RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES,

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE & ADDRESS

T.PONAMUTHACHRISTIAN COLLEGE OF NURSING#1621,HBR LAYOUTKALYAN NAGARHENNUR ROADBANGALORE-560043.

2.NAME OF THE INSTITUTION

CHRISTIAN COLLEGE OF NURSING#1621,HBR LAYOUTKALYAN NAGARHENNUR ROADBANGALORE-560043.

3.COURSE OF STUDY AND SUBJECT

M.Sc. NURSING FIRST YEAROBSTETRICAL & GYNAECOLOGICAL NURSING

4.DATE OF ADMISSION TO COURSE

10 – 10 - 2011

5.TITLE OF THE STUDY:

EFFECTIVENESS OF PLANNED TEACHING PROGRMME ON MENOPAUSAL OSTEOPOROSIS AND  ITS PREVENTION AMONG PERIMENOPAUSAL WOMEN IN SELECTED AREAS IN BANGALORE

6.0 BRIEF RESUME OF INTENDED WORK

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INTRODUCTION

“ A Cheerful Heart Is Good Medicine, But A Crushed Spirit Dries Up The Bones”.

----------- Bible

Normal aging brings physical changes in both men and women. These changes

sometimes affect the physical and mental ability. Menopause is a normal part of a

woman's aging process. Menopause is an unavoidable change that every woman will

experience, assuming she reaches middle age and beyond. It is helpful if women are able

to learn what to expect and what options are available to assist the transition, if that

becomes necessary. The transition from reproductive to non-reproductive is the result of

a reduction in female hormonal production by the ovaries. This transition is normally not

sudden or abrupt, tends to occur over a period of years, and is a natural consequence of

aging. However, for some women, the accompanying signs and effects that can occur

during the menopause transition years can significantly disrupt their daily activities and

sense of well-being.1

Menopause is a critical phase in the lives of women. It evokes discussion,

controversy, and concern among women and their health care providers about how best to

deal with acute symptoms and what changes or interventions are best for optimization of

long-term health.2

The word "menopause" literally means the "end of monthly cycles" from the

Greek word pausis (cessation) and the root men- (month), because the word "menopause"

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was created to describe this change in human females, where the end of fertility is

traditionally indicated by the permanent stopping of monthly menstruation or menses.

Menopause is a term used to describe the permanent cessation of the primary

functions of the human ovaries1: the ripening and release of ova and the release of

hormones that cause both the creation of the uterine lining and the subsequent shedding

of the uterine lining (a.k.a. the menses or the period). Menopause typically (but not

always) occurs in women in midlife, during their late 40s or early 50s, and signals the end

of the fertile phase of a woman's life.2

Perimenopause is defined as the natural transition period preceding menopause

that is often symptomatic of hormonal imbalance and fluctuations. In many ways it is the

flip side of puberty, beginning as early as our mid 30’s or as late as our 50’s for some.3

Osteoporosis is often called the "silent disease" because initially bone loss

occurs without symptoms. People may not know that they have osteoporosis until their

bones become so weak that a sudden strain, bump, or fall causes a fracture or a vertebra

to collapse. Collapsed vertebrae may initially be felt or seen in the form of severe back

pain, loss of height, or spinal deformities such as stooped posture. there is a direct

relationship between the lack of estrogen during perimenopause and menopause and the

development of osteoporosis. Early menopause (before age 40) and any prolonged

periods in which hormone levels are low and menstrual periods are absent or infrequent

can cause loss of bone mass.4

Osteoporosis is a disease that weakens bones, increasing the risk of sudden and

unexpected fractures. Literally meaning "porous bone," it results in an increased loss of

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bone mass and strength. The disease often progresses without any symptoms or pain.

There is a direct relationship between the lack of estrogen after menopause and the

development of osteoporosis. After menopause, bone resorption (breakdown) outpaces

the building of new bone. Early menopause (before age 45) and any prolonged periods in

which hormone levels are low and menstrual periods are absent or infrequent can cause

loss of bone mass. Osteoporosis is often called the "silent disease" because bone loss

occurs without symptoms. The important risk factors for osteoporosis include Age,

gender, race. bone structure and body weight and family history.

The World Health Organization (WHO) defines osteoporosis as "a

systemic skeletal disease characterized by low bone density and microarchitectural

deterioration of bone tissue," leading to increased bone fragility and fracture risk.

