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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Is Premenopausal Osteoporosis and How Is It Diagnosed&#63;</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoporosis is defined as a bone disease characterized by decreased bone strength that predisposes fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 1994 a committee of experts from the World Health Organization proposed the term densitometric osteoporosis&#44; defining a category applicable to postmenopausal white women who had a bone mineral density &#40;BMD&#41; less than or equal to &#8722;2&#46;5 standard deviations from a young population of same sex&#44; that is&#44; a <span class="elsevierStyleItalic">T</span> value less than &#8722;2&#46;5&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; there is no agreement in defining osteoporosis in premenopausal women and the diagnosis must be done carefully so as to not rely solely on densitometry<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> parameters&#46; The International Society for Clinical Densitometry has suggested that these criteria should not apply to young women and has argued for the use of the <span class="elsevierStyleItalic">Z</span> value in this population group&#58; a value of <span class="elsevierStyleItalic">Z</span> less than &#8722;2 at the lumbar spine or femur indicate a BMD value below normal for the age and sex of the individual&#46; However&#44; for a premenopausal osteoporosis diagnosis&#44; it is recommended not relying solely on densitometric parameters and taking into account the presence of other risk factors and a history of fragility fractures and diseases or bone loss inducing drugs&#46; This consideration is due to the fact that low BMD in a young individual can translate only a poor acquisition of peak bone mass and not related to an increased risk of fracture&#46; On the other hand&#44; the risk of fractures in postmenopausal women is higher than that of premenopausal women with the same BMD as premenopausal women have better estrogen stimulation&#44; increased muscle mass&#44; thicker bone cortex&#44; less bone turnover and fewer falls&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Is Its Impact&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Postmenopausal osteoporosis is well documented and studied&#44; but the pre-menopausal osteoporosis has been given less attention probably because of its low incidence&#46; In fact&#44; there are few studies on its actual incidence&#46; The prevalence of osteoporosis by densitometry in younger women &#40;20&#8211;44 years&#41; of our population is 0&#46;34&#37;&#8211;0&#46;17&#37; in the lumbar spine and femoral neck&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Studies examining the incidence of fractures in this group are limited&#59; it is estimated that the incidence of vertebral fractures in younger patients &#40;&#60;35 years&#41; is 3 per 100 000&#47;year and rises to 21 in the population aged 35&#8211;44 years but often are due to trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Note that the presence of fractures in this group&#44; with particular emphasis on those affecting the distal radius&#44; is associated with decreased bone mass and also constitutes a risk factor for fractures in older adults&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Moreover&#44; as in any silent disease that causes symptoms in its early stages&#44; it is probably an underdiagnosed disease&#46; However&#44; there are no studies on this in our environment&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Determines Peak Bone Mass&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Low BMD in premenopausal women is the result of the acquisition of a low peak bone mass&#44; its subsequent loss&#44; or both&#46; Peak bone mass is genetically determined&#44; but life habits&#44; exercise and diet&#44; and hormonal factors may contribute to this acquisition&#46; At the end of the second decade of life&#44; it is very similar in both sexes and lasts until age 40&#46; Several factors were independently associated with increased bone mass&#44; such as maintaining a BMI within the normal range at menarche&#44; physical exercise involving mechanical loading during adolescence and normal pubertal development&#46; It is estimated that the &#8220;peak&#8221; bone mass has a relatively greater influence on the development of osteoporosis in adulthood than the bone loss that occurs with age&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Are the Causes of Premenopausal Osteoporosis&#63;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Over 50&#37; of premenopausal women with osteoporosis will have a secondary cause&#59; the rest will be diagnosed as idiopathic osteoporosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Epidemiological studies on the etiology of this disease are very rare&#46; Peris et al&#46; analyzed the causes of secondary osteoporosis in a single center in a total of 52 premenopausal women&#46; Fifty-six percent had idiopathic osteoporosis&#46; The most common secondary causes were found to be Cushing&#39;s disease&#44; osteoporosis associated with pregnancy and osteogenesis imperfecta&#46; In a previous study by the same research group in men&#44; the most common causes were alcohol&#44; hypogonadism and treatment with glucocorticoids&#46; Another group in 1994&#44; studied a population of 22 patients with osteoporosis&#44; both young men and women&#44; and described treatment with glucocorticoids as the most frequent cause of secondary osteoporosis and&#44; in contrast&#44; found that idiopathic osteoporosis was unusual&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore&#44; before reaching a diagnosis&#44; the clinician should be thorough in finding an underlying cause&#46; The first thing that must be performed is a thorough medical history&#44; family history &#40;50&#37; of adult daughters of women with osteoporosis had low<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> bone mass&#41;&#44; a history of fractures&#44; menarche&#44; amenorrhea&#44; pregnancy and lactation&#44; diet and exercise&#44; gastrointestinal symptoms&#44; lifestyle and osteopenia associated medication&#46; The use of drugs and concomitant diseases should be carefully questioned&#46; Systemic physical examination should look for signs of underlying disease and laboratory tests are deemed necessary to rule out secondary causes of osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The basic study includes&#58; CBC&#44; ESR&#44; renal and liver function&#44; electrolytes&#44; calcium and phosphate in blood and urine&#44; alkaline phosphatase&#44; total serum protein and total proteins&#44; lipid profile&#44; ferritin&#44; urinalysis&#44; 24<span class="elsevierStyleHsp" style=""></span>h urine calcium&#44; 25-hydroxyvitamin D with estradiol and gonadotropins&#46; Depending on the degree of clinical suspicion&#44; parathyroid hormone&#44; thyroid hormones&#44; cortisol&#44; prolactin or growth hormone should be requested&#46; Clinical suspicion of celiac disease&#44; mastocytosis or hypophosphatasia should expand testing&#46; The determination of biochemical markers of bone turnover may provide additional information on bone remodeling in these patients and the therapeutic response&#46; On rare occasions it may be necessary to perform a bone biopsy&#44; especially to exclude osteomalacia&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Is There to Treat Premenopausal Osteoporosis&#63;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Therapeutic considerations are limited by the few studies in this group of patients&#44; especially in regard to the risk of fractures and treatment&#46; On the other hand&#44; we have no FRAX index because it cannot be employed in premenopausal patients&#46; For premenopausal osteoporosis there are several recommended treatments&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">General measures &#40;lifestyle adjustment&#41;&#46; Exercise&#44; a diet rich in calcium and vitamin D&#44; calcium supplements and vitamin D in case of nutritional deficit&#44; avoidance of smoking and alcohol&#44; and maintaining a body mass index above