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Data on the relation between skeletal BMD and tooth loss are not yet available from the described WHI cohort, but other studies have examined this issue. The Study for Osteoporotic Fractures Research Group reported an association between tooth loss and the rate of systemic bone loss among 4,524 U.S. women age > 65 who reported being dentate at baseline and who returned approximately 5.7 years later for a followup visit. On adjustment for age, weight, use of estrogen, and smoking status, it was found that women reporting tooth loss had higher annual decreases in hip BMD than women who did not lose teeth (0.68 percent versus 0.54 percent, p < 0.0029). 132 7.3 Approaches to Therapy Bone regenerative procedures, such as guided tissue regeneration and grafting, have already become commonplace for treatment of localized oral bony defects, and their use is likely to expand. State-of-the-art treatment for tooth loss focuses on the placement of single or multiple teeth implants; this approach, too, is gaining wide acceptance. Long-term studies are underway to evaluate the effect of antibiotics on progressive oral bone loss. Another promising area of research is the use of NSAIDs133 and bisphosphonates134 There are several important clinical implications of an association between oral status and skeletal status. to control host inflammatory and/or bone resorptive responses. Given the data relating oral bone loss and osteoporosis, it has been hypothesized that treatments used to maintain or improve skeletal bone density may favorably affect oral bone status and tooth loss. Two large cohort studies have examined the effect of HRT on reported tooth loss. 135,136 Analysis of data on 48,483 participants in the Nurses’ Health Study in the United States 136 showed that among women who reported regular dental visits there was an inverse relation between current hormone use and loss of teeth after controlling for age 194 and cigarette smoking. Among the 3,921 women in the Leisure World Cohort Study who provided suitable data with which to assess tooth status, estrogen users had significantly lower age-adjusted tooth loss and edentulism rates compared with nonusers. 111 Studies of the effect of other boneenhancing agents on tooth loss have been limited, but some trials have demonstrated positive findings. Data obtained from women with normal spine densities enrolled in a randomized nutritional intervention trial indicate that a smaller proportion of women taking calcium supplements reported tooth loss compared with those taking placebo. 137 A pilot trial has provided evidence of a lower RR for progressive oral bone loss among alendronatetreated participants than in placebo controls. 138 7.4 Clinical Perspective on Oral Bone Loss There are several important clinical implications of an association between oral status and skeletal status. On one side of the issue, it is possible that oral examination and radiographic findings may be useful signs of extra-oral bone diminution. Although preliminary studies along these lines have yielded promising findings, it is too early to know the value of routine dental visit information in signaling the need for skeletal bone evaluations. 139 On the other side, history of skeletal osteopenia may impact the need for, and outcome of, a variety of periodontal and prosthetic procedures including guided tissue regeneration and tooth implantations. If therapy for skeletal bone conditions is undertaken and is successful, the oral cavity may reap benefits as well. A connection between menopausal estrogen deficiency and oral bone loss is biologically plausible, and many research findings to date are consistent with that link. More research is needed to contextualize the relation fully and to understand the extent to which menopause increases a woman’s oral health risks. Even as we await more detailed information, women and their health care providers are advised to incorporate oral health into the menopausal conceptual milieu.
