique is as follows: the use of female sex hormones, antiestrogens, taking calcitonin drugs, bisphosphonates, stimulants for the formation of bone tissue.

The priority role in choosing a group of drugs or a combination of drugs is played by the goal - the result of the treatment. The maximum reduction in the risk of fractures of the spine and limbs - treating doctors prefer drugs of the bisphosphonate group.

The goal of treatment is to minimize the risk of spinal fractures - selective modulators, bisphosphonates, vitamins. Severe forms of the disease are treated with parathyroid hormones, vitamin preparations. The treatment process is long from 2 to 5–8 years, requiring special endurance from patients, revising their lifestyle.

After 50 years, it is important to periodically conduct diagnostics that clarify the state of the woman's body.

Preventive actions

Prevention of the disease in postmenopausal women includes:

• Complete nutrition.
• Preventive measures to prevent bone loss in case of early menopause.
• Regular intake of drugs, which contain vitamin D, and drugs containing calcium.
• Physical activity.
• Healthy way of life.

It must be remembered: if postmenopause has contributed to the disease, you must consult a specialist. Be sure to include vitamin D and calcium in your diet. It is necessary to avoid all kinds of negative effects on bone metabolism. It is recommended to monitor your movements, to carry out preventive measures for diseases of the endocrine and digestive systems. Wearing hip protectors or a corset is recommended if necessary.

Osteoporosis that occurs in the postmenopausal period is an extremely important and socially significant problem of the modern world. Before proceeding to the analysis of the basic principles of therapy for this disease, it is necessary to carefully analyze some issues.

What is postmenopausal osteoporosis?

Postmenopausal osteoporosis- This is a chronically progressive systemic, metabolic disease of the skeleton due to a decrease in the content of minerals in human bone tissue, against the background of age-related fading of ovarian function.

This defeat is very insidious, since outwardly it practically does not manifest itself in any way. Only in the later stages can a woman be bothered by pain in the joints, back, until everything develops into frequent fractures.

In the first 5 years after menopause, the skeletal system loses almost a third of the mineral components, and given the increase in the general age of the population, the problem of menopausal osteoporosis is becoming increasingly important.

Causes

The main reasons for the development of the disease are considered to be:

• Decreased levels of the female hormone estrogen. One of the functions of the hormone estrogen is to participate in the regulation of mineral metabolism, including calcium metabolism, which is the main element of the human musculoskeletal system. After the extinction of the reproductive function, the level of estrogen in the body decreases, which means that the level of the main component of the skeletal system decreases. As a result, it becomes porous, soft, ceases to withstand loads. This is called menopausal osteoporosis. .
• Irrational nutrition. Another factor whose importance is often underestimated. Experts note that the majority of those suffering from this pathology follow an extremely inadequate diet. Such people, as a rule, consume insufficient amounts of dairy products, meat, greens, beans, vegetables. In addition, they do not compensate for this deficiency, which inevitably leads to calcium deficiency in the body.
• Low mobility. With age, the physical activity of most people, including women, decreases markedly. There can be many reasons: heavy, overweight, the consequences of injuries and emergency conditions in the past. All this also leads to a decrease in time spent outside, which entails a decrease in the production in the body, which is a necessary component for the successful absorption of calcium and maintaining bone density.

What factors predispose to postmenopausal osteoporosis?

The risk groups include people:

• over 65 years old;
• who have had early menopause;
• abusing smoking;
• abusing alcoholic beverages;
• having hormonal disorders, especially disorders of thyroid hormones, adrenal glands, pituitary gland;
• having a genetic predisposition.

Detailed mechanism of occurrence of menopausal osteoporosis

In the bone tissue of a healthy person, remodeling processes, that is, restructuring, are constantly taking place. Cells continuously re-form and resorb bone. This balance is maintained by a number of hormones that are closely dependent on each other.

After the completion of the period of functioning of the reproductive function of a woman, the ovaries cease to perform their tasks, including the production of sex hormones, in particular estrogen. The synthesis of estrogen is associated with the synthesis of calcitonin, which, in turn, reduces the level of parathyroid hormone.

Parathyroid hormone increases the content of calcium ions in the blood due to increased absorption in the intestine, due to resorption of bone tissue and a decrease in its excretion in the urine.

As mentioned above, malnutrition and insufficient physical activity provide a deficiency in calcium intake in the body. Therefore, the only result will be permanent destruction of the bone.

Additional reasons will be a deficiency of vitamin D, which is directly involved in the absorption of calcium; insufficient bowel function due to the inevitable aging processes, which is the cause of insufficient absorption of calcium from food; low mobility, disrupting adequate blood supply to the bones.

What are the symptoms of postmenopausal osteoporosis?

Unfortunately, due to its asymptomatic nature, menopausal osteoporosis cannot be self-diagnosed. As a rule, such a diagnosis is made in a medical institution after a woman enters there with a spontaneous fracture.

Primary signs that are usually ignored are − pain in the lower back, back, pelvis, legs, joints, which appears after physical exertion and disappears after rest, fatigue, leg muscles. Over time, these symptoms bother a woman more and more often.

It may also be alarming curvature of the spine in the form of a “hump”, a decrease in height by several centimeters per year, weight loss without changing volumes and proportions.

Untimely referral to a specialist leads to spontaneous fractures of the femoral neck, forearms, lower legs, and thoracic spine. All this together can lead to severe disability of a person and a violation of his mental health.

How is the diagnosis carried out?

After collecting an anamnesis and identifying risk factors for the occurrence of menopausal osteoporosis, the specialist prescribes studies designed to assess the condition of the bone tissue, as well as to detect signs of its destruction in blood tests.