Modifiable risk factors include low calcium and vitamin D intake, sedentary lifestyle,

and smoking; nonmodifiable risk factors include advanced age, genetics, thinness, and

menopause status. 5

People may not know that they have osteoporosis until their bones become so weak

that a sudden strain, bump, or fall causes a fracture or a vertebra to collapse. Since

women are considered to be the backbone of the family they have a right to lead a

healthy and productive life.

6.1 NEED FOR THE STUDY

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One of the most important health issues for middle-aged women is the threat of

osteoporosis. bones are not inert. They are made up of healthy, living tissue which

continuously performs two processes: breakdown and formation of new bone tissue. The

two are closely linked. If breakdown exceeds formation, bone tissue is lost and bones

become thin and brittle. Gradually and without discomfort, bone loss leads to a weakened

skeleton incapable of supporting normal daily activities.

Each year about 500,000 American women will fracture a vertebrae, the bones

that make up the spine, and about 300,000 will fracture a hip. Nationwide, treatment for

osteoporotic fractures costs up to $10 billion per year, with hip fractures the most

expensive. Vertebral fractures lead to curvature of the spine, loss of height, and pain. A

severe hip fracture is painful and recovery may involve a long period of bed rest.

According to World Health Organization (WHO), osteoporosis is second only to

cardiovascular disease as a global healthcare problem and medical studies show a 50-

year-old woman has a similar lifetime risk of dying from hip fracture as from breast

cancer.Since osteoporosis affects the elderly population which is growing, it will put a

bigger burden to the healthcare system as treatment is expensive. Unless swift action is

taken, it can escalate into an economic threat. International Osteoporosis Foundation

(IOF) estimates that the annual direct cost of treating osteoporosis fractures of people in

the workplace in the USA, Canada and Europe alone is approximately USD48 billion.6

According to the National Osteoporosis Foundation (NOF), an estimated 10

million people in the United States have osteoporosis and 80% of them are women.

Osteoporotic fractures are a major cause of morbidity in older women and significantly

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decrease quality of life.2 In the United States about 40% of white women over the age of

50 will fracture their hip, vertebrae, or wrist because of osteoporosis; fracture rates in

other ethnic groups are much lower. For many women, the injury will be the first

indication that they have the disease. The annual cost of osteoporotic fractures in the

United States is projected to be more than $20 billion by 2015.7

With socio-economic development in many Asian countries and rapid ageing of

the Asian population, osteoporosis has become one of the most prevalent and costly

health problems in the region.Unsurprisingly, Asia is the region expecting the most

dramatic increase in hip fractures during coming decades; by 2050 one out of every two

hip fractures worldwide will occur in Asia.

China

Osteoporosis has reached epidemic proportion, 300% increase in the last 30 years

Singapore

It is estimated that 800 to 900 hip fractures occur in Singapore every year due to

osteoporosis

Malaysia

51.8% urban Malaysian women in her menopause age group had mild

osteoporosis.

India

1 out of 3 females in India suffers from osteoporosis, making India one of the largest

affected countries in the world.8

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From the above points the researcher is motivated to conduct the study on

postmenopausal osteoporosis. Osteoporosis is a major global public health problem

associated with significant morbidity, mortality, and socioeconomic burden. By creating

awareness among perimenopausal women each and every woman may be expected to get

the adequate knowledge at her old and helpless age. As such the researcher has expected

that the perimenopause women may have less exposure to postmenopausal osteoporosis.

6.2 REVIEW OF LITERATURE

Nadia studies shows that the Osteoporosis is characterized by skeletal

degeneration with low bone mass and destruction of microarchitecture of bone tissue

which is attributed to various factors including inflammation. Women are more likely to

develop osteoporosis than men due to reduction in estrogen during menopause which

leads to decline in bone-formation and increase in bone-resorption activity. Estrogen is

able to suppress production of proinflammatory cytokines such as IL-1, IL-6, IL-7, and

TNF-α. This is why these cytokines are elevated in postmenopausal women. Studies have

shown that estrogen reduction is able to stimulate focal inflammation in bone. Labisia

pumila (LP) which is known to exert phytoestrogenic effect can be used as an alternative

to ERT which can produce positive effects on bone without causing side effects. LP

contains antioxidant as well as exerting anti-inflammatory effect which can act as free

radical scavenger, thus inhibiting TNF-α production and COX-2 expression which leads

to decline in RANKL expression, resulting in reduction in osteoclast activity which

consequently reduces bone loss. Hence, it is the phytoestrogenic, anti-inflammatory, and

antioxidative properties that make LP an effective agent against osteoporosis.9

7

Reymondier cohort study within a national claims database evaluated

calcium/vitamin D co-prescription in postmenopausal women initiating an OP treatment.