underweight&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Bisphosphonates&#46; In studies with a limited number of patients&#44; risedronate and alendronate orally and zoledronate and pamidronate intravenously have proven effective in preventing bone loss&#46; It is important to note that bisphosphonates suffer bone accumulation&#44; so excretion is maintained for years despite their suspension&#46; This could determine a difficulty for the consolidation of fractures and a hypothetical teratogenicity&#46; There are no systematic studies of bisphosphonate use during pregnancy&#44; but animal studies suggest possible placental transfer and fetal skeletal development involvement&#46; A systematic review of the literature studied 58 women treated with oral bisphosphonates in the period before conception or during pregnancy and did not detect any congenital abnormality&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> There are also some documented cases of patients treated intravenously with pamidronate<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> who have had healthy children&#46; The only data that indicate teratogenicity is described by the unit of clinical genetics and epidemiology at the University of Padua&#44; which included 10 cases of women treated with bisphosphonates during pregnancy&#44; resulting in 20&#37; of congenital malformations&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However&#44; it is advisable to avoid conception while treated with the drug&#44; but if it occurred inadvertently&#44; interruption is not recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hormone replacement therapy and anovulatory drugs&#46; Applicable in patients with amenorrhea or early menopause&#46; There are no consensus guidelines and employed less frequently&#44; especially hormone replacement therapy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Teriparatide&#46; It is not accepted as first-line therapy in premenopausal patients with idiopathic osteoporosis because there are insufficient safety and efficacy long-term studies in young patients&#46; However&#44; a study lasting 6 months in young women with premature menopause showed prevention of bone mass loss&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Also&#44; intermittent therapy with teriparatide has recently proven useful in the treatment of osteoporosis secondary to glucocorticoid treatment&#44; being even superior to treatment with bisphosphonates in preventing vertebral fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Calcitonin&#46; It has not been shown to decrease the number of fractures in young women and it is not clear if it sufficiently improves BMD&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Low calcium &#40;thiazides&#44; amiloride&#44; chlorthalidone and indapamide&#41;&#46; In patients with hypercalciuria&#44; to avoid a negative balance&#46; It has shown an increase in BMD and a decrease in the risk of fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Drugs contraindicated in this age group are selective modulators of estrogen receptors&#44; which act by blocking estrogen action in bone and may cause increased bone loss&#59; they should only be indicated in younger patients if they are menopausal&#46; There are no studies of the effectiveness of strontium ranelate or denosumab in premenopausal women&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">How to Treat Premenopausal Osteoporosis&#63;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Women who have low BMD alone&#44; without other risk factors should not be diagnosed with osteoporosis and not receive any treatment&#46; They should undergo the same control as patients of any other age&#44; with the same general recommendations&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In women who in addition to low BMD have risk factors&#44; such as a fracture or secondary causes of osteoporosis&#44; should undergo a therapeutic intervention&#46; And treating the underlying cause always should be considered first&#46; There are very few studies on drug treatment in this population&#44; so we can divide the approach to be followed by the type of premenopausal osteoporosis&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Idiopathic osteoporosis&#46; Women with low bone mass and&#47;or a pathological fracture&#44; and in whom an underlying cause has not yet been found&#44; should be diagnosed as idiopathic osteoporosis&#46; This entity is rare&#44; affects both sexes equally and its cause is not clear&#46; Often these patients have a family history of osteoporosis&#44; which confirms the relevance of genetic factors&#46; A study showed that 50&#37; of daughters of women with postmenopausal osteoporosis showed a decrease in bone mass&#46; Between 36&#37; and 50&#37; of patients with idiopathic osteoporosis have associated hypercalciuria&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> quite often with kidney stones&#46; Also other findings&#44; described in isolation&#44; are alterations in the dynamics of parathyroid hormone secretion&#44; decrease in the values of growth hormone or serum estradiol&#44; alterations in osteoblasts &#945;-estrogen receptor expression or increased production of interleukin-1&#44; which stimulates bone resorption and decreases bone formation associated with impaired osteoblast proliferative capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding treatment&#44; the few existing studies show that some of these women just need general measures to stabilize bone mass&#46; In patients with hypercalciuria drugs that reduce calcium loss in urine and sodium restriction patterns in the diet may be added&#44; as well as avoidance of a decreased calcium intake to avoid a negative balance&#46; In young men with idiopathic osteoporosis&#44; bisphosphonates and teriparatide have been effective&#44; but there are little data on safety and efficacy of these treatments in young women with this disease&#44; so the establishment of systematic guidelines is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Secondary osteoporosis&#46; Each underlying disease has special considerations&#46; In many cases&#44; treating the underlying disease leads to an increase in BMD&#46; Here are the most frequent findings&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Treatment with glucocorticoids&#46; Treatment with glucocorticoids is the most common drug related cause of osteoporosis&#46; Glucocorticoids reduce the number and function of osteoblasts&#44; and increased half-life of osteoclasts&#46; Between 18&#37; and 22&#37; of young premenopausal women develop osteoporosis following prolonged and high doses of prednisone&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The incidence is related to dose and duration of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> A recent Japanese study shows that high doses of glucocorticoids in premenopausal patients with connective tissue diseases are associated with a high prevalence of symptomatic vertebral fractures &#40;11&#46;3&#37;&#41; and increase with age&#44; dose and duration of treatment&#44; and alcohol consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> There is limited experience in the treatment of glucocorticoid-induced osteoporosis in this group of patients&#46; The American College of Rheumatology &#40;ACR&#41; recommended patients taking glucocorticoids for more than 3 months with a dose above 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg daily and with a prior history of fracture&#44; to be treated&#44; in addition to general measures&#44; with bisphosphonates &#40;alendronate or risedronate as first options&#44; or zoledronate depending on the case&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;27</span></a> However&#44; the number of premenopausal women included in these studies is limited&#46; Another option that has proven effective in a recent study is intermittent therapy with teriparatide&#44; and is even superior to treatment with bisphosphonates in preventing vertebral fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> It should be used if the risk of fracture is high or the response is not considered appropriate&#46; However&#44; the long-term use of the drug