The most common methods:

• Densitometry. It is carried out using an apparatus, the action of which is based on x-ray radiation. It evaluates bone density. The same study is available with the help of ultrasound diagnostics, as well as with the help of computed tomography. Parts of the skeleton most susceptible to osteoporosis: spine, hip joint, pelvic bones, humerus, radius bones, hands, feet.
• Blood chemistry. Here they pay attention to the amount of calcium, phosphorus, alkaline phosphatase, osteocalcin, which are direct evidence of bone destruction. In some cases, it is additionally carried out for calcium content.
• Blood test for hormone levels. First of all, the level of thyrocalcitonin and parathyrin, thyroid hormones responsible for calcium balance in the body, is determined. An additional study of the content of sex hormones makes it possible to make the final diagnosis of menopausal osteoporosis.

What drugs are used for treatment?

Modern methods of therapy for postmenopausal osteoporosis are aimed at eliminating the links of the pathological process. Drugs increase bone mineralization, stop resorption processes and prevent complications.

Main groups:

1. Bone stimulants. This group includes hormonal and steroid drugs, minerals. They act on the hormonal regulation of bone destruction and stimulate cells to form new tissue.
2. Drugs with multifaceted action. These, first of all, include calcium preparations in combination with vitamin D. This combination contributes to adequate absorption of the mineral, which allows the body to successfully use it to build new bone tissue. Flavonoid compounds and osseino-hydroxylate complexes inhibit the processes of destruction of the skeleton, inhibiting the activity of the cells responsible for this.
3. Medicines that prevent the mechanisms of bone resorption. In addition to hormonal drugs, this group includes bisphosphonates. It also includes hormonal agents: estrogens and progestins, calcitonin.

Bisphosphonates as the main link in the treatment of menopausal osteoporosis

In simple terms, the mechanism of bisphosphonate drugs is to suppress the functions of osteoblasts, cells that destroy bone tissue. That is, they act on the final link of osteoporosis.

These medicines have been used for a long time, since the middle of the twentieth century. Since then, many new drugs have been invented that can be divided into three generations.

The use of bisphosphonates has also become possible in the treatment of oncological diseases, since they are able to prevent tumor metastasis.

All drugs based on bisphosphonates can be divided into two large groups:

• nitrogen-free
• nitrogen-containing

Due to their molecular structure, they have features in the mechanism of action, which determines the scope of their application in the treatment of menopausal osteoporosis.

Bisphosphonate preparations belonging to this group contain a number of active substances in their composition that determine their properties, pharmacodynamics and pharmacokinetics:

• Alendronate sodium is the basis for second-generation drugs. This is a specific regulator of bone tissue metabolism, which has a non-hormonal nature. Therefore, bisphosphonate preparations with this active ingredient can be used in both men and women.
• ibandronic acid(INN) or ibandronate sodium is the basis of a number of third-generation drugs. It is indicated for women who have entered a complicated menopausal phase, for the prevention of osteoporosis, as well as in the case of a pathologically high content of calcium ions in the blood. For men, the use of bisphosphonates from this group is not recommended.
• Zoledronic acid. Its unique property lies in its molecular affinity with the structure of bone tissue, which determines the selective action of these drugs. Studies have found that bisphosphonate preparations containing zoledronic acid also have anticancer effects.

Nitrogen free

Representatives of this group belong to the first generation. But do not think that these are outdated and ineffective drugs. The use of nitrogen-free bisphosphonates is still widely used in the treatment of menopausal osteoporosis.

• Sodium tiludronate. It is widely used in the treatment of patients with deforming osteodystrophy and Paget's disease. It slows down the destruction of bone tissue, promotes the accumulation of calcium and phosphates in it, increasing the percentage of mineral substances.
• Sodium etidronate. It is prescribed for Paget's disease, osteoporosis, increased calcium ions in the blood.
• Clodronate. Affects the final links of menopausal osteoporosis: it inhibits the process of resorption of bone tissue and prevents the leaching of calcium from it. This compound is able to integrate into the structure of the skeleton, changing its chemical composition, strengthening bonds between molecules.

Rules for taking bisphosphonates

These medicinal substances are classified as potent, and therefore their purpose, dose and regimen should be strictly controlled by the doctor. In order for the selected therapy to be as effective as possible and not cause side effects, it is necessary to adhere to the following rules for the use of bisphosphonates:

• take the drug on an empty stomach, half an hour before breakfast;
• drink plenty of tablets with clean water;
• within an hour do not take a horizontal position;
• preparations containing calcium in combination with vitamin D should be consumed 2-3 hours after the use of bisphosphonates.

Complications and side effects of bisphosphonate drugs

Any serious disease requires effective and powerful medicines. Despite the high efficiency, the use of bisphosphonates is often accompanied by a number of undesirable manifestations and the occurrence of pathological conditions:

• damage to the kidney tissue;
• hypocalcemia, that is, a condition in which there are too few calcium ions in the blood;
• ulcerative lesions of the gastrointestinal tract;
• digestive disorders;
• violations of the heart;
• increased risk of developing osteonecrosis as a result of trauma, including in the jaw area after extraction and treatment of teeth;
• allergic reactions;
• skin reactions;
• muscle pain, general malaise, aching joints, fever;
• visual impairment.

Ways to prevent menopausal osteoporosis

No matter how trite it may sound, it is much easier and cheaper to prevent the development of some kind of pathological condition than to treat it. Basic conditions for reducing the risk of developing osteoporosis:

• Maintaining a healthy lifestyle. Quitting smoking and alcohol will greatly contribute to the long-term preservation of the functions of all organ systems.
• Optimal mode of physical activity. Physical inactivity causes the development of degenerative processes in the musculoskeletal system, including bone tissue.
• Balanced diet. Every day with food, the body must receive all the necessary minerals and trace elements. Fat-reducing diets may also contribute to the development of osteoporosis in later life.

Interesting

Osteoporosis is a common chronic systemic disease of the skeleton, which is characterized by a decrease in bone mass and disturbances in the microarchitectonics of bone tissue. These changes lead to bone fragility and, consequently, to a tendency to fracture. For osteoporosis, compression fractures of the vertebrae and the following fractures of the peripheral skeleton are most characteristic: the distal forearm, the proximal femur (neck or transtrochanteric region), and the neck of the shoulder.

