Nursing Report: Osteoporosis, HRT, WHI Trials, Risk Factors Analysis

This nursing report delves into the complexities of osteoporosis, focusing on risk factors, lifestyle modifications, and the Women's Health Initiative (WHI) trials. It examines a case study involving a 59-year-old woman, Robyn, whose mother has osteoporosis and is undergoing HRT. The report analyzes the potential risks and benefits of HRT, considering factors like age, menopause, and family history. It explores the importance of calcium-rich diets, exercise, and vitamin D supplementation for managing osteoporosis. Furthermore, the report reviews the WHI trials, discussing the impact of hormone therapy on cardiovascular health, breast cancer, and other health outcomes. The report highlights the significance of understanding the timing of hormone therapy initiation and the importance of informed decision-making for women and healthcare providers. The document provides a comprehensive overview of osteoporosis management, emphasizing evidence-based practices and patient-centered care.

Running Head: NURSING 1
NURSING

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Table of Contents
Question 1........................................................................................................................................3
Risks with Osteoporosis and discussion with her............................................................................3
Are there any other factors that you identified in Robyn’s history which may be important to her
overall management?.......................................................................................................................4
Would you order any investigations at this point? If yes, which ones and how would these affect
your advice to Robyn?.....................................................................................................................5
What lifestyle changes/management options might you suggest to Robyn and why?....................6
Question 2........................................................................................................................................7
Overview..........................................................................................................................................7
Possibility of the Risks....................................................................................................................9
WHY THE DIFFERENCE IN RESULTS?..................................................................................10
Conclusion.....................................................................................................................................15
References......................................................................................................................................16

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Question 1
Risks with Osteoporosis and discussion with her
Osteoporosis is a disease in which the bones of the human being are more weak and brittle. The
situation has become so critical that even a mild stress such as bending or sneezing could cause a
fracture. The injuries are commonly found on hip, wrist or spine. The major factor that is
involved in case of the osteoporosis is cease of the building of the new bone. The loss of the old
bone is heavy that there is no formation of the new bone. Osteoporosis is found in White and
Asian Women specially when they get old and they are past with Menopause. In case of Robyn
she is of 59 years and her mother is suffering from osteoporosis that is 80 years in age. Also
since she had her last period ten years ago and the situation is even worse as her bones are
already weak due to the age factor and menopause is one of the critical factors that are an
addition in making the situation worst1. In a word with Robyn these symptoms are not found at
the early stages but once these bones are of low strength by osteoporosis the signs that have been
included are back pain, caused by a fracture or due to broken vertebra, loss of height over the
time, the posture gets stooped and it’s easy to break the bone. It is advised to Robyn that since
her mother is suffering from osteoporosis this is necessary to discuss and it can be discussed via
a formal face to face meeting to give the clear figures and facts2.
1 Finnerty F, Walker-Bone K, Tariq S. Osteoporosis in postmenopausal women living with HIV.
Maturitas. 2017 Jan 1;95:50-4.
2 Ghosh JS, Jog RP. Nutritional Factors are not Sufficient to Check Osteoporosis in Women after
Menopause-A Justification. Nutrition and Food Toxicology. 2018;3:556-7.