in premenopausal women and the number of young patients included in this study was limited&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> However&#44; in patients treated with lower doses of corticosteroids or no history of fractures&#44; the ACR concluded that currently there are not enough data to make specific recommendations&#44; insisting only on general measures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">Eating disorders and states of amenorrhea&#46; These situations are associated with significant bone loss&#44; especially when the onset occurs in adolescence&#46; Multiple factors are implicated&#58; malnutrition&#44; deficit of calcium and vitamin D&#44; estrogen deficiency&#44; increased production of cortisol and secondary hyperparathyroidism&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Treatment should include calcium and vitamin D&#46; Other treatments such as hormone replacement therapy&#44; oral contraceptives&#44; or bisphosphonates &#40;alendronate and risedronate&#41; have been shown to increase BMD in some studies&#44; but all agree that the most important determinant is weight gain&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Therefore&#44; pending further studies&#44; these drugs should not be used in a routine manner&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Endocrine&#46; Patients with primary hyperparathyroidism often have osteoporosis due to increased bone remodeling&#46; A <span class="elsevierStyleItalic">T</span> score &#60;&#8722;2&#46;5 and an age of less than 50 years are among the indications for surgery&#46; After surgery&#44; most patients manifested present an improvement in BMD&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Other examples of loss of bone due to increased remodeling are hyperthyroidism and Cushing&#39;s disease&#46; This decline can be reversed with adequate treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Gastrointestinal disorders and malabsorption&#46; Calcium absorption is mediated by the active metabolite of vitamin D &#40;1&#44;25-hydroxyvitamin D&#41;&#44; which is absorbed in the intestine&#46; Vitamin D deficiency can lead to loss of bone density due to secondary hyperparathyroidism&#46; Diseases such as celiac disease and pancreatic insufficiency&#44; women who have undergone bariatric surgery or have inflammatory bowel disease should be considered at risk for premenopausal osteoporosis&#46; Treatment can slow bone loss&#46; In the case of inflammatory bowel diseases&#44; the mechanism is multifactorial and includes the effect of inflammatory cytokines&#44; malabsorption&#44; and treatment for the disease&#44; which is often steroid based&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> The exact risk of fractures is unknown at present&#46; There is no consensus&#44; but bisphosphonates can be considered a good therapeutic option in the future&#44; although to date no sufficient scientific evidence for guidelines is systematic&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Transplantation of solid organs and bone marrow&#46; After transplantation there is a loss of bone mass and an increase in the number of fractures&#46; The reason for this&#44; besides the underlying disease&#44; is mainly immunosuppressive treatment&#46; A study of mineral metabolism before transplantation and densitometry is therefore recommended&#46; Treatment with vitamin D supplements&#44; if required&#44; as well as bisphosphonates has been shown to be useful to increase BMD&#46; However&#44; no studies on the reduction in the number of fractures exist to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Osteoporosis associated with pregnancy&#46; It presents with insufficiency fractures&#44; especially vertebral&#44; during late pregnancy or postpartum&#46; The etiology of this disease is not clear&#46; After pregnancy an increased spontaneous and progressive bone mass&#44; but not normalization may be seen&#46; Administration of bisphosphonates for a short period has been associated with improvement in BMD&#44; but no studies on reduction in the number of fractures are available&#46; Further studies are needed to establish specific recommendations&#46; In these patients breastfeeding is not recommended because it can contribute to further bone loss in this period&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Chronic inflammatory diseases &#40;rheumatoid arthritis&#44; lupus&#44; etc&#46;&#41;&#46; Both osteopenia inducing drugs in these patients and the disease inflammatory activity contributes to osteoporosis&#44; so the goal in this type of bone loss is the control of the underlying disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Other&#46; In patients treated with antiepileptics or other osteopenia inducing drugs&#44; guidelines consider supplemental calcium and vitamin D&#46; In other pathologies&#44; such as osteogenesis imperfecta or chemotherapy or hormone therapy for breast cancer&#44; intravenous bisphosphonates have proven useful&#46; However&#44; this is not the objective of the current review&#46;</p></li></ul></p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">Monitoring should be performed in premenopausal women with osteoporosis until BMD remains stable&#44; and should be monitored by performing densitometry every 18&#8211;36 months&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Since there are no treatment guidelines&#44; treatment should be individualized&#44; using common sense and experience with the help of therapy&#44; but few consensuses exist on secondary causes&#46; We should mention&#44; finally&#44; the need for further studies in this area&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Fundamental Ideas</span><p id="par0155" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">A low BMD in premenopausal women is not associated with the same risk of fractures as in postmenopausal women&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Z</span> score should be used in young people to define BMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">Z</span> score &#60;&#8722;2 is defined as &#8220;below the expected range for age&#8221;&#44; not as pre-menopausal osteoporosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Premenopausal osteoporosis diagnosis requires not only densitometry but the consideration of other risk factors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Over 50&#37; of premenopausal osteoporosis are secondary&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">If no secondary cause is found&#44; the diagnosis is &#8220;idiopathic osteoporosis&#46;&#8221;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">All premenopausal women should receive basic recommendations on the prevention of osteoporosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Secondary causes should be treated first&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">The use of other therapies is limited to situations with high risk of fracture or rapid loss of bone mass&#44; as well as some secondary causes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">More studies are needed to specify when to start treatment in premenopausal osteoporosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">There are no guides&#44; so use common sense and experience&#44; and individualize treatment&#46;</p></li></ul></p></span></span>"
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          "titulo" => "Keywords"
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          "identificador" => "xres125709"
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          "identificador" => "xpalclavsec113001"
          "titulo" => "Palabras clave"
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        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "What Is Premenopausal Osteoporosis and How Is It Diagnosed&#63;"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "What Is Its Impact&#63;"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "What Determines Peak Bone Mass&#63;"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "What Are the Causes of Premenopausal Osteoporosis&#63;"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "What Is There to Treat Premenopausal Osteoporosis&#63;"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "How to Treat Premenopausal Osteoporosis&#63;"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Fundamental Ideas"