A WHO report (2007) provides evidence of a high prevalence of this disease in various populations. Thus, osteoporosis is the cause of 8.9 million fractures occurring in the world annually. The lifetime risk of breaking a forearm, hip or spine is 30-40%, which corresponds to the risk of coronary heart disease. It is also important that osteoporosis occupies one of the leading places among diseases leading to immobility, disability and death. The vast majority of cases of osteoporosis occur in postmenopausal women (postmenopausal osteoporosis).

It is estimated that 14 million people in the Russian Federation (10% of the country's population) suffer from osteoporosis, and another 20 million have osteopenia. Thus, in Russia, 24% (34 million) of the population is in the group of potential risk of osteoporotic fractures. At the same time, every minute in the country in people over 50 years old, 7 fractures of the vertebrae occur, every 5 minutes - a fracture of the femoral neck.

Diagnosis of postmenopausal osteoporosis and subsequent treatment is based on clinical manifestations and an assessment of the risk of fracture. Postmenopausal osteoporosis can be diagnosed clinically based on the patient's minor traumatic fracture. The very fact of having such a fracture in history is evidence that the risk of subsequent fractures is very high. In addition, the risk of fracture can be assessed by densitometric examination of bone tissue (X-ray dual energy absorptiometry), as well as by calculating the 10-year absolute risk of fractures (FRAX) at http://www.shef.ac.uk/FRAX/index.jsp ?lang=rs . The FRAX calculator determines the likelihood of osteoporotic bone fractures based on the presence of clinical risk factors for osteoporosis and fractures in a patient, and the calculation is possible even without a densitometric study.

The main cause of bone loss in postmenopausal women is estrogen deficiency. Already in the first 5 years of postmenopause, the annual loss of bone mass in the spine is about 3%. Postmenopausal osteoporosis develops due to a significant increase in the rate of bone tissue remodeling due to the fact that estrogen deficiency leads to an increase in the number and activity of osteoclasts. The associated increased resorption, not compensated by adequate bone formation, leads to irreversible bone loss. High activity of osteoclasts causes perforation of trabeculae at the site of resorption, which leads to disturbances in the microarchitectonics of the bone and a decrease in its density. Thus, pharmacological correction of these pathogenetic mechanisms should be aimed at suppressing excessive bone resorption by osteoclasts and stimulating bone formation by osteoblasts.

Treatment of postmenopausal osteoporosis

The main goal of osteoporosis treatment is to prevent fractures. Based on the essence of the disease itself, this goal is achieved by increasing bone mineral density and improving its quality. In addition, a patient with pain syndrome must be adequately anesthetized, especially for patients with spinal lesions. One of the most important tasks of treatment is also the prevention of falls.

The effectiveness of the drug in the treatment of osteoporosis must be proven in multicenter, randomized, double-blind, placebo-controlled studies in which the primary endpoint is a reduction in the number of fractures characteristic of osteoporosis. A decrease in bone resorption markers and an increase in bone mineral density should also be demonstrated during long-term treatment (3-5 years). According to the recommendations of the Russian Osteoporosis Association, nitrogen-containing bisphosphonates and strontium ranelate are the first-line drugs for the treatment of osteoporosis. Recently, a new drug, denosumab, has joined them.

Bisphosphonates are stable analogues of naturally occurring pyrophosphates. They are embedded in the bone matrix, remain there for a long time and suppress bone resorption by reducing the activity of osteoclasts. Bisphosphonates are now an established method for the prevention and treatment of osteoporosis in both men and women. Studies successfully conducted in tens of thousands of patients have shown that bisphosphonates are safe, well tolerated, have few side effects, inhibit bone resorption, increase bone mineral density (BMD), and reduce the risk of fracture.

Currently, several bisphosphonates (alendronate, risedronate, ibandronate, zoledronic acid) are used in clinical practice with various routes and regimens of administration. The best known and well studied bisphosphonate is alendronate. Its clinical efficacy has been proven in qualitative studies in patients with osteoporosis, in particular in the presence of vertebral fractures (recommendation grade A). It is also effective in preventing osteoporosis in postmenopausal women with osteopenia (recommendation grade A). On average, alendronate reduces the risk of fractures of various locations by 50%, and the risk of multiple vertebral fractures by 90%. The drug is prescribed at a dose of 70 mg (1 tab.) once a week. In postmenopausal osteoporosis, risedronate 35 mg per week is also used.

Bisphosphonates have low bioavailability and also have a number of side effects, in particular, they can cause inflammatory lesions and erosion of the lower esophagus. To prevent this side effect and increase bioavailability, a bisphosphonate tablet should be taken in the morning on an empty stomach with 1-1.5 glasses of water, after which do not take a horizontal position and do not eat for 40-60 minutes. Such a complex regimen, unfortunately, leads to low adherence of patients to compliance with the recommendations. It is known that after a year only 30% of those patients who take bisphosphonates daily, and about 45% of those who take them once a week, continue treatment.

Recently, new bisphosphonates have appeared that have shown high efficacy and good tolerability with less frequent use, which increases compliance and adherence of patients to treatment. This is ibandronate, which is taken orally as a tablet 150 mg once a month or intravenously at a dose of 3 mg every 3 months, is indicated for postmenopausal osteoporosis; and zoledronic acid given once a year (5 mg).

Strontium ranelate is the first anti-osteoporotic drug that has a dual mechanism of action: it simultaneously stimulates bone formation and inhibits bone resorption. Strontium ranelate restores the balance of bone metabolism in favor of the formation of new and strong bone tissue, which provides early and long-term efficacy in the prevention of fractures of the spine and peripheral skeleton in postmenopausal osteoporosis. The drug is taken in powder (sachet 2 g) once a day, preferably at night, it must first be dissolved in a glass of water. Treatment with strontium ranelate, as with other drugs for osteoporosis, must be combined with calcium and vitamin D, but taken no earlier than 2 hours after calcium.