8. FUTURE NEEDS • We must improve methods for identifying people at risk for fracture; develop inexpensive and accurate machines to measure BMD and bone structural integrity; develop simple clinical means for determining risk of serious falls; and validate algorithms that combine clinical risk factors, bone density, and so forth, to accurately predict an individual’s fracture risk in the next 5–10 years. • Improve interventions; finding ways to enhance long-term compliance with calcium, vitamin D, and exercise; develop drugs that stimulate bone formation, which will restore bone mass and bone structural integrity; learn how to use drugs in combination or in sequence; have a better understanding of the optimal time to start drugs, how long to use them, and effects of their withdrawal; and know more about the long-term safety of drugs, that cumulate in bone, for example, bisphosphonates. • Understand skeletal factors responsible for maintaining bone mass and bone strength, in particularly bone cytokines and growth factors, the effects of mineralization and hypermineralization on bone strength, and the way that bone anabolic agents signal bone cells. • Improve tests that monitor bone health, including densitometric, ultrasonographic, and biochemical tests. • Understand the relationship between oral bone loss and loss in the rest of the skeleton. • Find therapies that will reduce bone loss that occurs early in life before osteoporosis becomes a clinical problem. 195
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National Heart, Lung, and Blood Ins
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CHAIRS AND EDITORS Chair and Editor
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Anne McTiernan, M.D., Ph.D. Associa
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Lenore Manderson, Ph.D. Director an
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Michael Mendelsohn, M.D. Director,
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TABLE OF CONTENTS Preface XIII 1 Ex
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PREFACE Women’s health and menopa
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CHAPTER 1: EXECUTIVE SUMMARY Nanett
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TABLE 1-1 Evidence Categories Evide
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TABLE 1-2 (continued) Possible Bene
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symptom measures, cultural factors,
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5. PHYSIOLOGICAL ROLE OF ESTROGEN A
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The atherogenic risk profile of old
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• Hormone replacement therapy: Fi
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tion of the remaining ridge in area
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9.3.1 Interventions • In many cas
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Parkinson’s disease, no overall p
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TABLE 1-3 (continued) Sexuality •
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CHAPTER 2: THE MENOPAUSE AND AGING
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oped and are less prepared to addre
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FIGURE 2-4 Diabetes Mellitus. Estim
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Sarcopenia, defined as reduced musc
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Perimenopause WHO The term “perim
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decrease about 2 years before the F
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4.3 Menstrually Defined Menopausal
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to be under stress and to hold part
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21 Brincat MP. Hormone replacement
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62 Orentreich N, Brind JL, Rizer RL
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CHAPTER 3: SYMPTOMS AND THE MENOPAU
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women who may have reached natural
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numb-tingling feelings, headaches,
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(47 percent), problems sleeping (39
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FIGURE 3-2 Proportion of Women Both
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tomized hypogonadotropic women expe
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5.1 Exercise It has been suggested
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to consume 20-150 mg/day of isoflav
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REFERENCES 1 Stewart AL, Hays RD, W
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48 Avis NE, Crawford SL, McKinlay S
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92 Albertazzi P, Pansini F, Bonacco
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Hällström wrote that the psycholo
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countries. Perhaps, as the authors
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Beyene used a systematic ethnograph
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ange of variables, such as genetic
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REFERENCES 1 Gannon L, Ekstrom B. A
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47 George T. Women in a south India
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9. Estrogen and inhibins produced b
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HRT) display tissue-selective estro
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a partial agonist. In contrast, wit
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3. UROGENITAL TRACT ERα and ERβ a
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4. BONE: DEVELOPMENT AND HOMEOSTASI
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in response to estrogen. 106,105 In
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lation of sleep, motor behavior, an
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7. HORMONE REPLACEMENT THERAPY: TRA
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REFERENCES 1 Jensen EV, Jacobsen HI
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40 Power RF, Mani SK, Codina J, Con
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83 Oursler MJ, Pederson L, Fitzpatr
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125 Gabrielsson BG, Carmignac DF, F
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169 Renier MA, Vereecken A, Buytaer
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FIGURE 6-1 Structural features of E
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ound, the conformation of the recep