A high co-prescription rate was observed with three quarters of women supplemented

with calcium and/or vitamin D in agreement with current recommendations.Adequate

calcium/vitamin D supplementation should be taken in combination with antiresorptive

drugs in OP treatment. Despite guidelines, supplementation appears to be insufficient.

The objective of this study was to describe and estimate co-prescription rates of

calcium/vitamin D among postmenopausal women initiating an OP treatment.All women

over 50 years with a first claim for a bisphosphonates, raloxifene, or strontium

prescription filled between May and August 2010 were included in a retrospective cohort

study. Data source was the health insurance claims database of the Rhône-Alpes

area.Among 4,415 women, 77.0 % had co-prescription of calcium or vitamin D with

initial OP treatment, of which 2,150 (49.7 %) had both calcium and vitamin D. The

proportion of women with calcium and/or vitamin D (81.7 %) was significantly higher

when OP treatment was a bisphosphonate compared to strontium (70.9 %) or raloxifene

(67.0 %) (p < 0.05). Among women prescribed both calcium and vitamin D, 7.6 %

received a bisphosphonate and vitamin D ± calcium fixed-combination pack. General

practitioners prescribed two thirds of initial supplementation treatment (66.9 %). Patients

were twice as likely to be prescribed supplementation when the prescriber was a

rheumatologist (OR = 2; 95 % CI = 1.57-2.54).10

Osteoporotic patients with insufficient calcium intake and/or vitamin D

insufficiency need adequate calcium and vitamin D supplementation with their

bisphosphonate treatment. Two quantitative patient research survey studies were

8

conducted using standard questionnaires in face-to-face interviews with 400

postmenopausal women in several French cities. Participants were given the combined

pack and two separate packs (risedronate 35 mg once weekly and calcium/vitamin D

effervescent granules in sachets). In the first study, participants' understanding of

administration instructions and preferences were evaluated. In the second study,

participants' perception of compliance, convenience and completeness of the new

combination pack of risedronate 35 mg plus calcium/vitamin D compared with two

separate packs were evaluated. Seventy percent of participants believed that use of the

combination pack would help them to not forget to take calcium/vitamin D

supplementation.Use of the fixed-combination pack of risedronate 35 mg plus

calcium/vitamin D once weekly could increase the likelihood that postmenopausal

osteoporotic patients will receive a complete bisphosphonate, calcium and vitamin D

therapy course and is likely to enhance correct intake of combination therapy. Use of this

fixed-combination product will provide patients with a tool for improving adherence to

recommended osteoporosis therapy and optimize the effectiveness of such treatment.11

Malochet-Guinamand.S et al conducted a study to evaluate the impact of

information alerting general practitioners to the need for osteoporosis treatment and

prevention in postmenopausal women with a recent history of peripheral fracture.We

conducted a prospective 7-month follow-up study of 78 postmenopausal women, with a

mean age of 81.5 years, admitted to the emergency department for peripheral fractures.

Three months after the fracture, we sent a letter to the general practitioner of each patient

emphasizing the probable contribution of osteoporosis to the fracture and the need for

osteoporosis treatment. Six months after the fracture, we interviewed the patients by

9

telephone, and one month later we mailed a questionnaire to those physicians who had

not followed the treatment recommendation.At emergency room admission, 9 patients

were receiving treatment for osteoporosis (hormone replacement therapy in one patient

and calcium and vitamin D supplementation in eight patients). Admission to a ward was

required in 66 (85%) patients. No treatment for osteoporosis was given at discharge. Six

months after discharge, seven patients reported recent initiation of calcium and vitamin D

supplementation, and none reported other osteoporosis treatments. 12

Birkhäuser study showed that the three modern Selective Estrogen Receptor

Modulators (SERMs) Raloxifene, Lasoxifene and Bazedoxifene registered in Europe

reduce in postmenopausal women with a high risk for osteoporosis the incidence of

vertebral fractures by 30 - 50 %, depending on the subgroup they belong to. Solid

prospective fracture data for risk reduction in non-vertebral fractures, including the hip,

are missing for Raloxifene and Bazedoxifene. However, a post hoc analysis suggests that

the risk for non-vertebral fractures is significantly reduced by Raloxfene in women with

severe osteoporosis.Looking at other hormonal options, Hormone Replacement Therapy