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Are there any other factors that you identified in Robyn’s history which may be important
to her overall management?
The other factors that are identified in the history of Robyn were the importance for the overall
management is the HRT therapy that her mother is taking regularly for a period of the 4 years.
Basically HRT therapy is also known as Hormone Therapy, menopausal therapy or estrogen
replacement theory. Under the Hormone Replacement therapy the estrogen level generally falls
and it becomes uncomfortable for the women’s as they feel dry flushes or the dry vagina
problems. There are several methods of applying the HRT and this is decided on the basis of the
situation prevailing with the patient. In case of the Robyn’s mother, HRT is being used in the
case of the hot flushes. Also in the present case the GP of Robyn’s mother is being advised to
stop the HRT therapy, gradually over the period of the time. A heavy dose of the HRT is
retentions of the fluids, bloating, tenderness in the breast or swelling, headaches, depression as
well indigestion3. Though there are benefits of the HRT such as it is very sound and the effective
in case of the menopause and it can reduce the development of the osteoporosis and the cancer of
the colon and rectum. But since every treatment has the pros along with the cons and one of the
cons faced is the real development of the breast cancer, womb cancer and ovarian cancer as well.
The process of the HRT also increases the risk of the vein thrombosis and pulmonary embolism.
Hence, the decision given by GP is correct as the continuous therapy process would create more
3 Falk RT, Anderson GL, Barnabei VM, Brinton LA, Cauley JA, Chen C, Chlebowski RT,
Coburn SB, Manson JE, Pfeiffer RM, Reding KW. Estrogen metabolism in menopausal hormone
users: Does it differ between estrogen plus progestin and estrogen alone users in the Women’s
Health Initiative Observational Study.

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problems for her mother. Further, the home remedies can be considered as one of the side
treatment. At times in order to save the situation from being too worse the therapy shall be
restricted and hence the decision taken by the GP is best in accordance with the case4.
Would you order any investigations at this point? If yes, which ones and how would these
affect your advice to Robyn?
The further investigations are really not considered as useful as the situation that Robyn’s mother
is suffering is not curable on the permanent basis and can be only reduced to a low level. Further,
what Robyn can do is that it can consult with her mother’s GP for any subsidy remedy or any
replacement cure that could help her for the future years. The continuous sessions of the therapy
would only increase problems in the other sides of the body and hence, no further in depth
investigations are required5.
What lifestyle changes/management options might you suggest to Robyn and why?
There could be certain changes or the amendments that shall be made in the lifestyle of Robyn as
these would help live her life with smoothness and stability. There could be certain options to
change the lifestyle prospects and this can be achieved with the help of the following steps.
4 [Internet]. Nursing.ceconnection.com. 2019 [cited 20 July 2019]. Available from:
https://nursing.ceconnection.com/ovidfiles/00000446-201106000-00025.pdf
5 Bhupathiraju SN, Stampfer MJ. Menopausal hormone therapy and cardiovascular disease:
unraveling the role of age and time since menopause onset. Clinical chemistry. 2018 May
1;64(5):861-2.

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In order to maintain the lifestyle changes in case of the Osteoporosis and the low bones mass.
Due to the formation of the bone partly with the calcium, the best solution for such patients could
be eating foods that are highly rich in calcium and can assist in prevention of the loss of thee
bone post menopause6. Further it is also advised to have Dairy foods; vegetables that are dark in
color, nuts, and soy products as well as calcium-fortified foods all help build bone strength.
Robyn shall provide all these supplements to her mother in order to see the positive results over
the months. In case of the Robyn’s mother the additional supplements can also be required which
are rich in calcium citrate or calcium carbonate; after the detailed discussion with the GP7.
The second best solution for the patients suffering from the osteoporosis is the regular exercise
as well as the sue of the Vitamin D that is required to maintain bone health because it promotes
calcium absorption in the intestines and helps to maintain proper calcium levels in the other parts
of the boy as well. Once the doctor measures the level of the vitamin D in the body it can allow
several substitutes according to the requirements of the body. Hence these two options can be
availed by Robyn’s mother to cure the long ongoing problem of osteoporosis8.
6 Van Dijk GM, Kavousi M, Troup J, Franco OH. Health issues for menopausal women: the top
11 conditions have common solutions. Maturitas. 2015 Jan 1;80(1):24-30.
7 Greer G. The change: Women, ageing and the menopause. Bloomsbury Publishing; 2018 May
17.
8 Chlebowski RT, Mortimer JE, Crandall C, Pan K, Manson JE, Nelson RA, Johnson K, Vitolins
M, Lane D, Wactawski-Wende J, Kwan KW. Persistent vasomotor symptoms and breast cancer
in the Women’s Health Initiative (WHI).