        ]
        11 => array:1 [
          "titulo" => "References"
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    "fechaRecibido" => "2011-04-17"
    "fechaAceptado" => "2011-05-15"
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec113000"
          "palabras" => array:4 [
            0 => "Osteoporosis"
            1 => "Premenopausal"
            2 => "Treatment"
            3 => "Young"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec113001"
          "palabras" => array:4 [
            0 => "Osteoporosis"
            1 => "Menopausia"
            2 => "Tratamiento"
            3 => "Joven"
          ]
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There is no agreement in defining osteoporosis in premenopausal women and diagnosis must be done carefully and not based on densitometric parameters&#46; One must take into account the presence of other risk factors and history of fragility fractures&#44; diseases or drugs that cause bone loss&#46; Over 50&#37; of premenopausal women with osteoporosis will have a secondary cause&#44; with the remainder diagnosed with idiopathic osteoporosis&#46; Therapeutic considerations are limited by a few studies in this group of patients&#44; especially in regard to the risk of fractures&#46; On the other hand&#44; the FRAX index cannot be applied to premenopausal women&#46; This article will review the measures to apply depending on the type of premenopausal osteoporosis&#44; based on current scientific evidence&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">No existe un acuerdo para definir la osteoporosis en mujeres premenop&#225;usicas y el diagn&#243;stico debe realizarse cuidadosamente y sin basarse &#250;nicamente en par&#225;metros densitom&#233;tricos&#46; Hay que tener en cuenta la presencia de otros factores de riesgo como los antecedentes de fracturas por fragilidad&#44; enfermedades o f&#225;rmacos osteopenizantes&#46; M&#225;s del 50&#37; de las mujeres con osteoporosis premenop&#225;usica van a presentar una causa secundaria&#44; el resto ser&#225;n diagnosticadas de osteoporosis idiop&#225;tica&#46; Las consideraciones terap&#233;uticas est&#225;n limitadas por los escasos estudios en este grupo de pacientes&#44; sobre todo en lo que se refiere al riesgo de fracturas&#46; Por otro lado&#44; no disponemos del &#237;ndice de FRAX&#44; ya que no se puede aplicar a pacientes premenop&#225;usicas&#46; Este art&#237;culo pretende realizar una revisi&#243;n sobre la actitud que se debe seguir seg&#250;n el tipo de osteoporosis premenop&#225;usica bas&#225;ndonos en la evidencia cient&#237;fica actual&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please&#44; cite this article as&#58; Mart&#237;nez-Morillo M&#44; et al&#46; Osteoporosis premenop&#225;usica&#58; &#191;c&#243;mo tratarla&#63; Reumatol Clin&#46; 2012&#59;<span class="elsevierStyleBold">8&#40;2&#41;</span>&#58;93&#8211;7&#46;</p>"
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                  \t\t\t\t">Pharmacologic or toxic treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glucocorticoids&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Heparin&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LHRH analogues&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Endocrine diseases&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypogonadism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hyperthyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cushing&#39;s disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Growth hormone deficiency&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Panhypopituitarism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hyperparathyroidism&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Malnutrition or malabsorption&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Anorexia nervosa&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Inflammatory intestinal disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Celiac disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intestinal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic inflammatory disease &#40;rheumatoid arthritis&#44; SLE&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Liver disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Osteogenesis imperfecta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Transplant patients &#40;solid organs and bone marrow&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">HIV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemochromatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Osteoporosis associated to pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systemic mastocytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Causes of Secondary Osteoporosis in Premenopausal Women&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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Continuing medical education
Premenopausal Osteoporosis: How to Treat?
Osteoporosis premenopáusica: ¿cómo tratarla?
Melania Martínez-Morillo
Corresponding author
melaniamm@gmail.com

Corresponding author.
, Dolors Grados, Susana Holgado
Sección de Reumatología, Hospital Universitario Germans Trias i Pujol, Barcelona, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Is Premenopausal Osteoporosis and How Is It Diagnosed&#63;</span><p id="par0005" class="elsevierStylePara elsevierViewall">Osteoporosis is defined as a bone disease characterized by decreased bone strength that predisposes fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> In 1994 a committee of experts from the World Health Organization proposed the term densitometric osteoporosis&#44; defining a category applicable to postmenopausal white women who had a bone mineral density &#40;BMD&#41; less than or equal to &#8722;2&#46;5 standard deviations from a young population of same sex&#44; that is&#44; a <span class="elsevierStyleItalic">T</span> value less than &#8722;2&#46;5&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">However&#44; there is no agreement in defining osteoporosis in premenopausal women and the diagnosis must be done carefully so as to not rely solely on densitometry<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> parameters&#46; The International Society for Clinical Densitometry has suggested that these criteria should not apply to young women and has argued for the use of the <span class="elsevierStyleItalic">Z</span> value in this population group&#58; a value of <span class="elsevierStyleItalic">Z</span> less than &#8722;2 at the lumbar spine or femur indicate a BMD value below normal for the age and sex of the individual&#46; However&#44; for a premenopausal osteoporosis diagnosis&#44; it is recommended not relying solely on densitometric parameters and taking into account the presence of other risk factors and a history of fragility fractures and diseases or bone loss inducing drugs&#46; This consideration is due to the fact that low BMD in a young individual can translate only a poor acquisition of peak bone mass and not related to an increased risk of fracture&#46; On the other hand&#44; the risk of fractures in postmenopausal women is higher than that of premenopausal women with the same BMD as premenopausal women have better estrogen stimulation&#44; increased muscle mass&#44; thicker bone cortex&#44; less bone turnover and fewer falls&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Is Its Impact&#63;</span><p id="par0015" class="elsevierStylePara elsevierViewall">Postmenopausal osteoporosis is well documented and studied&#44; but the pre-menopausal osteoporosis has been given less attention probably because of its low incidence&#46; In fact&#44; there are few studies on its actual incidence&#46; The prevalence of osteoporosis by densitometry in younger women &#40;20&#8211;44 years&#41; of our population is 0&#46;34&#37;&#8211;0&#46;17&#37; in the lumbar spine and femoral neck&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> Studies examining the incidence of fractures in this group are limited&#59; it is estimated that the incidence