Denosumab is a new distinct class of drugs. It is a biological product that is a monoclonal antibody to the kappa-B factor activator receptor ligand (RANKL). The receptor itself (RANK) is the most important link in the activation of osteoclasts, however, without the presence of a ligand (RANKL), its activation does not occur. It has been shown that excessive production of RANKL by osteoblasts underlies the development of postmenopausal osteoporosis. It leads to the formation of a large number and excessive activity of osteoclasts, which is manifested in increased bone resorption. Blockade of RANKL by the corresponding monoclonal antibody, which is denosumab, leads to a rapid decrease in the concentration of bone resorption markers in blood serum and an increase in bone mineral density in all parts of the skeleton. These processes are accompanied by a reduced risk of fractures, including fractures of the spine, proximal femur, and other non-vertebral fractures. Denosumab is injected subcutaneously through a syringe tube already filled with the drug once every 6 months.

Before prescribing anti-osteoporotic drugs, it is necessary to examine serum calcium and creatinine clearance. Low serum calcium levels are most commonly caused by vitamin D deficiency and are fully corrected when given with adequate dietary and/or drug calcium intake. With creatinine clearance less than 30 ml / min, bisphosphonates and strontium ranelate are not prescribed. However, denosumab can be prescribed for chronic renal failure, while dose adjustment is not required.

Treatment of osteoporosis with any of these drugs should be long - at least 3-5 years. An obligatory component of any treatment regimen for osteoporosis is an adequate intake of calcium and vitamin D, although they have no independent value in the treatment of the disease, except for the prevention of hip fracture in elderly patients with vitamin D deficiency.

The daily requirement of calcium depends on the age of the patient and ranges from 800 to 1500 mg of ionized calcium. Dairy products are the main source of calcium. In addition, calcium is found in green leafy vegetables, cereals and soft fish bones, but in significantly lower amounts than in dairy products. To cover the daily need for calcium, it is enough to eat 6 glasses of low-fat milk or sour-milk products, or 200 g of hard cheese, or 1.5 kg of low-fat cottage cheese. In the case of low intake of calcium from food, which most often happens when dairy products are intolerant or unwilling to include them in the diet, in order to prevent osteoporosis (or if the disease has already developed), it is necessary to add calcium to food in the form of drugs. More than 70% of Russian residents consume less than half of the calcium required by age with food, which needs to be corrected.

Vitamin D is a group of steroid hormones that are formed in the body from dietary vitamins D2 and D3 and synthesized in the skin under the influence of ultraviolet rays (UVB) of vitamin D3. Vitamin D is an important regulator of bone metabolism. It enhances calcium absorption in the gastrointestinal tract, reduces calcium excretion in the kidneys, improves bone quality and enhances bone repair. A very important effect of vitamin D is to increase muscle strength and coordination. Co-administration of vitamin D3 with calcium has been shown to significantly reduce the risk of falls and, in older women, to reduce the incidence of hip fracture. Recently, evidence has appeared that vitamin D deficiency may be associated with the development of other diseases, such as arterial hypertension, diabetes mellitus, multiple sclerosis, tumors of various localizations, etc.

People living north of the 40th latitude, during 3-4 winter months (and in some areas up to 6 months) are not exposed to sunlight, which means that during this time vitamin D is not synthesized in their skin. It is believed that for inhabitants of the northern latitudes, sunlight is not enough without taking vitamin D with food. However, vitamin D is only found in a limited number of foods. These are fatty fish (herring, mackerel, salmon), fish oil, liver and fat of aquatic mammals.

It is known that in older people the ability of the skin to produce D3 is reduced. There is evidence that its absorption in the intestine also decreases with age. In addition, many people in older age groups do not leave the house due to chronic diseases that cause shortness of breath or joint pain, which limits their insolation. All this makes the additional administration of vitamin D extremely important. It is worth recalling that the intake of vitamin D must necessarily accompany the pathogenetic treatment of osteoporosis with antiresorptive agents or strontium ranelate. An additional benefit is the reduction in the risk of falls while taking vitamin D supplements, which plays a positive role in the prevention of fractures. The daily dose of vitamin D should be at least 800 IU. Vitamin D is desirable to add to calcium preparations, since it increases the absorption of calcium in the gastrointestinal tract by 50-80%. It should be noted that an adequate intake of calcium and vitamin D is important at any time in a woman's life and should not be limited to postmenopausal women. With a lack of dairy products in the diet, as well as in late winter - early summer, it is useful to additionally take calcium and vitamin D supplements.

In addition to the above first-line treatment of osteoporosis, salmon calcitonin, a synthetic analogue of the thyroid hormone calcitonin, which is involved in the regulation of calcium homeostasis, can be used in some cases. A feature of the drug Miacalcic containing salmon calcitonin is that it reduces the risk of fractures in the absence of pronounced BMD dynamics, which is explained by its positive effect on the quality of bone tissue (its microarchitectonics). The risk of new vertebral fractures in the treatment of Myacalcic is reduced by 36%. At the same time, the drug has another property that is widely used in clinical practice: Myacalcic has a pronounced analgesic effect in pain caused by fractures.

Hormone replacement therapy (HRT) with female sex hormones is highly effective in postmenopausal women with low mineral density (osteopenia) in preventing osteoporosis and vertebral and other fractures, including the femoral neck (recommendation grade A). However, it is known that the risks of its use may outweigh the benefits. Thus, it has been shown that long-term use (more than 5 years) is associated with the risk of developing breast cancer, coronary heart disease and stroke (recommendation grade A). In addition, one of the serious side effects of hormone replacement therapy is venous thrombosis (A). Therefore, when prescribing this treatment, the patient should be warned about possible complications.

At the same time, HRT is a first-line prophylactic therapy in women with menopause up to 45 years of age (recommendation level D), as well as an agent that effectively relieves clinical autonomic symptoms characteristic of menopause. In any case, the issue of prescribing HRT to a patient requires a thorough gynecological and mammological examination and monitoring.

