Title Page Type of article: Original Title of the article: Bone mineral density and its correlation with

serum estradiol level in postmenopausal women: a cross sectional study Authors 1. Dr Pratiksha Gupta, Associate Professor Department Of Gynaecology and Obstetrics PGIMSR, ESIC, Basaidarapur, New Delhi, India 2. Dr Manjari Sinha, Post Graduate Student. Department Of Gynaecology and Obstetrics PGIMSR, ESIC, Basaidarapur, New Delhi, India 3. Dr Gelabhai R. Jograjiya, Post Graduate Student. Department Of Gynaecology and Obstetrics PGIMSR, ESIC, Basaidarapur, New Delhi, India Corresponding Author Dr Pratiksha Gupta Department Of Gynaecology and Obstetrics PGIMSR, ESIC, Basaidarapur, New Delhi, India. Tel no: +919871128703 Fax no: 01123611560 Email id: drpratiksha@gmail.com Running Title Postmenopausal Bone moneral density and estradiol correlation

Abstract Page

Title

Bone mineral density and its correlation with serum estradiol level in postmenopausal women: a cross sectional study.

Abstract

Objectives: To evaluate BMD in postmenopausal women by dual-energy x-ray absorptiometry (DEXA) scan. To correlate the possible association of BMD with the serum estradiol level in postmenopausal women. Design: This was a cross-sectional study to evaluate BMD and its correlation with serum estradiol level in postmenopausal women. Settings: Department Of Gynaecology and Obstetrics, Post Graduate Institute of Medical Sciences and Research (PGIMSR), ESIC, Basaidarapur, New Delhi-110015, India. Population: Fifty-three postmenopausal women who fulfilled the inclusion and exclusion criteria were enrolled in the study. Methods: Serum estradiol level were measured by ELISA technique on weekly basis using kits from Biocheck (USA). BMD of lumbar spine, the right femoral neck and distal radius were determined by DEXA scan using a dexa lunar prodigy system. Main Outcome Measures: Postmenopausal womens Serum estradiol level and BMD. Results: BMD of lumbar spine, right femoral neck and distal radius was positively correlated with serum estradiol level. This correlation was statistically significant (p < 0.0001). Conclusion: Postmenopausal womens serum estradiol level was directly correlated with bone mineral density of lumbar spine, right femoral neck and distal radius.

Text Introduction

Menopause is defined as the cessation of menstruation for 12 months in a woman and occurs on an average at the age of 51 years. It represents permanent failure of ovarian function secondary to depletion of the follicular pool. The age of menopause in India is around 40-50 years. In postmenopausal period, the ovaries are no longer functional leading to decreased level of estradiol.
[1]

The remaining source of estradiol is the adrenals, adipose tissues and

[2]

muscle through aromatization of androstenedione.

After the age of 30 years, there is

gradual diminution of bone mass which is most clearly seen in women who experience significant decreases in bone mass. This is associated with lowered estrogen production several years prior to the onset of menopause. [3] The abrupt decline in serum estradiol levels after menopause contributes to accelerated bone loss.
[4]

Osteoporosis is a condition of

diminished bone mass and change in bone architecture up to the fracture threshold without clinical signs or symptoms. [5] In this disorder, the rate of bone formation is frequently normal but the rate of bone absorption is increased. Bone loss occurs more frequently in trabecular bone such as in the vertebrae, femoral neck and distal radius. [6]

Aims and objectives

To evaluate BMD in postmenopausal women by DEXA scan. To correlate the possible association of BMD with the serum estradiol level in postmenopausal women.