of vertebral fractures in younger patients &#40;&#60;35 years&#41; is 3 per 100 000&#47;year and rises to 21 in the population aged 35&#8211;44 years but often are due to trauma&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Note that the presence of fractures in this group&#44; with particular emphasis on those affecting the distal radius&#44; is associated with decreased bone mass and also constitutes a risk factor for fractures in older adults&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Moreover&#44; as in any silent disease that causes symptoms in its early stages&#44; it is probably an underdiagnosed disease&#46; However&#44; there are no studies on this in our environment&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Determines Peak Bone Mass&#63;</span><p id="par0025" class="elsevierStylePara elsevierViewall">Low BMD in premenopausal women is the result of the acquisition of a low peak bone mass&#44; its subsequent loss&#44; or both&#46; Peak bone mass is genetically determined&#44; but life habits&#44; exercise and diet&#44; and hormonal factors may contribute to this acquisition&#46; At the end of the second decade of life&#44; it is very similar in both sexes and lasts until age 40&#46; Several factors were independently associated with increased bone mass&#44; such as maintaining a BMI within the normal range at menarche&#44; physical exercise involving mechanical loading during adolescence and normal pubertal development&#46; It is estimated that the &#8220;peak&#8221; bone mass has a relatively greater influence on the development of osteoporosis in adulthood than the bone loss that occurs with age&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#44;8</span></a></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Are the Causes of Premenopausal Osteoporosis&#63;</span><p id="par0030" class="elsevierStylePara elsevierViewall">Over 50&#37; of premenopausal women with osteoporosis will have a secondary cause&#59; the rest will be diagnosed as idiopathic osteoporosis &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Epidemiological studies on the etiology of this disease are very rare&#46; Peris et al&#46; analyzed the causes of secondary osteoporosis in a single center in a total of 52 premenopausal women&#46; Fifty-six percent had idiopathic osteoporosis&#46; The most common secondary causes were found to be Cushing&#39;s disease&#44; osteoporosis associated with pregnancy and osteogenesis imperfecta&#46; In a previous study by the same research group in men&#44; the most common causes were alcohol&#44; hypogonadism and treatment with glucocorticoids&#46; Another group in 1994&#44; studied a population of 22 patients with osteoporosis&#44; both young men and women&#44; and described treatment with glucocorticoids as the most frequent cause of secondary osteoporosis and&#44; in contrast&#44; found that idiopathic osteoporosis was unusual&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">Therefore&#44; before reaching a diagnosis&#44; the clinician should be thorough in finding an underlying cause&#46; The first thing that must be performed is a thorough medical history&#44; family history &#40;50&#37; of adult daughters of women with osteoporosis had low<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> bone mass&#41;&#44; a history of fractures&#44; menarche&#44; amenorrhea&#44; pregnancy and lactation&#44; diet and exercise&#44; gastrointestinal symptoms&#44; lifestyle and osteopenia associated medication&#46; The use of drugs and concomitant diseases should be carefully questioned&#46; Systemic physical examination should look for signs of underlying disease and laboratory tests are deemed necessary to rule out secondary causes of osteoporosis&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">The basic study includes&#58; CBC&#44; ESR&#44; renal and liver function&#44; electrolytes&#44; calcium and phosphate in blood and urine&#44; alkaline phosphatase&#44; total serum protein and total proteins&#44; lipid profile&#44; ferritin&#44; urinalysis&#44; 24<span class="elsevierStyleHsp" style=""></span>h urine calcium&#44; 25-hydroxyvitamin D with estradiol and gonadotropins&#46; Depending on the degree of clinical suspicion&#44; parathyroid hormone&#44; thyroid hormones&#44; cortisol&#44; prolactin or growth hormone should be requested&#46; Clinical suspicion of celiac disease&#44; mastocytosis or hypophosphatasia should expand testing&#46; The determination of biochemical markers of bone turnover may provide additional information on bone remodeling in these patients and the therapeutic response&#46; On rare occasions it may be necessary to perform a bone biopsy&#44; especially to exclude osteomalacia&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">What Is There to Treat Premenopausal Osteoporosis&#63;</span><p id="par0045" class="elsevierStylePara elsevierViewall">Therapeutic considerations are limited by the few studies in this group of patients&#44; especially in regard to the risk of fractures and treatment&#46; On the other hand&#44; we have no FRAX index because it cannot be employed in premenopausal patients&#46; For premenopausal osteoporosis there are several recommended treatments&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">General measures &#40;lifestyle adjustment&#41;&#46; Exercise&#44; a diet rich in calcium and vitamin D&#44; calcium supplements and vitamin D in case of nutritional deficit&#44; avoidance of smoking and alcohol&#44; and maintaining a body mass index above underweight&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0055" class="elsevierStylePara elsevierViewall">Bisphosphonates&#46; In studies with a limited number of patients&#44; risedronate and alendronate orally and zoledronate and pamidronate intravenously have proven effective in preventing bone loss&#46; It is important to note that bisphosphonates suffer bone accumulation&#44; so excretion is maintained for years despite their suspension&#46; This could determine a difficulty for the consolidation of fractures and a hypothetical teratogenicity&#46; There are no systematic studies of bisphosphonate use during pregnancy&#44; but animal studies suggest possible placental transfer and fetal skeletal development involvement&#46; A systematic review of the literature studied 58 women treated with oral bisphosphonates in the period before conception or during pregnancy and did not detect any congenital abnormality&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> There are also some documented cases of patients treated intravenously with pamidronate<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> who have had healthy children&#46; The only data that indicate teratogenicity is described by the unit of clinical genetics and epidemiology at the University of Padua&#44; which included 10 cases of women treated with bisphosphonates during pregnancy&#44; resulting in 20&#37; of congenital malformations&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> However&#44; it is advisable to avoid conception while treated with the drug&#44; but if it occurred inadvertently&#44; interruption is not recommended&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0060" class="elsevierStylePara elsevierViewall">Hormone replacement therapy and anovulatory drugs&#46; Applicable in patients with amenorrhea or early menopause&#46; There are no consensus guidelines and employed less frequently&#44; especially hormone replacement therapy&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0065" class="elsevierStylePara elsevierViewall">Teriparatide&#46; It is not accepted as first-line therapy in premenopausal patients with idiopathic osteoporosis because there are insufficient safety and efficacy long-term studies in young patients&#46; However&#44; a study lasting 6 months in young women with premature menopause showed prevention of bone mass loss&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Also&#44; intermittent therapy with teriparatide has recently proven useful in the treatment of osteoporosis secondary to glucocorticoid treatment&#44; being even superior to treatment with bisphosphonates in preventing vertebral fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a></p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0070" class="elsevierStylePara