In order to monitor the effectiveness of the treatment of osteoporosis with an interval of 1-2 years, an assessment of bone mineral density is carried out. At the same time, an increase in mineral density or even the absence of negative dynamics is interpreted as a manifestation of the fact that the treatment is effective. If possible, it is useful to study the dynamics of bone resorption markers (for example, degradation products of type I collagen - N-telopeptide (NTX) in the urine or C-telopeptide (CTX) in the blood serum): before the start of therapy and after 3 months. A decrease in their level by 30% indicates the effectiveness of the treatment, as well as that the patient is taking it correctly. If, while taking the recommended treatment, the patient does not experience a decrease in the level of resorption markers, or a decrease in bone mineral density, or a low-traumatic fracture occurs, the physician should evaluate the following factors before concluding that the treatment is ineffective. First, check whether the patient is taking treatment, if so, how much constantly and whether she takes breaks. Secondly, whether she takes it correctly (observing the regimen and frequency of administration) and whether the treatment with anti-osteoporotic drugs is accompanied by the intake of vitamin D and calcium. As experience shows, it is in these simple things that the cause of inefficiency most often lies.

In general, low compliance is a major problem in the treatment of osteoporosis. They manifest themselves in non-fulfillment or incomplete fulfillment of medical recommendations on diet and physical activity, complete refusal of treatment, interruption of the started therapy. Even the creation of easy-to-take dosage forms (prescribed once a week, once a year, drugs with fewer side effects, etc.) does not lead to a significant improvement in compliance rates. One of the possible reasons is incorrect or incomplete ideas of patients about osteoporosis, misunderstanding of the goals and methods of its treatment. So, according to the results of our study, out of 128 surveyed patients with osteoporosis, 54 people. (42%) were unaware that skipping a prescribed medication increases the risk of fractures; 118 respondents (92%) believed that only taking vitamin D and calcium in therapeutic doses was enough to prevent fractures; 55 people (43%) were sure that pharmacotherapy allows them to stop doing physical exercises. At the same time, the vast majority (> 90%) of the doctors who treated these patients noted that at each or almost each consultation they provide information to patients on these issues. Low awareness led to a decrease in patients' motivation: patients did not see the benefits of osteoporosis treatment, and one in three of them did not take anti-osteoporotic drugs.

In addition, other factors worsen compliance: the severe physical condition of the patient; financial difficulties; lack of family support; negative experience (fracture occurred against the background of prescribed therapy); denial by the patient of personal responsibility for their health. A special place among these factors is occupied by psychosocial components, primarily the presence of a depressive disorder in a patient. According to population studies, about 42% of the population have depressive symptoms above the threshold level, and in older age groups this figure rises to 76%.

The relationship between osteoporosis and depressive disorders is complex and multilevel. There are a number of common risk factors and pathogenetic components associated with both diseases: female gender, advanced age, chronic pain, chronic disabling diseases, malnutrition (low weight or, conversely, abdominal obesity), prolonged immobilization, sleep disturbances, a tendency to fall from - for frailty, hypercortisolemia, vitamin D deficiency, etc. Older-specific risk factors for depression that are also related to osteoporosis, falls and fractures - visual and hearing impairment, sleep disturbances, recent identification of a new disease, smoking and alcohol abuse. The last two are proven risk factors for osteoporosis. It has been proven that depressive disorders lead to a decrease in bone mineral density and an increase in the risk of fractures. In turn, depression worsens the course of osteoporosis, slowing down rehabilitation and reducing adherence to treatment.

The features of the clinical picture of this pathology in the elderly make it difficult to diagnose depression. This is the absence or minimal severity of sadness, melancholy, complaints of a bad mood and manifestation only (or predominantly) of somatic disorders: persistent pain of different localization, autonomic dysfunction, deterioration in physical performance, changes in sleep, appetite, weight. All of the above dictates the need for timely targeted detection and treatment of depression in patients with osteoporosis, as well as the detection and treatment of osteoporosis in patients with depression in the general medical network, which is consistent with WHO recommendations, but is not yet a daily practice.

On the other hand, low compliance in osteoporosis may be associated with the lack of skills of doctors in counseling a patient with this pathology. Common mistakes are the abuse of medical terms, a directive (paternalistic) approach to prescribing recommendations, ignoring the psychological characteristics and circumstances of the patient's life, excessive attempts to "push" the patient to make the only correct (from the doctor's point of view) decision, cultural, language barriers, etc. Therefore, today there is a need for doctors to acquire the skills of behavioral counseling. Such counseling is aimed at lifestyle modification and systematic medication in a patient who does not yet have symptoms of the disease (and problems associated with it), but at a high risk of complications. The key features of behavioral counseling in osteoporosis are the doctor's ability to determine the patient's level of knowledge about his illness and individual risk of fractures, the ability to assess the patient's readiness for treatment, find the patient's individual sources of motivation, and competently encourage the patient to change behavior (diet, exercise, medication).

In general, possible ways to improve compliance in osteoporosis are seen in the following areas. Firstly, it is an improvement in the quality of interaction between the doctor and the patient. Thus, a number of studies testify to the effectiveness of educational programs for doctors (on the identification and treatment of depression, training in conducting preventive motivational interviews, etc.), although this issue requires further study. Secondly, educational programs have proven themselves well - the so-called "Health Schools for Patients with Osteoporosis". In addition, long-term management of a patient with osteoporosis by one doctor is desirable, which allows monitoring risk factors, observing and consulting him in dynamics, correcting therapy taking into account comorbidities, psychological support and work with the family. The competence of a general practitioner allows the best way to carry out such work, however, any qualified specialist can take on the functions of a “doctor-manager” and carry out high-quality treatment of a patient with osteoporosis.