Material and methods

This a cross-sectional study to evaluate BMD and its correlation with serum estradiol level in postmenopausal women. The study was approved by the Ethics Committee, and 53 postmenopausal women were included in the study, based on inclusion & exclusion criteria. The criteria taken in consideration are: Inclusion Criteria were

Postmenopausal women 40 years and above, actively mobile (Requiring no walking aids), willing to participate in study. Exclusion Criteria were women undergone hysterectomy or bilateral Oophorectomy (Surgical menopause), acute infection, diabetes mellitus, diseases of kidney, diseases of liver, malignancies, hormonal replacement therapy in the last 3 years and chemoradiation. At recruitment, informed consent was obtained from each woman. Serum estradiol and Serum FSH level were measured by ELISA technique on weekly basis using kits from Biocheck (USA). Standard curves were plotted for both the tests using multipoint calibration and values were calculated from the standard curve. BMD of Lumbar Spine, the right femoral neck and distal radius were determined by DEXA scan using a dexa lunar prodigy system. In the DEXA technique, two x-ray energies are used to estimate the area of mineralized tissue, and the mineral content is divided by the area, which partially corrects for body size. It produced images of spine, hip or even the whole body and the computer was able to determine how much bone mineral was present. In our study WHO guidelines was used for assessment of bone loss. According to WHO guidelines, bone loss was divided into following categories. Normal Osteopenia Osteoporosis - T Score above - T Score between - T Score below -1 -1 to -2.5 -2.5

A total of 53 cases further divided into two groups A & B. Group A were cases in whom serum estradiol level was <5 pg./ml and Group B were cases with serum estradiol level >5 pg./ml. A total of 20 cases were enrolled in Group A and 33 cases were enrolled in group B. After measurement of serum estradiol level and BMD by DEXA scan at lumbar spine, right femoral neck and distal radius, correlations were calculated. The data thus collected were transferred into a computer based spread sheet and the statistical analysis carried out. Karl Pearson's correlation coefficient were calculated.

Result BMD of lumbar spine, right femoral neck and distal radius was positively correlated with serum estradiol level. This correlation were statistically significant P<0.0001. (Figure: 1, Table: 1) Mean serum estradiol level, BMD of lumbar spine, right femoral neck and distal radius of Group A were 3.95+/- 0.63 pg./ml, -2.29 +/- 0.66, -1.90 +/- 0.48, -2.22 +/- 0.61 respectively (Figure: 2). Group A- BMD of lumbar spine, right femoral neck and distal radius was more positively correlated with serum estradiol level. This correlation was statistically significant P < 0.0001. (Figure: 3, Table: 2) Mean serum estradiol level and BMD of lumbar spine, right femoral neck and distal radius of group B were 17.13+/- 7.20 pg. /ml, -1.76 +/0.53, -1.40 +/- 0.40 and -1.79 +/- 0.58 respectively. (Figure: 4) Group B BMD of lumbar spine, right femoral neck and distal radius was positively correlated with serum estradiol level. This correlation was statistically significant P < 0.0001. (Figure: 5, Table: 3) Discussion Main findings: The present study was conducted to evaluate the correlation of BMD with serum estradiol level in postmenopausal women. In order to describe the relationship between serum estradiol level and bone mineral density in postmenopausal women, we carried out a cross-sectional study of 53 hospital-based women, who were fulfilled the inclusion and exclusion criteria. None was currently using hormone replacement therapy. In our study bone mineral density of lumbar spine was significantly correlated with serum estradiol level of study subjects. We found that women with serum estradiol levels below 5 pg. /mL had substantially less BMD at lumbar spine. Group A had substantially less BMD at lumbar spine, right femoral neck and distal radius than Group B. Strengths: With the increased longevity there is concomitant increase in the numbers of the elderly, particularly postmenopausal women, in developed as well as developing countries.

