European Journal of Cardiovascular Medicine

Osteoporosis is a progressive systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue, resulting in increased bone fragility and susceptibility to fractures. It is a major public health concern, particularly among postmenopausal women due to estrogen deficiency, which accelerates bone resorption and decreases bone formation1,4. The risk of osteoporotic fractures significantly increases after menopause and contributes to reduced quality of life, physical disability, and higher healthcare costs2,5.

In South Asian countries, including India and Nepal, the prevalence of osteoporosis among postmenopausal women remains high, with studies reporting osteopenia or osteoporosis in over 70% of women above 50 years3. Factors such as early menopause, sedentary lifestyle, poor nutritional intake, low BMI, and lack of awareness contribute to the increasing burden6. Early menopause, in particular, has been linked to higher rates of osteoporosis, fragility fractures, and mortality over long-term follow-up4.

Despite the high prevalence and associated morbidity, osteoporosis often remains undiagnosed until a fracture occurs. This is compounded by the lack of routine screening in outpatient settings, especially in gynecology departments where postmenopausal women frequently seek care for other health concerns2,3. Studies have shown that interventions, including antiresorptive therapy like denosumab, can significantly improve bone mineral density and reduce fracture risk when initiated early3.

This study was conducted to assess the prevalence of osteoporosis in postmenopausal women attending a gynecology outpatient department and to evaluate the associated clinical symptoms and risk factors. Understanding these associations may help formulate targeted strategies for prevention and management, ultimately improving health outcomes in this vulnerable population.

Study Design and Setting:
This was a hospital-based prospective observational study conducted in the Gynecology Outpatient Department at Andhra Medical College, Visakhapatnam, a tertiary care teaching hospital in Andhra Pradesh, India.

Study Period:
The study was carried out over a period of four months, from January to April 2024.

Study Population:

The study included postmenopausal women aged 50 to 80 years attending the gynecology OPD during the study period. Postmenopausal status was defined as the absence of menstruation for at least 12 consecutive months.

Inclusion Criteria:

Women aged ≥50 years with natural menopause

Willing to participate and provide informed consent

Exclusion Criteria:

Women with secondary causes of osteoporosis (e.g., corticosteroid therapy, thyroid disorders)

Known cases of metabolic bone disease or malignancy

Women on long-term hormone replacement therapy

Sample Size:
A total of 100 postmenopausal women were consecutively enrolled during the study period using a non-randomized, convenient sampling technique.

Data Collection:
A structured proforma was used to collect data on:

Demographic details

Menstrual and reproductive history

Lifestyle factors (physical activity, diet, calcium/vitamin D use)

Clinical symptoms (low back pain, height loss, fractures)

Family history of osteoporosis

Bone Mineral Density (BMD) Assessment:
BMD was measured at the lumbar spine and femoral neck using Dual-energy X-ray Absorptiometry (DEXA). T-scores were classified based on WHO criteria into normal (≥ -1), osteopenia (-1 to -2.5), and osteoporosis (≤ -2.5).

Functional Assessment:
Functional disability was assessed using the Health Assessment Questionnaire (HAQ).

Statistical Analysis:
Data were entered into Microsoft Excel and analyzed using SPSS version 26. Descriptive statistics were used to summarize the data. Categorical variables were expressed as frequencies and percentages. Continuous variables were presented as mean ± standard deviation (SD). The chi-square test was used to assess associations between osteoporosis and risk factors. A p-value < 0.05 was considered statistically significant.

Ethical Considerations:
Necessary permissions were taken from concerned authorities before starting the study. Written informed consent was obtained from all participants prior to enrollment.

A total of 100 postmenopausal women were enrolled in the study. The mean age of the participants was 61.4 ± 7.5 years, with a mean duration of menopause of 12.2 ± 5.8 years. The mean body mass index (BMI) was 23.8 ± 3.6 kg/m². Notably, 34% of the participants had attained menopause before the age of 45 years, 58% reported a sedentary lifestyle, and only 26% were on calcium or vitamin D supplementation. A family history of osteoporosis was reported in 18% of women (Table 1).