Literature

1. Kanis J.A. On behalf of the World Health Organization Scientific Group (2007). Assessment of osteoporosis at the primary health care level. technical report. World Health Organization Collaborating Center for Metabolic Bone Diseases, University of Sheffield, UK. 2007: Printed by University of Sheffield.
2. Lesnyak O. M. Audit of the state of the problem of osteoporosis in the Russian Federation // Preventive Medicine. 2011, vol. 14, no. 2, 7-10.
3. Osteoporosis / Ed. O. M. Lesnyak, L. I. Benevolenskaya. 2nd ed., revised. and additional (Series "Clinical recommendations"). M.: GEOTAR-Media, 2011. 272 ​​p.
4. Zakroeva A. G. Andriyanova O. V., Solodovnikov A. G. Comparative study of mental health indicators and their associations with risk factors for chronic non-communicable diseases in rural and urban populations // Ural Medical Journal. 2009; 2: 83-93.
5. Chang-Quan H., Xue-Mei.Z., Bi-Rong D., Zhen-Chan L., Ji-Rong Y., Qing-Xiu L. Health status and risk for depression among the elderly: a meta-analysis of published literature // Age Aging. 2010; 39:23-30.
6. Paudel M. L., Taylor B. C., Diem S. J., Stone K. L., Ancoli-Israel S., Redline S., Ensrud K. E. Osteoporotic Fractures in Men Study Group. Association between depressive symptoms and sleep disturbances in community-dwelling older men // Am Geriatr Soc. 2008; 56(7): 1228-1235.
7. Zakroyeva A., Goldberg D., Gask L., Leese M. Training Russian family physicians in mental health skills // Eur J Gen Practice. 2008; 14(1):19-22.
8. Toroptsova N. V., Nikitinskaya O. A."Osteoscreening Russia" - a social program to identify the risk of fractures in the population: first data // Practitioner. 2012, No. 3, 45-48.

O. M. Lesnyak,doctor of medical sciences, professor
A. G. Zakroeva, Candidate of Medical Sciences, Associate Professor

GBOU VPO UGMA of the Ministry of Health and Social Development of Russia, Ekaterinburg

Osteoporosis is a systemic skeletal disease characterized by a decrease in bone mass, a violation of bone microarchitectonics, followed by an increase in bone fragility and an increased risk of fractures. The loss of bone mass occurs gradually and is often diagnosed only after fractures. As women live longer, the risk of osteoporosis and fracture increases.

In adult individuals, the mineral composition of bone tissue is determined by the influence of several factors: heredity, physical activity, dietary habits and hormonal status. A few years after reaching the peak of bone mass by the age of 30-35, its loss begins, which is a universal phenomenon of human biology, occurring regardless of gender, race, profession, habitual activity, features of economic development, geographical area of ​​​​residence and historical era. The average bone loss in a woman is approximately 1% per year relative to the level of peak bone mass in reproductive age. The acceleration of this process occurs within the first five years after menopause.

Primary or involutional osteoporosis is a systemic lesion of the skeleton of the elderly (50 years and older).

Primary

Primary osteoporosis pathogenetically develops in the form of two clinical variants:

• postmenopausal;
• senile or senile

Risk factors for primary osteoporosis are often hereditary and are also associated with family and/or personal history:

• elderly age;
• graceful, short women with a fragile physique and fair skin, especially from among the inhabitants of the countries of Northern Europe and Asia;
• family history of fractures;
• later than menarche (after 15 years);
• early menopause (before 50 years);
• oligo- or amenorrhea in reproductive age;
• anovulation and infertility;
• more than 3 pregnancies and childbirth in reproductive age;
• prolonged lactation (more than 6 months)

Secondary

Secondary osteoporosis is a multifactorial disease in which the following factors play a role:

• endocrine (hyperthyroidism, hypoparathyroidism, hypercortisolism, diabetes, hypogonadism);
• malnutrition and calcium deficiency in the diet;
• excessive intake of alcohol, nicotine, coffee (more than 5 cups a day);
• long-term use (over 4 weeks) of corticosteroids, heparin, anticonvulsants;
• genetic factors: incomplete osteogenesis, low peak bone mass;
• other factors: chronic renal failure, decreased absorption of calcium in the intestine, prolonged immobilization, physical inactivity.

The frequency of primary osteoporosis in developed countries is 25-40% with a predominance of this disease among white women. By the age of 70, 40% of white women have a history of at least one fracture due to osteoporosis. Among black African women, the incidence of osteoporosis is 11-12%. Among the residents of Moscow, osteoporosis of the lumbar vertebrae in the population of women aged 50 and over was found in 23.6%. The frequency of bone fractures in women in the age group of 50-54 years increases by 4-7 times in comparison with men of the same age and continues to increase in older age groups. Among women who have undergone bone fractures, osteoporosis is found in 70% of cases.

In bone tissue, the processes of formation and resorption are constantly taking place. In the processes of its formation, osteoblasts play a leading role, resorption - osteoclasts (Fig. 14). In the period of reaching peak bone mass, the processes of formation prevail over the processes of resorption. Loss of bone mass in menopause is primarily accompanied by damage to bones with a predominance of spongy substance (vertebral bodies, distal forearm bones, etc. (Fig. 15).

Senile osteoporosis develops after 70 years of age and is characterized by a predominant lesion of tubular bones with an increase in hip fractures. With the same rate of bone loss, the severity of its deficiency in elderly women primarily depends on the magnitude of its peak mass. Deficiency of sex hormones in menopause can have both direct and indirect effects on the state of bone tissue.

Pathogenesis

The pathogenesis of osteoporosis in estrogen-deficient conditions is characterized by:

• increased sensitivity to parathyroid hormone due to an increase in the content of parathyroid hormone receptors in the bone tissue and increased resorption;
• a decrease in the level of calcitonin, which stimulates the synthesis of calcitriol in the kidneys and, accordingly, a decrease in Ca absorption;
• increased Ca excretion in the urine;
• decreased absorption of calcium in the intestine;
• decreased hydroxylation of vitamin D in the kidneys;
• insufficient supply of Ca to bone tissue

The direct effect of exogenous and endogenous sex hormones (estradiol, progesterone and testosterone) on bone tissue is carried out by binding them to specific receptors on osteoblasts. Thus, spongy bone tissue is a kind of target organ for sex hormones.