(HRT) remains the first line therapy for fracture reduction in the peri- and early

postmenopause. SERMs are an appropriate choice for the continuation of fracture

prevention after an initial HRT, particularly for the prevention of osteoporosis.13

A multicenter, double-blind, randomized, placebo-controlled study were to

examine the efficacy, tolerability, and optimal dose of oral daily ibandronate in the

prevention of bone loss in postmenopausal women.In total, 653 women (mean bone

mineral density [BMD] T-score > -2.5 at the lumbar spine), who had been

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postmenopausal for at least 1 year, were allocated to one of four strata based on time

since menopause and baseline lumbar spine BMD. Women were randomized to receive

calcium (500 mg daily) plus either placebo (n = 162) or ibandronate 0.5 mg (n = 162), 1

mg (n = 166), or 2.5 mg (n = 163) as once-daily oral treatment for 2 years. After 2 years,

oral daily ibandronate produced a dose-related and sustained maintenance or increase in

BMD at the lumbar spine and hip (total hip, femoral neck, trochanter), together with a

dose-related reduction in the rate of bone turnover. In summary, oral daily ibandronate

2.5 mg decreases bone turnover, preserves or increases BMD in the spine and proximal

femur, and is well tolerated. Oral ibandronate provides a promising option for the

prevention of bone loss in postmenopausal women.14

Osteoporosis is a debilitating disease characterized by decreased bone mineral

density (BMD) leading to fractures. It primarily affects postmenopausal women and

elderly men. Prevention of osteoporosis is very important because present therapies do

not have the potential to mend damage to the bone microarchitecture caused by

osteoporosis. The first line of prevention and treatment of osteoporosis is hormone

replacement therapy (HRT). All of the approved drugs for the prevention and treatment

of osteoporosis act as inhibitors of bone resorption; these drugs include HRT, selective

estrogen receptor modulators, calcitonin, and bisphosphonates. The latter two drugs have

also been shown to prevent fractures. This article discusses data from nine controlled

prospective clinical studies. Study 1 was designed to assess the efficacy of combined

HRT and bisphosphonate in preventing osteoporosis during the early stages of

menopause. This combined therapy increased the lumbar spine BMD by 10.9% and

femoral BMD by 7.3% over 4 yr, compared with 6.8 and 4.0% with HRT alone, and 6.8

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and 1.2% with bisphosphonate alone. Study 2 was conducted on postmenopausal women

with established osteoporosis. These results showed a 10.4 and 7.0% increase in BMD in

vertebrae and femora, respectively, compared with 7.3 and 4.8% increases in the HRT

group, and 6.8 and 0.9% in the bisphosphonate group. Data from study 3 demonstrated

similar findings in that the combination of alendronate and HRT also enhanced BMD

values. Studies 4 and 5 assessed the efficacy of the combined therapy of HRT and

calcitonin in the prevention of early postmenopausal bone loss. Both studies

demonstrated a significant increase in BMD over and above that observed with either

HRT or calcitonin alone. Studies 6, 7, and 8 demonstrated that the addition of

testosterone to estrogen therapy further increased BMD when compared to estrogen

therapy alone, and also prevented the expected decreases in markers of bone formation in

early postmenopausal women. Study 9 demonstrated a synergistic effect on BMD in

postmenopausal women, when HRT was coadministered with monofluorophosphate.

These studies illustrate that in a subgroup of patients (i.e., patients with high bone

turnover and/or severe osteoporosis), specific combination treatments such as HRT with

bis-phosphonates, calcitonin, or androgens (and perhaps also with PTH, fluoride, nitric

oxide donors) provide additional beneficial effects over a single-drug therapy. Whether

these combination therapies are more effective than individual drugs in reducing fractures

still needs to be determined.15

Two long-used interventions for reducing the morbidity and mortality associated

with osteoporosis are postmenopausal hormone replacement therapy (HRT) and

treatment with antiresorptive agents. Postmenopausal HRT works through prevention of

osteoporosis, whereas antiresorptive agents, such as the bisphosphonates, reverse low

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bone mass. Because of their different mechanisms, it has been thought that combining the

two therapies would yield additive improvements in bone mineral density (BMD) and in

fracture risk reduction. Results from several recent clinical trials in postmenopausal

women with low bone mass support this idea, demonstrating clinically relevant additive

improvements in BMD after treatment with HRT (or a selective estrogen receptor

modulator) plus a bisphosphonate. Treatment with PTH stimulates new bone formation,

and recent studies have shown that PTH monotherapy reduces fracture rates. And

osteoporosis16

6.3 STATEMENT OF THE PROBLEM

“A study to assess the effectiveness of Planned Teaching Programme on

menopausal osteoporosis and  its prevention among perimenopausal women working in

selected  areas at  Bangalore.