elsevierViewall">Calcitonin&#46; It has not been shown to decrease the number of fractures in young women and it is not clear if it sufficiently improves BMD&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0075" class="elsevierStylePara elsevierViewall">Low calcium &#40;thiazides&#44; amiloride&#44; chlorthalidone and indapamide&#41;&#46; In patients with hypercalciuria&#44; to avoid a negative balance&#46; It has shown an increase in BMD and a decrease in the risk of fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a></p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">-</span><p id="par0080" class="elsevierStylePara elsevierViewall">Drugs contraindicated in this age group are selective modulators of estrogen receptors&#44; which act by blocking estrogen action in bone and may cause increased bone loss&#59; they should only be indicated in younger patients if they are menopausal&#46; There are no studies of the effectiveness of strontium ranelate or denosumab in premenopausal women&#46;</p></li></ul></p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">How to Treat Premenopausal Osteoporosis&#63;</span><p id="par0085" class="elsevierStylePara elsevierViewall">Women who have low BMD alone&#44; without other risk factors should not be diagnosed with osteoporosis and not receive any treatment&#46; They should undergo the same control as patients of any other age&#44; with the same general recommendations&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In women who in addition to low BMD have risk factors&#44; such as a fracture or secondary causes of osteoporosis&#44; should undergo a therapeutic intervention&#46; And treating the underlying cause always should be considered first&#46; There are very few studies on drug treatment in this population&#44; so we can divide the approach to be followed by the type of premenopausal osteoporosis&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">1&#46;</span><p id="par0095" class="elsevierStylePara elsevierViewall">Idiopathic osteoporosis&#46; Women with low bone mass and&#47;or a pathological fracture&#44; and in whom an underlying cause has not yet been found&#44; should be diagnosed as idiopathic osteoporosis&#46; This entity is rare&#44; affects both sexes equally and its cause is not clear&#46; Often these patients have a family history of osteoporosis&#44; which confirms the relevance of genetic factors&#46; A study showed that 50&#37; of daughters of women with postmenopausal osteoporosis showed a decrease in bone mass&#46; Between 36&#37; and 50&#37; of patients with idiopathic osteoporosis have associated hypercalciuria&#44;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> quite often with kidney stones&#46; Also other findings&#44; described in isolation&#44; are alterations in the dynamics of parathyroid hormone secretion&#44; decrease in the values of growth hormone or serum estradiol&#44; alterations in osteoblasts &#945;-estrogen receptor expression or increased production of interleukin-1&#44; which stimulates bone resorption and decreases bone formation associated with impaired osteoblast proliferative capacity&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">Regarding treatment&#44; the few existing studies show that some of these women just need general measures to stabilize bone mass&#46; In patients with hypercalciuria drugs that reduce calcium loss in urine and sodium restriction patterns in the diet may be added&#44; as well as avoidance of a decreased calcium intake to avoid a negative balance&#46; In young men with idiopathic osteoporosis&#44; bisphosphonates and teriparatide have been effective&#44; but there are little data on safety and efficacy of these treatments in young women with this disease&#44; so the establishment of systematic guidelines is recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">21</span></a></p></li><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">2&#46;</span><p id="par0105" class="elsevierStylePara elsevierViewall">Secondary osteoporosis&#46; Each underlying disease has special considerations&#46; In many cases&#44; treating the underlying disease leads to an increase in BMD&#46; Here are the most frequent findings&#58;<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">-</span><p id="par0110" class="elsevierStylePara elsevierViewall">Treatment with glucocorticoids&#46; Treatment with glucocorticoids is the most common drug related cause of osteoporosis&#46; Glucocorticoids reduce the number and function of osteoblasts&#44; and increased half-life of osteoclasts&#46; Between 18&#37; and 22&#37; of young premenopausal women develop osteoporosis following prolonged and high doses of prednisone&#46;<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">22</span></a> The incidence is related to dose and duration of treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> A recent Japanese study shows that high doses of glucocorticoids in premenopausal patients with connective tissue diseases are associated with a high prevalence of symptomatic vertebral fractures &#40;11&#46;3&#37;&#41; and increase with age&#44; dose and duration of treatment&#44; and alcohol consumption&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> There is limited experience in the treatment of glucocorticoid-induced osteoporosis in this group of patients&#46; The American College of Rheumatology &#40;ACR&#41; recommended patients taking glucocorticoids for more than 3 months with a dose above 7&#46;5<span class="elsevierStyleHsp" style=""></span>mg daily and with a prior history of fracture&#44; to be treated&#44; in addition to general measures&#44; with bisphosphonates &#40;alendronate or risedronate as first options&#44; or zoledronate depending on the case&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">25&#8211;27</span></a> However&#44; the number of premenopausal women included in these studies is limited&#46; Another option that has proven effective in a recent study is intermittent therapy with teriparatide&#44; and is even superior to treatment with bisphosphonates in preventing vertebral fractures&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> It should be used if the risk of fracture is high or the response is not considered appropriate&#46; However&#44; the long-term use of the drug in premenopausal women and the number of young patients included in this study was limited&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">28</span></a> However&#44; in patients treated with lower doses of corticosteroids or no history of fractures&#44; the ACR concluded that currently there are not enough data to make specific recommendations&#44; insisting only on general measures&#46;</p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">-</span><p id="par0115" class="elsevierStylePara elsevierViewall">Eating disorders and states of amenorrhea&#46; These situations are associated with significant bone loss&#44; especially when the onset occurs in adolescence&#46; Multiple factors are implicated&#58; malnutrition&#44; deficit of calcium and vitamin D&#44; estrogen deficiency&#44; increased production of cortisol and secondary hyperparathyroidism&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">29</span></a> Treatment should include calcium and vitamin D&#46; Other treatments such as hormone replacement therapy&#44; oral contraceptives&#44; or bisphosphonates &#40;alendronate and risedronate&#41; have been shown to increase BMD in some studies&#44; but all agree that the most important determinant is weight gain&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">30</span></a> Therefore&#44; pending further studies&#44; these drugs should not be used in a routine manner&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">31</span></a></p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">-</span><p id="par0120" class="elsevierStylePara elsevierViewall">Endocrine&#46; Patients with primary hyperparathyroidism often have osteoporosis due to increased bone remodeling&#46; A <span class="elsevierStyleItalic">T</span> score &#60;&#8722;2&#46;5 and an age of less than 50 years are among the indications for surgery&#46; After surgery&#44; most patients