Table 1: Baseline Characteristics of Study Participants (n = 100)

Bone Mineral Density (BMD) assessment using DEXA scan revealed that 42% of the women had osteoporosis (T-score ≤ -2.5), 38% had osteopenia (T-score between -1 and -2.5), and 20% had normal BMD (T-score ≥ -1) (Table 2).

Table 2: Bone Mineral Density Classification (DEXA-based)

The prevalence of clinical symptoms and complications increased with the severity of bone loss. Low back pain was reported in 66.7% of osteoporotic women compared to 47.4% in those with osteopenia and 20% in those with normal BMD. A significant reduction in height (>2 cm) was noted in 28.6% of the osteoporotic group. History of fragility fractures was observed in 16.7% of women with osteoporosis, while none of the women with normal BMD reported such fractures. Additionally, 35.7% of women in the osteoporotic group reported moderate to severe disability, as compared to 5% in the normal BMD group (Table 3).

Table 3: Prevalence of Clinical Symptoms and Complications (by BMD Status)

Analysis of associated risk factors revealed a statistically significant association between osteoporosis and multiple variables. A sedentary lifestyle was observed in 71.4% of osteoporotic women compared to 48.3% of those without osteoporosis (p = 0.015). Women with osteoporosis had a significantly lower BMI, with 61.9% having a BMI less than 23 kg/m² compared to 25.9% in the non-osteoporotic group (p < 0.001). Early menopause (before 45 years) was more common in the osteoporotic group (47.6% vs. 24.1%, p = 0.014). Lack of calcium and vitamin D supplementation was also significantly associated with osteoporosis (85.7% vs. 65.5%, p = 0.021) (Table 4).

Table 4: Association of Risk Factors with Osteoporosis

This study revealed a high prevalence of osteoporosis (42%) and osteopenia (38%) among postmenopausal women attending a gynecology outpatient department. These findings are consistent with previous literature highlighting a significant burden of osteoporosis in postmenopausal populations, particularly in developing countries. Despite being a major contributor to morbidity through fractures and functional decline, awareness and screening for osteoporosis remain suboptimal7.

In our study, clinical symptoms such as low back pain, height reduction, and fragility fractures were more frequent in women with low bone mineral density (BMD). These results support earlier findings that decreased BMD is a strong predictor of future fracture risk, and regular monitoring can improve fracture discrimination9.

Importantly, early menopause, low BMI, physical inactivity, and lack of calcium/vitamin D supplementation were significantly associated with osteoporosis. These modifiable risk factors have been well-documented in global guidelines and support the need for early risk assessment12. The World Health Organization (WHO) has emphasized the use of T-score-based BMD evaluation and clinical risk factors for fracture risk prediction and screening strategies12.

However, studies have shown that knowledge regarding osteoporosis, even among women on antiresorptive therapy, remains limited, affecting treatment compliance and outcomes7,8. Long-term adherence to antiresorptive agents like denosumab has been shown to significantly reduce fracture risk, yet real-world studies reveal gaps in persistence and adherence8.

Current recommendations from the U.S. Preventive Services Task Force (USPSTF) advise routine osteoporosis screening in women aged ≥65 years and in younger postmenopausal women with equivalent fracture risk10,11. Yet, such protocols are rarely implemented in gynecologic outpatient settings, which serve as key access points for postmenopausal care.

Our findings underscore the necessity of integrating osteoporosis screening and education into routine gynecologic visits. Targeted interventions aimed at modifiable risk factors, along with sustained pharmacological management and patient education, can help reduce the clinical burden and improve quality of life in this vulnerable population.

This study reveals a high prevalence of osteoporosis and osteopenia among postmenopausal women attending a gynecology outpatient department, with significant associations between low bone mineral density and modifiable risk factors such as sedentary lifestyle, low BMI, early menopause, and lack of calcium/vitamin D supplementation. Clinical manifestations like back pain, height loss, and functional disability were more common in osteoporotic women, highlighting the substantial burden of undiagnosed disease. Routine screening for osteoporosis during gynecologic visits, along with lifestyle counseling and nutritional support, is essential for early detection and prevention. Integrating osteoporosis assessment into women’s healthcare can significantly reduce future fracture risk and improve quality of life.

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