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Question 2
Overview
There have been several articles on the Lessons Learned from the Women’s Health Initiative
Trials of Menopausal Hormone Therapy and the major reasons for the publication of the July
2002 was to make aware about the importance of the Women’s Health Initiative and to make the
women of the country healthy as well as happy. Prior to the year 2002, the prescriptions for
menopausal hormone therapy (HT) were accelerated and the organizations were announcing the
cure for the osteoporosis as well as the other heart related issues to be serious9.
There was a real time survey vi questionnaire and the open ended questions that has been
administered in the family practice, from the period of the August to October in the year 2003.
That time the rationale was specifically sought. Women who were aged from the year 50-70
attended the office regularly in order to participate. The government of the health was analyzing
the data in the terms of the statistics and quarterly analysis10.
These prescriptions were mostly for the women who are aged past 60 years. In response to this a
campaign was introduced by the National Institute of Health under the name of the Women’s
Health Initiative (WHI). These alternative trials of the menopause HT was conducted to test
9 Hormone replacement therapy (HRT) [Internet]. Nhsinform.scot. 2019 [cited 20 July 2019].
Available from: https://www.nhsinform.scot/tests-and-treatments/medicines-and-medical-aids/
types-of-medicine/hormone-replacement-therapy-hrt
10 Crawford SL, Crandall CJ, Derby CA, El Khoudary SR, Waetjen LE, Fischer M, Joffe H.
Menopausal hormone therapy trends before versus after 2002: impact of the Women's Health
Initiative Study Results. Menopause. 2019 Jun 1;26(6):588-97.

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whether the association with the lower risk for the CHD found in the observational studies or
whether to obtain the reliable information would help in creating for the benefits. The WHI trials
in the year 2002 in Women for the procedure of extracting the uterus was stopped early because
of the risks of the cancer in the breast, heart attack, pulmonary embolism11.
Possibility of the Risks
The possibility of risks was overlapping the benefits from reductions in hip fractures and
colorectal cancer. In the year 2004 there was a cease in the hysterectomies which were stopped
prematurely because of the increased risk of the stroke and the chances of the benefits from the
CHD would emerge. The major difference is in the trial of the ET as well as EPT in showing
zero effect on CHD. This would result in the low creation of the cancer in the breast in the older
women.
The hormone therapy continued until the year 2002 when the results from the Women’s Health
Initiative (WHI) estrogen-plus-progestin study indicated that the heart risk have the high factors
due to the continuous use of the hormonal therapy and it has been observed that anything in
excess would create an increased risk of the coronary heart. Due to the high level of fear many
women stopped taking the hormone therapy. In fact by the year 2004, the prescriptions saw a
decline by 49% and the EPP was declined by 71%. The situation became complex when every
women was taking the decision despite knowing the proper facts and the procedures of the same.
Not all women were required to perform such action12. A detailed analysis was carried out after
the initiative in which it was decided which women were able to use the benefits of the hormonal
11 Huang X, inventor; New York University, assignee. Treatment of osteoporosis in peri-and
post-menopausal women with hepcidin. United States patent US 8,999,935. 2015 Apr 7.

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therapy and that was particularly in case of the protection of the bone and can get a bit of a relief
from vasomotor symptoms. With the up to date knowledge the GP and the nurses can help the
women make aware about the decision and the WHI findings and what they actually mean for
her. This altogether changed the perspective and the mood of the country towards the dealing of
the menopause.
Due to the increased studies and the distressing news spread amongst the women, after the usage
of the postmenopausal hormone therapy and their health care providers. It’s very necessary to
understand the risk and the harm it can cause to each individual. The numbers and the ongoing
results were somewhat similar ad that the risk is minimal13.
Research of the WHI has shown that estrogen multiple effects on the blood vessels of ladies
either aged between 50-60 and the 60-70. The same case is also evaluated on the basis of the
healthy cells of the women in early menopause. From the overall study it can be reflected that the
12 Jacques E. Rossouw G. Lessons Learned From the Women’s Health Initiative Trials of
Menopausal Hormone Therapy [Internet]. PubMed Central (PMC). 2019 [cited 20 July 2019].
Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547645/
13 Umland EM, Karel L, Santoro N. Bazedoxifene and conjugated equine estrogen: a combination
product for the management of vasomotor symptoms and osteoporosis prevention associated
with menopause. Pharmacotherapy: The Journal of Human Pharmacology and Drug Therapy.
2016 May;36(5):548-61.