There is a paucity of Indian literature regarding serum estradiol level and bone mineral density in postmenopausal women. Due to a relative paucity of Indian studies in this field, and its high significance it is important that more studies to be done on this topic. Our study was therefore an attempt to bring to light the risk of osteopenia and osteoporosis in Indian postmenopausal women. This will help in counseling these subjects regarding the relevant lifestyle modifications and hormone replacement therapy. Limitations: As this was a cross-sectional study, no conclusions can be drawn as regards the cause-effect relationship between estradiol levels and BMD and longitudinal studies will be necessary to confirm our conclusions. The sample size was small, hence the results of our study need to be corroborated by a larger study. It was a single centre study and the results cannot be extrapolated to the general population, hence the need for community based studies. Interpretation: Additional supportive data were reported by Bagur et al. 2004 in postmenopausal women < 65 years of age, who had estradiol levels of > 10 pg./ml and higher BMD values in all skeletal sites examined, in comparison with women whose estradiol levels were < 10 pg./ml.[7] Van Geel et al. 2009 in his study involving 370 postmenopausal women aged between 55 and 85 years found a significant positive relationship between serum estradiol levels and BMD values for the lumbar spine (r= 0.201, p<0.001).[8] In the study by Rogers et al.2002 a positive association was found between estradiol and bone density at all body sites examined (r=0.19, p<0.01).[9] Zarrabeitia et al. 2007 revealed a significant correlation of serum estradiol concentration with BMD of the spine in postmenopausal women.[10] Murphy et al.1992 in his study found a positive correlation between total estradiol and BMD of lumbar spine (Correlation coefficient- 0.30 p < 0.01).[11] Ettinger et al.1998 found BMD of lumbar spine showed a similar trend to be higher with higher levels of estradiol. Compared to women with serum estradiol levels less than 5 pg./ml,

those with levels between 1025 pg./ml had statistically significant greater mean BMD at lumbar spine; the differences were 7.2% (p<0.05).[12] Finally we hypothesized that bone mineral density of lumbar spine was positively correlated with serum estradiol level. We have extended and validated the findings of Bagur et al.2004 [7], Van Geel et al.2009[8], Rogers et al.2002[9], Zarrabeitia et al. 2007[10], Murphy et al.1992[11] and Ettinger et al.1998[12]. The results of present study was similar to study done by Mawi 2010 in postmenopausal women aged between 47 and 60 years with the estradiol concentration more than 5 pg./ml, showed a significant positive relationship between estradiol levels and T-scores for the femoral neck region.[13] Conclusion Serum estradiol level was directly correlated with bone mineral density of lumbar spine, right femoral neck and distal radius. Serum estradiol level was positively correlated with BMD of lumbar spine, right femoral neck and distal radius as evidence by Karl Pearson coefficient of correlation. The correlation was stronger in cases with serum estradiol level < 5 pg. /ml than serum estradiol level > 5 pg. /ml. Disclosure of interest There is no conflict of interest financial, personal, political, intellectual or religious interest. All the authors have contributed equally to qualify for authorship. Contribution to authorship All the authors have substantial contribution to conception and design, acquisition of data, or analysis and interpretation. All the authors contributed equally in drafting the article, revising it critically for important intellectual content, all have finally approved the version to be published.

Ethical approval The study was approved by Institutional ethical committee.

Funding

Funds of Post Graduate Institute of Medical Sciences and Research (PGIMSR), ESIC, Basaidarapur, New Delhi-110015, India.

References 1. Sacco SM, Ward WE. Revisiting estrogen: efficacy and safety for postmenopausal bone health. J Osteoporos 2010;2010:708931. doi: 10.4061/2010/708931. 2. Simpson ER. Aromatization of androgens in women: current concepts and findings. Fertil Steril 2002;77:6-10. 3. Speert H. Obstetrics and gynecology in America: A history. Batimorc: Waverly Press 1980. 4. Sanchez-Ramos L, Kaunitz AM, Wears RL, Delke I, Gaudier FL. Misoprostol for cervical ripening and labor induction: a meta-analysis. Obstet Gynecol 1997;89:633642. 5. Norman JE, Thong KJ, Baird DT. Uterine contractility and induction of abortion in early pregnancy by misoprostol and mifepristone. Lancet 1991;338:1233-6. 6. Bishop EH. Elective induction of labor. Obstet Gynecol 1955;5:519- 527. 7. Bagur A, Oliveri B, Mautalen C, Beotti M, Mastaglia S, Yankelevich D, et al. Low level of endogenous estradiol protects bone mineral density in young postmenopausal women. Climacteric 2004;7:181-8. 8. Van Geel TACM, Geusens PP, Winkens B, Sels JPJE, Dinant GJ. Measures of bioavailable testosterone and estradiol and their relationships with muscle mass, muscle strength and bone mineral density in postmenopausal women: a crosssectional study. Eur J Endocrinol 2009;160:681-7. 9. Rogers A, Saleh G, Hannon RA, Greenfield D, Eastell A. Circulating estradiol and osteoprotegerin as determinants of bone turnover and bone density in postmenopausal women. J Clin Endocrinol Metab 2002;87:4470-5.