The processes of formation and resorption of bone tissue are also associated with the influence of a number of local factors that can have an inhibitory and stimulating effect on osteoblasts and osteoclasts. Thus, proliferation, differentiation and overall activity of osteoblasts (collagen synthesis, bone matrix formation) are stimulated by transforming growth factor, insulin-like growth factors (somatomedins), α-microglobulin, osteopectin and other factors. Stimulation of proliferation, differentiation and resorptive activity of osteoclasts is carried out by prostaglandins E2, interleukins-1 and -6, vasoactive intestinal peptide, interferon, tumor necrosis factor, lymphotoxins, macrophage colonizing factor, etc. Age-related loss of a part of the spongy layer disrupts the bone structure and contributes to fractures.

The generally accepted hypothesis about the mechanism of development of osteoporosis is based on the idea of ​​the protective effect of estrogens in relation to bone tissue. A decrease in the level of estrogenic influences of various etiologies makes the bone tissue more sensitive to the resolving effect of parathyroid hormone and / or vitamin D3. The protective effect of estrogens is realized through calcitonin, the secretion of which is stimulated by estrogens. In this regard, in postmenopause, the need for Ca increases, to maintain the balance of which it is necessary to replenish the daily requirement in the amount of 500 to 1500 mg. In accordance with changes in bone density, with a decrease in bone density by 10%, the risk of fractures of the vertebral column and the proximal part of the femur increases by 2-3 times.

The decrease in the density of the spongy substance of the vertebrae in early postmenopause is in direct relation to the initial volume of bone tissue: the higher the density of the latter, the greater the magnitude of the absolute loss. Especially great is the loss of bone tissue in early postmenopause, when the mass of the spongy substance of the vertebral processes decreases per year by 5%, and the cortical layer - by 1.5%.

In the development of age-related OP, parathyroid hormone plays the role of a mediator. Changes in mineral homeostasis and bone tissue deficiency develop against the background of a decrease in the function of the parathyroid glands, the endocrine function of the kidneys, and other manifestations of age-related involution.

Clinical picture

Osteoporosis develops gradually and may go unnoticed for a long time. The manifestation of its characteristic symptoms reaches a maximum after about 10-15 years (Fig. 16).

The main clinical symptoms are bone pain, especially often in the bones of the lumbar or thoracic spine, which can transform into a picture of sciatica. There is a slow decrease in height with corresponding changes in posture, a progressive limitation of motor activity of the spine, and loss of body weight.

Patients are often treated for a long time without sufficient effect for "radiculitis", erroneously diagnosed multiple myeloma, malignant tumor metastases, multiple spinal injuries.

Fractures are the late and most striking manifestations of osteoporosis. Often, fractures occur at home when falling from a height of growth. The most frequently observed fractures of the radius, vertebrae. Especially tragic are fractures of the femoral neck, mortality in which is observed in 20-25% of cases during the first 6 months, and severe disability occurs in 40-45% of cases.

Diagnosis of osteoporosis

1. Studying the anamnesis
2. Determination of body weight and height
3. Determination of bone mineral density

Single Photon Densitometers commonly used to measure bone mineral density in the hand, distal bones of the forearm or lower leg. The equipment of this class is easy to operate, mobile, small in size and light in weight, does not require a separate room and long-term training of operators. The duration of one study (without data analysis) is 5-10 minutes. Single photon densitometers can be used for screening studies.

At the same time, it should be taken into account that the indicators of mineral density of the distal parts of the bone skeleton in a significant number of women in peri- and postmenopause may differ little from the norm and do not always reflect age-related metabolic changes.

Two-photon X-ray densitometry is based on the use of a modification of two-photon radionuclide densitometers. The latest models make it possible to examine any bone and the entire skeleton in two or more projections. The examination time has been significantly reduced by increasing the number of detectors. The duration of the study is 1-15 minutes, depending on the immediate task and the model of the device.

Quantitative computed tomography. The main disadvantages of this method are associated with the difficulties that arise in the study of small bones due to the so-called "partial volume effect" and with a relatively large total radiation exposure during long-term dynamic observations.

Ultrasonic densitometry. It has advantages in the examination of postmenopausal women, since against the background of estrogen deficiency, trabecular bones are primarily affected. The object of study is usually the calcaneus.

X-ray diagnostics- informative when the loss of bone mass is over 30%.

To assess the activity of the processes of bone formation and resorption, as well as in the dynamic assessment of the effectiveness of the treatment, they resort to the determination of biochemical markers.

Prevention

Maintaining bone mass is an easier task than restoring it. In this regard, the prevention of osteoporosis, which should be carried out throughout the life of a woman, is of particular importance. At the same time, serious attention should be paid to the formation of peak bone mass and the creation of a skeleton with maximum strength by puberty and the prevention of postmenopausal and age-related deficiency of the mineral composition of bone tissue.

Since the genetic determinants of bone tissue are predetermined, the focus should be on environmental factors, the period of bone growth during adolescence, pregnancy, lactation, and the perimenopausal period.

• complete nutrition with adequate intake of calcium-containing foods;
• physical activity, "ability to fall";
• exclusion of bad habits (smoking, coffee, alcohol);
• maintaining a regular menstrual cycle in reproductive age;
• active advertising of preference of dairy drinks to carbonated ones;
• timely identification of risk groups;
• the appointment of vitamin D and calcium supplements, incl. and in women over 70;
• prevention of a progressive decrease in peri- and postmenopausal bone loss is also achieved through the administration of sex hormone preparations

It is generally accepted that a postmenopausal woman should receive 1200-1500 mg of calcium per day, which is preferably compensated by a complete diet. Dairy products are the most natural source of calcium. In cases of enzyme deficiency, milk allergy, or blood lipid problems, calcium tablets may be used. Vitamin D stimulates the absorption of calcium in the intestine, reduces the activity of parathyroid hormone and increases the activity of bone formation processes.