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women who initiated the hormone therapy within the time period of the 10 years of menopause
had a lower risk compared to the women who have started the process a little later14.
WHY THE DIFFERENCE IN RESULTS?
There are particulars instincts due to which the results are different than from the actual which
have been outlined below.
Healthy user bias
Constant evaluations of the WHI trials were the major reason for the controversy and the long
term debates. Most of the skilled people thought why the most of the results were different in
comparison to the refelctions which reflect the use of the hormone therapy declines the risk of
the CVD.
One probability talked about the investigations experienced solid client predisposition; that is,
the results are positive in case of the cardiovascular diseases among estrogen clients in light of
the fact that the decision to utilize estrogen was related with other wellbeing advancing elements,
for example, advanced education and more noteworthy physical action 24-26.
Matter of Timing
Plausibility was what wound up known as the postmenopausal planning speculation. 27 This
theory set that hormone treatment began inside 10 years of menopause would affect wellbeing
results, especially CVD, while hormone treatment began in late menopause would not. The WHI
14 Lello S, Capozzi A, Scambia G. Osteoporosis and cardiovascular disease: an update.
Gynecological Endocrinology. 2015 Aug 3;31(8):590-4.

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analysts completed various auxiliary investigations of the hormone preliminaries' information.
They found that ladies who began hormone treatment inside 10 years of menopause had a
diminished danger of CHD, though the individuals who began it later had an expanded hazard
was 0.28. Despite the fact that this discovering simply missed factual noteworthiness (P = 0.06),
it was the main sign that the planning of commencement of hormone treatment may affect
chance. Advocates of the postmenopausal planning speculation guaranteed that this wonder
clarified the contrast between the WHI preliminaries and prior observational investigations on
the grounds that a huge extent of WHI members were more established (mean age, 63.6 years),
and in this way more distant from menopause15.
Ladies ought to be recounted elective treatments for hot flashes, for example, social techniques,
different meds, phytoestrogens, certain dietary enhancements, and needle therapy. There's some
proof to help constrained viability of these techniques; be that as it may, you ought to encourage
these ladies to talk about any elective treatment with their supplier first. There's a great deal of
deceiving data out there, particularly on the Internet, and ladies can wind up spending a ton of
cash on items that are pointless and even risky. Ladies taking estrogen in addition to progestin
should likewise choose what sort of progestin to utilize. There are various alternatives; the best
for any lady is typically an individual decision dependent on the level of withdrawal draining
related with every technique16.
15 Levine ME, Lu AT, Chen BH, Hernandez DG, Singleton AB, Ferrucci L, Bandinelli S, Salfati
E, Manson JE, Quach A, Kusters CD. Menopause accelerates biological aging. Proceedings of
the National Academy of Sciences. 2016 Aug 16;113(33):9327-32.
16 Lifestyle Changes for Osteoporosis & Low Bone Mass [Internet]. Nyulangone.org. 2019 [cited
20 July 2019]. Available from: https://nyulangone.org/conditions/osteoporosis-low-bone-mass-

