Commentary on guidelines on osteoporosis and menopause - Indian Menopause Society

The rapid advances in our knowledge can make it challenging for medical practitioners to keep up to date with best practice medicine. Increasingly the publication of Guidelines enables this information to be disseminated in a coherent way.[1] The Indian Menopause Society (IMS) has recently produced two significant and comprehensive Guidelines – Menopause and post-menopausal osteoporosis. Both of these documents summarize the current evidence and most importantly apply it to the Indian environment.

The Osteoporosis Guideline not only discusses the diagnosis and management of osteoporosis, but also has specific epidemiological data for the Indian population. Although information on fracture incidence is limited, the prevalence of this condition appears to be high and may relate to nutritional and life-style factors. An earlier than average menopause is also critical. The Guidelines highlight important issues such as the use of bone mineral density and Fracture risk assessment tool (FRAX) to assess fracture risk particularly when country-specific data is not available and what is relevant in Europe and North America may not be applicable to India. The document provides a comprehensive list of Indian foods and their calcium content, which practitioners and the public will find very useful.

The use of calcium supplementation has been controversial in some parts of the world and the role of vertebroplasty/kyphoplasty continues to be debated. However, the IMS has taken a clear position on their role in managing osteoporosis.[2,3] Clinical studies have shown an increased fracture and fall risk with high dose intermittent vitamin D supplementation and hence collecting some local Indian data would be important given the recommendations for high dose vitamin D supplementation.[4] The IMS has commendably stayed well-clear of recommending vitamin D for extra-skeletal benefits in the absence of convincing data.

I am delighted to see the inclusion of Hormone replacement therapy (HRT) as a prevention and treatment option for the early post-menopausal woman. The Women’s Health Initiative lead to the abandonment of hormone therapy in this area and we now know that it is safe and effective in the younger group. Recommendations about the yearly use of zoledronate may alter with time as more data showing efficacy with less frequent dosing becomes available.

The flow chart is something that every doctor should have in their office to guide their practice.

The Menopause Guideline is an extremely comprehensive document on managing mid-life women’s health and has useful demographic data for India, highlighting the earlier age of menopause and the earlier age of onset of fractures, and cardiovascular disease. The discussion on country-specific rates of disease, contraceptive use, and the variability of menopause symptoms is very valuable.

It is helpful in outlining the process of diagnosing menopause, relying on history rather than blood tests. Too often a woman is dismissed if her Follicular stimulating hormone (FSH) is normal. There are few indications for measuring an FSH and these are discussed. However, women taking the oral contraceptive pill will continue to have low FSH and estradiol levels and these tests will still not be helpful as diagnostic tools in this group. In the future, the Guidelines may highlight the utility of measuring Anti Mullerian Hormone (AMH) as validated assays become available and its role is clarified.

There has been a growing body of research examining the benefits and risks of a variety of hormone products and I was pleased to see that the Guideline also sets out the potential advantages of using micronized progesterone and transdermal estrogen over alternative products.

The IMS deserves congratulations on a monumental amount of work to put these guidelines together. They follow in the footsteps of the International and North American Menopause Societies. It would have been very easy to replicate their work. However, the IMS has produced two documents that are country-specific and this makes these Guidelines much more relevant. The challenge will be to update them on a regular basis to ensure they remain a best-practice guide for Indian medical practitioners.