manifested present an improvement in BMD&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">32</span></a> Other examples of loss of bone due to increased remodeling are hyperthyroidism and Cushing&#39;s disease&#46; This decline can be reversed with adequate treatment&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a></p></li><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0125" class="elsevierStylePara elsevierViewall">Gastrointestinal disorders and malabsorption&#46; Calcium absorption is mediated by the active metabolite of vitamin D &#40;1&#44;25-hydroxyvitamin D&#41;&#44; which is absorbed in the intestine&#46; Vitamin D deficiency can lead to loss of bone density due to secondary hyperparathyroidism&#46; Diseases such as celiac disease and pancreatic insufficiency&#44; women who have undergone bariatric surgery or have inflammatory bowel disease should be considered at risk for premenopausal osteoporosis&#46; Treatment can slow bone loss&#46; In the case of inflammatory bowel diseases&#44; the mechanism is multifactorial and includes the effect of inflammatory cytokines&#44; malabsorption&#44; and treatment for the disease&#44; which is often steroid based&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">34</span></a> The exact risk of fractures is unknown at present&#46; There is no consensus&#44; but bisphosphonates can be considered a good therapeutic option in the future&#44; although to date no sufficient scientific evidence for guidelines is systematic&#46;<a class="elsevierStyleCrossRef" href="#bib0175"><span class="elsevierStyleSup">35</span></a></p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0130" class="elsevierStylePara elsevierViewall">Transplantation of solid organs and bone marrow&#46; After transplantation there is a loss of bone mass and an increase in the number of fractures&#46; The reason for this&#44; besides the underlying disease&#44; is mainly immunosuppressive treatment&#46; A study of mineral metabolism before transplantation and densitometry is therefore recommended&#46; Treatment with vitamin D supplements&#44; if required&#44; as well as bisphosphonates has been shown to be useful to increase BMD&#46; However&#44; no studies on the reduction in the number of fractures exist to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">36&#44;37</span></a></p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0135" class="elsevierStylePara elsevierViewall">Osteoporosis associated with pregnancy&#46; It presents with insufficiency fractures&#44; especially vertebral&#44; during late pregnancy or postpartum&#46; The etiology of this disease is not clear&#46; After pregnancy an increased spontaneous and progressive bone mass&#44; but not normalization may be seen&#46; Administration of bisphosphonates for a short period has been associated with improvement in BMD&#44; but no studies on reduction in the number of fractures are available&#46; Further studies are needed to establish specific recommendations&#46; In these patients breastfeeding is not recommended because it can contribute to further bone loss in this period&#46;<a class="elsevierStyleCrossRefs" href="#bib0190"><span class="elsevierStyleSup">38&#44;39</span></a></p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0140" class="elsevierStylePara elsevierViewall">Chronic inflammatory diseases &#40;rheumatoid arthritis&#44; lupus&#44; etc&#46;&#41;&#46; Both osteopenia inducing drugs in these patients and the disease inflammatory activity contributes to osteoporosis&#44; so the goal in this type of bone loss is the control of the underlying disease&#46;<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">40&#44;41</span></a></p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0145" class="elsevierStylePara elsevierViewall">Other&#46; In patients treated with antiepileptics or other osteopenia inducing drugs&#44; guidelines consider supplemental calcium and vitamin D&#46; In other pathologies&#44; such as osteogenesis imperfecta or chemotherapy or hormone therapy for breast cancer&#44; intravenous bisphosphonates have proven useful&#46; However&#44; this is not the objective of the current review&#46;</p></li></ul></p></li></ul></p><p id="par0150" class="elsevierStylePara elsevierViewall">Monitoring should be performed in premenopausal women with osteoporosis until BMD remains stable&#44; and should be monitored by performing densitometry every 18&#8211;36 months&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">33</span></a> Since there are no treatment guidelines&#44; treatment should be individualized&#44; using common sense and experience with the help of therapy&#44; but few consensuses exist on secondary causes&#46; We should mention&#44; finally&#44; the need for further studies in this area&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Fundamental Ideas</span><p id="par0155" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0160" class="elsevierStylePara elsevierViewall">A low BMD in premenopausal women is not associated with the same risk of fractures as in postmenopausal women&#46;</p></li><li class="elsevierStyleListItem" id="lsti0095"><span class="elsevierStyleLabel">-</span><p id="par0165" class="elsevierStylePara elsevierViewall">The <span class="elsevierStyleItalic">Z</span> score should be used in young people to define BMD&#46;</p></li><li class="elsevierStyleListItem" id="lsti0100"><span class="elsevierStyleLabel">-</span><p id="par0170" class="elsevierStylePara elsevierViewall">A <span class="elsevierStyleItalic">Z</span> score &#60;&#8722;2 is defined as &#8220;below the expected range for age&#8221;&#44; not as pre-menopausal osteoporosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0105"><span class="elsevierStyleLabel">-</span><p id="par0175" class="elsevierStylePara elsevierViewall">Premenopausal osteoporosis diagnosis requires not only densitometry but the consideration of other risk factors&#46;</p></li><li class="elsevierStyleListItem" id="lsti0110"><span class="elsevierStyleLabel">-</span><p id="par0180" class="elsevierStylePara elsevierViewall">Over 50&#37; of premenopausal osteoporosis are secondary&#46;</p></li><li class="elsevierStyleListItem" id="lsti0115"><span class="elsevierStyleLabel">-</span><p id="par0185" class="elsevierStylePara elsevierViewall">If no secondary cause is found&#44; the diagnosis is &#8220;idiopathic osteoporosis&#46;&#8221;</p></li><li class="elsevierStyleListItem" id="lsti0120"><span class="elsevierStyleLabel">-</span><p id="par0190" class="elsevierStylePara elsevierViewall">All premenopausal women should receive basic recommendations on the prevention of osteoporosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0125"><span class="elsevierStyleLabel">-</span><p id="par0195" class="elsevierStylePara elsevierViewall">Secondary causes should be treated first&#46;</p></li><li class="elsevierStyleListItem" id="lsti0130"><span class="elsevierStyleLabel">-</span><p id="par0200" class="elsevierStylePara elsevierViewall">The use of other therapies is limited to situations with high risk of fracture or rapid loss of bone mass&#44; as well as some secondary causes&#46;</p></li><li class="elsevierStyleListItem" id="lsti0135"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">More studies are needed to specify when to start treatment in premenopausal osteoporosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0140"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">There are no guides&#44; so use common sense and experience&#44; and individualize treatment&#46;</p></li></ul></p></span></span>"
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          "identificador" => "xres125710"
          "titulo" => "Abstract"
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        1 => array:2 [
          "identificador" => "xpalclavsec113000"
          "titulo" => "Keywords"
        ]
        2 => array:2 [
          "identificador" => "xres125709"
          "titulo" => "Resumen"
        ]
        3 => array:2 [
          "identificador" => "xpalclavsec113001"
          "titulo" => "Palabras clave"
        ]
        4 => array:2 [
          "identificador" => "sec0005"
          "titulo" => "What Is Premenopausal Osteoporosis and How Is It Diagnosed&#63;"
        ]