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It's additionally been noticed that, similarly as the more seasoned time of members in the WHI
hormone studies may have been a factor in the outcomes, so may the way that every preliminary
tried just one portion of an oral detailing of hormones. Earlier research has demonstrated that
transdermal estrogen doesn't have a similar procoagulation impacts that oral estrogen has.38, 39
Is it conceivable that various courses of organization or doses would affect CVD results17.
Other Evidence: Deeper understanding
In case of the United States the heart stroke results are higher in the case of the women as
compared to the males. Hence it becomes critical towards the follow up on any evidence that
would suggest the early usage of the estrogen theory that would also result in the cardiovascular
protection. Though the risk associated with the hormone therapy increase the chances of breast
cancer but at the same time the women suffering from CHD also die in large number.
Up-to-date information
The implications of the WHI finding shall be understood clearly as the real talking would help
the women in finding the real difference between the numbers follow up studies and this will
help in forming the correct perspective. There is piled up information which is also available on
in-adults/treatments/lifestyle-changes-for-osteoporosis-low-bone-mass
17 Shufelt C, Merz CN, Pettinger MB, Choi L, Chlebowski R, Crandall CJ, Liu S, Lane D,
Prentice R, Manson JE, Women's Health Initiative Investigators. Estrogen-alone therapy and
invasive breast cancer incidence by dose, formulation, and route of delivery: findings from the
WHI observational study. Menopause. 2018 Sep 1;25(9):985-91.

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the net. This is one of the factors that would create the confusion in Women to avoid those
websites that would claim for the dramatic solutions18. The discussion of the bio identical
hormones is in demand these days and therefore they are reviewed carefully as these products are
being aggressively marketed on the internet. In case the women still tends to use them they shall
discus personally with the doctor and encourage them to keep a follow up.
In case of the dryness in vagina or dyspareunia the local estrogens are made use as the best
option. When the women complain of hot flashes therapies like short term oral and the
transdermal therapy are considered. But in case of the history of hypertension the oral forms are
avoided. The biggest relief to the women’s can be when they are completely aware of the
alternative solution19.
18 Lupsa BC, Insogna K. Bone health and osteoporosis. Endocrinology and Metabolism Clinics.
2015 Sep 1;44(3):517-30.
19 Shufelt C, Merz CN, Pettinger MB, Choi L, Chlebowski R, Crandall CJ, Liu S, Lane D,
Prentice R, Manson JE, Women's Health Initiative Investigators. Estrogen-alone therapy and
invasive breast cancer incidence by dose, formulation, and route of delivery: findings from the
WHI observational study. Menopause. 2018 Sep 1;25(9):985-91.

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Appropriate ongoing monitoring
The proper and the regular monitoring was one of the best decisions anyone could take. The
women need to know that hormone therapy should be making use of at the lowest effective dose
for the short time period. This is useful but not after five years. The profile of the women must
be reassured on the constant basis after the age of the 45 years. The women shall be forced to
follow the prescribe guidelines, also in case of the GP the changes in the health status. Women
will have to make choices and their own relevant decisions in order to use the hormone therapy
during the time of the life. The main duty of the nurse is to provide the best support and care
possible to make her feel loved as well as positive20.
Conclusion
From the overall analysis it can be stated that the Women suffering from the osteoporosis and
facing issues post menopause can have the discussions with their GP and they can instruct the
women on how to cooperate and further move ahead with the process. Further the women can
also have the detailed discussion in order to have a deeper understating of the body and what
particular methods can be used to treat the osteoporosis. After the analysis of the WHI report the
osteoporosis and menopause the awareness have been increased and various alternatives and the
solutions are also available.
20 Paolucci T, Saraceni VM, Piccinini G. Management of chronic pain in osteoporosis: challenges
and solutions. Journal of pain research. 2016;9:177.