Treatment

Due to the fact that the pathogenesis of postmenopausal osteoporosis is quite complex and ambiguous, the treatment of this group of patients aims to block the processes of bone resorption and, at the same time, activate the processes of bone formation.

For the treatment of osteoporosis are used:

1. Sex hormone preparations:
   • estrogens + gestagens, in the form of mono-, two- and three-phase preparations;
   • estrogens + androgens
2. Calcitonin
3. Bisphosphonates
4. Vitamin D

I. The mechanism of the protective effect of estrogens on bone tissue:

• activation of calcitonin synthesis;
• blockade of parathyroid hormone activity by reducing its synthesis or reducing the sensitivity of osteoclasts;
• decreased sensitivity of bone tissue to the absorbable action of vitamin D3 metabolites;
• activation of the processes of hydroxylation of vitamin D 3 in the kidneys and its transformation into the active form 1,25-dihydroxycholecalciferol;
• increased absorption of calcium in the intestine;
• decrease in the catabolic effect of thyroxine due to increased thyroglobulin synthesis

Optimal doses of estrogens for the prevention and treatment of osteoporosis:

• estradiol-valerate 2 mg per day;
• conjugated estrogens - 0.625 mg

The protective effect of gestagens on bone tissue is manifested in the form of a direct effect through specific receptors on osteoblasts and indirectly by blocking receptors for glucocorticoids and reducing their inhibitory effect on bone tissue.

Contraindications for hormone replacement therapy in osteoporosis:

• tumors of the uterus, ovaries and mammary glands;
• uterine bleeding of unknown origin;
• acute thrombophlebitis;
• acute thromboembolic disease;
• thromboembolic disorders associated with estrogen intake;
• renal and liver failure;
• severe forms of diabetes

In the course of substitution therapy, blood pressure control, oncocytological examination, ultrasound of the genitals and mammography once a year, regular participation of patients in mini-lectures and group discussions about the benefits and safety of hormone therapy are required every three months.

Postmenopausal hormone therapy remains the therapy of choice for the prevention and treatment of postmenopausal osteoporosis.

Hormone replacement therapy has a positive effect on bone mass. A placebo-controlled study showed that after three years of continuous treatment, the mineral composition of the bones of the forearm was 9% higher than that of women in the placebo group (Fig. 17).

In order to prevent osteoporosis, the appointment of hormonal drugs is indicated for a period of time within 5-8 years of postmenopause. When carrying out replacement therapy, not only does bone loss stop, but the mineral density of bone tissue increases both in the spine and, importantly, in the femoral neck.

II. Calcitonin(CT) is prescribed in cases of verified osteoporosis if there are contraindications to the prescription of sex hormones or if the patient has a negative attitude towards them.

The main biological effect of CT:

• inhibits bone resorption by inhibiting activity and reducing the number of osteoclasts;
• has a pronounced analyzing effect on bone pain through interaction with P-endorphins;
• contributes to the reparative formation of bones in fractures, blocking the breakdown of collagen;
• increases the supply of calcium and phosphorus to the bone

The formation of CT in the body can be stimulated by prescribing testosterone, estrogens, progestogens, and combined estrogen-progestin preparations.

In clinical practice, synthetic CT is widely used, which is 20-40 times more active than natural (Table 4).

Patients should receive 600–1200 mg of calcium daily in addition to taking CT. Adverse reactions are observed in 10-30% of cases (nausea, dizziness, polyuria, chills, hot flashes).

III. Bisphosphonates(ksidifon) - active analogues of pyrophosphate, which blocks the processes of bone resorption and is prescribed at a dose of 5-7 mg / kg of body weight for 14 days, one course of treatment in 3 months. According to biochemical and densitometric studies, the stop of bone resorption is determined. In high doses, bisphosphonates can block bone mineralization (!).

IV. Vitamin D 3. Its biological action is:

• stimulation of absorption of calcium and phosphorus in the intestine;
• simultaneous impact on the processes of resorption and formation of bone tissue through the blockade of parathyroid hormone secretion;
• increasing the concentration of calcium and phosphorus in the matrix and stimulating its maturation;
• influence on growth factors, which contributes to increased bone strength

The selection of the dose of vitamin D 3 is carried out during the first two weeks under the control of serum calcium levels. Subsequently, it is necessary to control the calcium balance every 2-3 months. Vitamin D supplementation is indicated for life, as it can be an effective way to prevent senile osteoporosis.

Activation of bone formation processes can be achieved by prescribing sodium fluoride, anabolic steroids and active forms of vitamin D. Sodium fluoride at a dose of 75 mg with the addition of calcium has a long-term anabolic effect on bone tissue. Anabolic steroids can be used for severe osteoporosis in the elderly, however, side effects (hirsutism, deepening of the voice, increased atherogenic lipid fractions, etc.) limit their use for a long time.

Despite the variety of methods for the prevention and treatment of postmenopausal osteoporosis, the most reasonable method of exposure for the purpose of prevention and pathogenetically sound treatment is the use of sex hormone preparations.

A serious argument in favor of prescribing hormone replacement therapy for women of any age for the prevention and treatment of hormone deficiency conditions is evidence of a 50% reduction in the risk of fractures of the bones of the forearm and femoral neck after treatment during the first 5-7 years after menopause.

Due to the important medical and social significance of the problem of postmenopausal osteoporosis and the significant material costs associated with the treatment and rehabilitation of patients with osteoporosis and bone fractures in modern society, special attention should be paid to screening examinations to identify risk groups.

• Carrying out the first screening at the age of 50 makes it possible to identify three degrees of risk, justify the need for hormonal exposure and clarify the time of re-screening;
• Screening at age 70 provides more accurate risk prediction by age 80.