10. Zarrabeitia MT, Hernandez JL, Valero C, Ziarrabeitia A, Amado JA, Macias JG, et al. Adiposity, estradiol, and genetic variants of steroid-metabolizing enzymes as determinants of bone mineral density. Eur J Endocrinol 2007;156:117-22. 11. Murphy S, Khaw KT, Sneyd MJ and Compston JE. Endogenous sex hormones and bone mineral density among community-based postmenopausal women. Postgrad Med J 1992;68:908 -13. 12. Ettinger B, Pressman A, Sklarin P, Bauer D, Cauley J, Cummings S. Associations between low levels of serum estradiol, bone density, and fractures among elderly women: the study of osteoporotic fractures, J Clin Endocrinol Metab 1998;83:223943. 13. Mawi M. Serum estradiol levels and bone mineral density in postmenopausal women. Univ Med 2010;29:90-95.

Table: 1 Result of correlation between Serum Estradiol (pg. /ml) and lumbar spine, right femoral neck and distal radius T-Score in postmenopausal women (n=53)
Number of XY Pairs Pearson r 95% confidence interval P value (two-tailed) P value summary Is the correlation significant? (alpha=0.05) R squared "Lumbar Spine" 53 0.6693 0.4871 to 0.7957 P<0.0001 *** Yes 0.4480 "Right Femoral Neck " 53 0.6654 0.4817 to 0.7931 P<0.0001 *** Yes 0.4428 "Distal Radius " 53 0.5932 0.3845 to 0.7442 P<0.0001 *** Yes 0.3519

Table: 2 Result of correlation between Serum Estradiol (pg. /ml) and lumbar spine, right femoral neck and distal radius T-Score in Group A (n=20)
Number of XY Pairs Pearson r 95% confidence interval P value (two-tailed) P value summary Is the correlation significant? (alpha=0.05) R squared "Lumbar Spine" 20 0.7983 0.5500 to 0.9169 P<0.0001 *** Yes 0.6372 "Right Femoral Neck " 20 0.8004 0.5540 to 0.9178 P<0.0001 *** Yes 0.6406 "Distal Radius " 20 0.8405 0.6335 to 0.9352 P<0.0001 *** Yes 0.7064

Table: 3 Result of correlation between Serum Estradiol (pg. /ml) and lumbar spine, right femoral neck and distal radius T-Score in Group B (n=33)
"Lumbar Spine" 33 0.7917 0.6157 to 0.8925 P<0.0001 *** Yes 0.6268 "Right Femoral Neck" 33 0.6544 0.4012 to 0.8147 P<0.0001 *** Yes 0.4283 "Distal Radius " 33 0.6686 P<0.0001 *** Yes 0.4470

Number of XY Pairs Pearson r 95% confidence interval P value (two-tailed) P value summary Is the correlation significant? (alpha=0.05) R squared

Figure Legends Figure 1 Correlation between Serum Estradiol (pg. /ml) and lumbar spine, right femoral neck and distal radius T-Score in postmenopausal women.

Figure 2 Mean and Standard deviation of BMD of lumbar spine, right femoral neck and distal radius T-score and serum estradiol level of Group A.

Figure 3 Correlation between Serum Estradiol (pg. /ml) and lumbar spine, right femoral neck and distal radius T-Score in group A.

Figure 4 Mean and Standard deviation of BMD of lumbar spine, right femoral neck and distal radius T-score and serum estradiol level of Group B.

Figure 5 Correlation between serum estradiol (pg. /ml) and lumbar spine, right femoral neck and distal radius T-score in Group B.