        5 => array:2 [
          "identificador" => "sec0010"
          "titulo" => "What Is Its Impact&#63;"
        ]
        6 => array:2 [
          "identificador" => "sec0015"
          "titulo" => "What Determines Peak Bone Mass&#63;"
        ]
        7 => array:2 [
          "identificador" => "sec0020"
          "titulo" => "What Are the Causes of Premenopausal Osteoporosis&#63;"
        ]
        8 => array:2 [
          "identificador" => "sec0025"
          "titulo" => "What Is There to Treat Premenopausal Osteoporosis&#63;"
        ]
        9 => array:2 [
          "identificador" => "sec0030"
          "titulo" => "How to Treat Premenopausal Osteoporosis&#63;"
        ]
        10 => array:2 [
          "identificador" => "sec0035"
          "titulo" => "Fundamental Ideas"
        ]
        11 => array:1 [
          "titulo" => "References"
        ]
      ]
    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-04-17"
    "fechaAceptado" => "2011-05-15"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec113000"
          "palabras" => array:4 [
            0 => "Osteoporosis"
            1 => "Premenopausal"
            2 => "Treatment"
            3 => "Young"
          ]
        ]
      ]
      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palabras clave"
          "identificador" => "xpalclavsec113001"
          "palabras" => array:4 [
            0 => "Osteoporosis"
            1 => "Menopausia"
            2 => "Tratamiento"
            3 => "Joven"
          ]
        ]
      ]
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    "resumen" => array:2 [
      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">There is no agreement in defining osteoporosis in premenopausal women and diagnosis must be done carefully and not based on densitometric parameters&#46; One must take into account the presence of other risk factors and history of fragility fractures&#44; diseases or drugs that cause bone loss&#46; Over 50&#37; of premenopausal women with osteoporosis will have a secondary cause&#44; with the remainder diagnosed with idiopathic osteoporosis&#46; Therapeutic considerations are limited by a few studies in this group of patients&#44; especially in regard to the risk of fractures&#46; On the other hand&#44; the FRAX index cannot be applied to premenopausal women&#46; This article will review the measures to apply depending on the type of premenopausal osteoporosis&#44; based on current scientific evidence&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">No existe un acuerdo para definir la osteoporosis en mujeres premenop&#225;usicas y el diagn&#243;stico debe realizarse cuidadosamente y sin basarse &#250;nicamente en par&#225;metros densitom&#233;tricos&#46; Hay que tener en cuenta la presencia de otros factores de riesgo como los antecedentes de fracturas por fragilidad&#44; enfermedades o f&#225;rmacos osteopenizantes&#46; M&#225;s del 50&#37; de las mujeres con osteoporosis premenop&#225;usica van a presentar una causa secundaria&#44; el resto ser&#225;n diagnosticadas de osteoporosis idiop&#225;tica&#46; Las consideraciones terap&#233;uticas est&#225;n limitadas por los escasos estudios en este grupo de pacientes&#44; sobre todo en lo que se refiere al riesgo de fracturas&#46; Por otro lado&#44; no disponemos del &#237;ndice de FRAX&#44; ya que no se puede aplicar a pacientes premenop&#225;usicas&#46; Este art&#237;culo pretende realizar una revisi&#243;n sobre la actitud que se debe seguir seg&#250;n el tipo de osteoporosis premenop&#225;usica bas&#225;ndonos en la evidencia cient&#237;fica actual&#46;</p>"
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please&#44; cite this article as&#58; Mart&#237;nez-Morillo M&#44; et al&#46; Osteoporosis premenop&#225;usica&#58; &#191;c&#243;mo tratarla&#63; Reumatol Clin&#46; 2012&#59;<span class="elsevierStyleBold">8&#40;2&#41;</span>&#58;93&#8211;7&#46;</p>"
      ]
    ]
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                  \t\t\t\t">Pharmacologic or toxic treatment&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Glucocorticoids&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Antiepileptics&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Alcohol&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>LHRH analogues&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Endocrine diseases&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hypogonadism&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Cushing&#39;s disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Growth hormone deficiency&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Malnutrition or malabsorption&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Anorexia nervosa&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Inflammatory intestinal disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Celiac disease&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Intestinal resection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Chronic inflammatory disease &#40;rheumatoid arthritis&#44; SLE&#44; etc&#46;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">Liver disease&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">Osteogenesis imperfecta&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">Transplant patients &#40;solid organs and bone marrow&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">HIV infection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Hemochromatosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Idiopathic osteoporosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Osteoporosis associated to pregnancy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Systemic mastocytosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Causes of Secondary Osteoporosis in Premenopausal Women&#46;</p>"
        ]
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    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:41 [
            0 => array:3 [
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              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "NIH Consensus Development Paper on osteoporosis prevention&#44; diagnosis and therapy&#46; J Am Med Assoc 2001&#59;285&#58;785&#8211;95&#46;"
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0010"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:1 [
                  "referenciaCompleta" => "World Health Organization&#46; Assessment of fracture risk and its application to screening for postmenopausal osteoporosis&#46; Technical report series 843&#46; Geneva&#58; WHO&#59; 1994&#46;"
                ]
              ]
            ]
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                    0 => array:2 [
                      "titulo" => "Osteoporosis en individuos j&#243;venes"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:1 [
                            0 => "P&#46; Peris"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rheumatol Clin"
                        "fecha" => "2010"
                        "volumen" => "6"
                        "paginaInicial" => "217"
                        "paginaFinal" => "223"
                      ]
                    ]
                  ]
                ]
              ]
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              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalencia de osteoporosis determinada por densitometr&#237;a en la poblaci&#243;n femenina espa&#241;ola"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; D&#237;az Curiel"
                            1 => "J&#46;J&#46; Garc&#237;a"
                            2 => "J&#46;L&#46; Carrasco"
                            3 => "J&#46; Honorato"
                            4 => "R&#46; P&#233;rez Cano"
                            5 => "A&#46; Rapado"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Med Clin"
                        "fecha" => "2001"
                        "volumen" => "116"
                        "paginaInicial" => "86"
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Article information
ISSN: 21735743
Original language: English
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Idiomas
Reumatología Clínica (English Edition)
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