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with extremely potent estrogenic ac
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Its potency as an antiestrogen was
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The observation that the degree of
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findings were remarkable because a
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Recently, the use of phage display
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20 Crawley G. Non steroidal estroge
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65 Qu Q, Zheng H, Dahllund J, et al
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in their survey of postmenopausal w
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where over half the world’s popul
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The Danish study of Koster and Gard
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Many studies of sexual interest in
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7. ASSESSING SEXUAL ACTIVITY Clinic
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None of these studies evaluated the
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estrogen-androgen group during the
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REFERENCES 1 Sarrel PM, Whitehead M
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52 Utian WH. The true clinical feat
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140
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outes of administration and differe
Page 160 and 161: FIGURE 8-2 Change in Age-Adjusted D
Page 162 and 163: fied as overweight or obese. 32 The
Page 164 and 165: TABLE 8-1 148 Guide to Risk Reducti
Page 166 and 167: TABLE 8-1 (continued) 150 Recommend
Page 168 and 169: TABLE 8-1 (continued) 152 Recommend
Page 170 and 171: Interesting differences in atherosc
Page 172 and 173: similar effects in both patients wi
Page 174 and 175: a lowering of triglycerides, 140 an
Page 176 and 177: may account for a substantial propo
Page 178 and 179: associated with an independent prot
Page 180 and 181: eases preoperatively. Quality of li
Page 182 and 183: excess risk of 6-18 per 10,000 per
Page 184 and 185: REFERENCES 1 NHLBI Morbidity and Mo
Page 186 and 187: 36 Samaras K, Hayward CS, Sullivan
Page 188 and 189: 79 Collins P, Rosano GM, Jiang C, L
Page 190 and 191: 121 Mäkelä S, Savolainen H, Aavik
Page 192 and 193: 162 Clarke S, Kelleher H, Lloyd-Jon
Page 194 and 195: 201 Rahimtoola SH, Bennett AJ, Grun
Page 196 and 197: 243 Varas-Lorenzo C, Garcia-Rodriqu
Page 198 and 199: 7. A connection between menopausal
Page 200 and 201: 3. PATHOGENESIS OF FRACTURE Fractur
Page 202 and 203: Diagnosis of osteoporosis according
Page 204 and 205: density and has a favorable effect
Page 206 and 207: How should this information be inco
Page 208 and 209: emergence of proved treatment alter
Page 212 and 213: REFERENCES 1 Osteoporosis Preventio
Page 214 and 215: 42 Gluer CC. Quantitative ultrasoun
Page 216 and 217: 85 Ettinger B, Pressman A, Silver P
Page 218 and 219: 130 Jeffcoat MK, Lewis CE, Reddy M,
Page 220 and 221: 1. INTRODUCTION Perimenopausal wome
Page 222 and 223: for breast cancer are at increased
Page 224 and 225: findings on biopsy in women with an
Page 226 and 227: thra. Patients typically describe l
Page 228 and 229: Biofeedback: Used in conjunction wi
Page 230 and 231: There has been one systematic revie
Page 232 and 233: ence in pelvic organ prolapse. The
Page 234 and 235: 21 Ferenczy A. Endometrial carcinom
Page 236 and 237: 65 Wyman JF, Fantl JA, McClish DK,
Page 238 and 239: 222
Page 240 and 241: 1. INTRODUCTION Worldwide, breast c
Page 242 and 243: difficult to compare because of com
Page 244 and 245: Although HRT has been related to an
Page 246 and 247: cyclic use and 2.9 (95 percent CI 2
Page 248 and 249: TABLE 11-3 Selected Studies on Horm
Page 250 and 251: TABLE 11-3 (continued) Thus, a stro
Page 252 and 253: TABLE 11-4 236 Cohort Studies on Ho
Page 254 and 255: TABLE 11-5 238 Case-Control Studies
Page 256 and 257: TABLE 11-5 (continued) 240 Adjustme
Page 258 and 259: When the same women in NSABP were r
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REFERENCES 1 Pisani P, Parkin DM, B
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47 Day NE. Epidemiology: the role o
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93 Rodriguez C, Patel AV, Calle EE,
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139 Parazzini F, La Vecchia C, Negr
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1. INTRODUCTION Menopause is associ
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inverse relation with nonverbal mem
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ease decreased significantly with i
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of households selected to be repres
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standard antipsychotic drugs increa
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5. FUTURE NEEDS • Explore the pos
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19 Berman KF, Schmidt PJ, Rubinow D
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64 Lerner A, Koss E, Debanne S, Row
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114 Smith R, Studd JW. A pilot stud
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162 Klein BE. Lens opacities in wom
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patients with strong personal convi
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Therefore, convincing evidence of t
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3.1.1 Risk Factors Many factors are
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278 lower dosages of estrogen will
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• Diabetes: Women with diabetes b
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Lipids and lipoproteins • LDL cho
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284 persists but is less steep in w
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5.2.3 Pharmacotherapy Breast Cancer
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• There is no clinical trial evid
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Sirtori CR, Pazzucconi F, Colombo L
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Hansson L, Zanchetti A, Carruthers
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Dementia and Mental Health Forette
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CRP C-reactive protein CT computed
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PTCA percutaneous transluminal coro
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U.S. DEPARTMENT OF HEALTH AND HUMAN
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