Running Head: NURSING
References
1. [Internet]. Nursing.ceconnection.com. 2019 [cited 20 July 2019]. Available from:
https://nursing.ceconnection.com/ovidfiles/00000446-201106000-00025.pdf
2. Bhupathiraju SN, Stampfer MJ. Menopausal hormone therapy and cardiovascular
disease: unraveling the role of age and time since menopause onset. Clinical chemistry.
2018 May 1;64(5):861-2.
3. Chlebowski RT, Mortimer JE, Crandall C, Pan K, Manson JE, Nelson RA, Johnson K,
Vitolins M, Lane D, Wactawski-Wende J, Kwan KW. Persistent vasomotor symptoms
and breast cancer in the Women’s Health Initiative (WHI).
4. Crawford SL, Crandall CJ, Derby CA, El Khoudary SR, Waetjen LE, Fischer M, Joffe H.
Menopausal hormone therapy trends before versus after 2002: impact of the Women's
Health Initiative Study Results. Menopause. 2019 Jun 1;26(6):588-97.
5. Falk RT, Anderson GL, Barnabei VM, Brinton LA, Cauley JA, Chen C, Chlebowski RT,
Coburn SB, Manson JE, Pfeiffer RM, Reding KW. Estrogen metabolism in menopausal
hormone users: Does it differ between estrogen plus progestin and estrogen alone users in
the Women’s Health Initiative Observational Study.
6. Finnerty F, Walker-Bone K, Tariq S. Osteoporosis in postmenopausal women living with
HIV. Maturitas. 2017 Jan 1;95:50-4.
7. Ghosh JS, Jog RP. Nutritional Factors are not Sufficient to Check Osteoporosis in
Women after Menopause-A Justification. Nutrition and Food Toxicology. 2018;3:556-7.
8. Greer G. The change: Women, ageing and the menopause. Bloomsbury Publishing; 2018
May 17.

Running Head: NURSING
9. Hormone replacement therapy (HRT) [Internet]. Nhsinform.scot. 2019 [cited 20 July
2019]. Available from: https://www.nhsinform.scot/tests-and-treatments/medicines-and-
medical-aids/types-of-medicine/hormone-replacement-therapy-hrt
10. Huang X, inventor; New York University, assignee. Treatment of osteoporosis in peri-
and post-menopausal women with hepcidin. United States patent US 8,999,935. 2015
Apr 7.
11. Jacques E. Rossouw G. Lessons Learned From the Women’s Health Initiative Trials of
Menopausal Hormone Therapy [Internet]. PubMed Central (PMC). 2019 [cited 20 July
2019]. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3547645/
12. Lello S, Capozzi A, Scambia G. Osteoporosis and cardiovascular disease: an update.
Gynecological Endocrinology. 2015 Aug 3;31(8):590-4.
13. Levine ME, Lu AT, Chen BH, Hernandez DG, Singleton AB, Ferrucci L, Bandinelli S,
Salfati E, Manson JE, Quach A, Kusters CD. Menopause accelerates biological aging.
Proceedings of the National Academy of Sciences. 2016 Aug 16;113(33):9327-32.
14. Lifestyle Changes for Osteoporosis & Low Bone Mass [Internet]. Nyulangone.org. 2019
[cited 20 July 2019]. Available from: https://nyulangone.org/conditions/osteoporosis-
low-bone-mass-in-adults/treatments/lifestyle-changes-for-osteoporosis-low-bone-mass
15. Lupsa BC, Insogna K. Bone health and osteoporosis. Endocrinology and Metabolism
Clinics. 2015 Sep 1;44(3):517-30.
16. Paolucci T, Saraceni VM, Piccinini G. Management of chronic pain in osteoporosis:
challenges and solutions. Journal of pain research. 2016;9:177.
17. Shufelt C, Merz CN, Pettinger MB, Choi L, Chlebowski R, Crandall CJ, Liu S, Lane D,
Prentice R, Manson JE, Women's Health Initiative Investigators. Estrogen-alone therapy

Running Head: NURSING
and invasive breast cancer incidence by dose, formulation, and route of delivery: findings
from the WHI observational study. Menopause. 2018 Sep 1;25(9):985-91.
18. Umland EM, Karel L, Santoro N. Bazedoxifene and conjugated equine estrogen: a
combination product for the management of vasomotor symptoms and osteoporosis
prevention associated with menopause. Pharmacotherapy: The Journal of Human
Pharmacology and Drug Therapy. 2016 May;36(5):548-61.
19. Van Dijk GM, Kavousi M, Troup J, Franco OH. Health issues for menopausal women:
the top 11 conditions have common solutions. Maturitas. 2015 Jan 1;80(1):24-30.