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Prediction of bone loss in postmenopausal women

Identification of women at greatest risk of future osteoporotic fracture could allow targeting of preventative therapy. The risk of spine, hip and vertebral fractures is related to bone mineral density [I], and bone density at the time of the menopause and the rate of bone loss thereafter are likely to be major predictors of future fracture. The potential to identify those women likely to lose bone most rapidly has developed dramatically over recent years as a result of improved biochemical and densitometric methods. There is some evidence that biochemical measurements can predict the rate of bone loss soon after the menopause [2,3]. Combinations of serum total alkaline phosphatase, urinary calcium, urinary hydroxyproline and serum osteocalcin, with an estimate of body fat content can predict about 60% of the variability in measured fractional bone loss in the ‘proximal distal’ forearm in early postmenopausal women. The potential usefulness of collagen derived biochemical markers of bone turnover remain to be established. In particular, the use of urinary pyridinium crosslinks as a specific and quantitative measure of bone resorption has aroused much interest [4]. The paper by Mole et al., in this issue of the Journal highlights the possible role of urinary oestrogens and pyridinium crosslinks in the prediction of bone loss from the distal forearm. They demonstrate that a combination of urinary pyridinoline, urinary oestradiol glucuronide and body mass index could explain up to 58% of the variation in bone loss in the forearm. Despite these encouraging developments, there is as yet no convincing evidence that the use of these measurements would provide a significant benefit in the context of a screening programme. The rate of bone loss at any particular skeletal site in the early postmenopausal period is of no importance per se. Biochemical measurements must predict long-term rates of bone loss, and risk of vertebral and femoral neck fractures decades after the menopause if their use to select women for preventative therapy can be justified. Several important questions remain to be answered. Perhaps the first question that should be asked is whether the pattern of postmenopausal bone loss