6.4 OBJECTIVES OF THE STUDY

1. To assess the level of knowledge of perimenopause women regarding menopausal

osteoporosis and its prevention before and after the test.

2. To prepare and implement planned teaching programme on menopausal

osteoporosis and its prevention for perimenopause women in selected areas.

3. To evaluate the effectiveness of planned teaching programme regarding

menopausal osteoporosis and its prevention among perimenopause women in

selected areas.

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4. To find out the association between the mean post test knowledge scores of

perimenopause women regarding menopausal osteoporosis and its prevention

with their selected demographic variables.

6.5 HYPOTHESIS

H1 There is a significant difference between pretest and posttest knowledge of

perimenopausal women on menopausal osteoporosis and  its prevention.

H2 There is a significant association between the demographic variables and knowledge

on menopausal osteoporosis and  its prevention.

VARIABLES

Independent variable:

Planned teaching programme on menopausal osteoporosis and  its prevention.

Dependent variable:-

Knowledge on menopausal osteoporosis and  its prevention among

perimenopausal women

6.6.OPERATIONAL DEFINITIONS

Assess:

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Systematic determination of merit, worth, and significance of safe motherhood

using criteria.

Effectiveness:-

It refers to desirable change brought about by the structured teaching programmed

as measured in terms of significant knowledge gain in the post test and graded as

adequate knowledge, moderately adequate knowledge and inadequate knowledge

Planned Teaching Programme:

It is systematically developed instruction and teaching aids designed for a group

of women to provide information regarding menopausal osteoporosis and  its prevention.

Menopausal Osteoporosis

Osteoporosis is a disease that weakens bones, increasing the risk of sudden and

unexpected fractures during their late 40s or early 50s

Perimenopause:

It is the stage of a woman’s reproductive life that begins 8 to 10 years before

menopause, when the ovaries gradually begin to produce less estrogen. It usually starts in

a woman's 40s, but can start in the 30s as well.

Perimenopause Women:

Women who are ten to fifteen years before menopause .

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6.7 ASSUMPTIONS.

1. Perimenopausal women may have have inadequate knowledge regarding

menopausal osteoporosis.

2. Prior knowledge can help in preventing osteoporosis.

3. Women will be interested to know about this transitional phase.

6.8 DELIMITATIONS:

The study is limited to perimenopausal women in selected areas of Bangalore.

7.0 MATERIALS AND METHOD

7.1 SOURCE OF DATA

Data will be collected from perimenopausal women in selected areas of

Bangalore.

7.2 METHODS OF COLLECTION OF DATA

7.2.1 RESEARCH APPROACH:

A quantitative approach is used.

7.2.2 RESEARCH DESIGN

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The research design selected for this study is quasi-experimental one group pre

test, post test design.

7.2.3 RESEARCH SETTING:

The study will be conducted at selected areas of Bangalore.

7.2.4 POPULATION

In the present study the population consists of perimenopausal women at selected

areas in Bengaluru.

7.2.5. SAMPLE SIZE

Sample size is 60 perimenopausal women who are fulfilling inclusive and

exclusive criteria.

7.2.6 SAMPLING TECHNIQUE

Non-probability purposive sampling technique.

7.2.7 SAMPLE CRITERIA

INCLUSION CRITERIA:

The study includes perimenopausal women who are.

Willing to participate in the study.

Present and available at the time of study.

Able to read and write English and Kannada

EXCLUSION CRITERIA

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The study excludes perimenopausal women who are.

Not available during data collection.

Not willing to participate.

7.2.8 DATA COLLECTION TOOL

The Semi structured interview schedule was organized into 2 sections.

Section 1 : Demographic Data of Perimenopausal women

It consists of selected demographic variables like age, religion, education,

occupation, and source of information.

Section 2 : Semi Structured Knowledge questionnaires

A questionnaire to assess the level of knowledge of the subjects on menopausal

osteoporosis and its prevention.

7.2.9 DATA ANALYSIS METHOD:

Descriptive statistics:

Mean frequency, standard deviation and percentage will be used to analyze.

Inferential statistics:

Paired t test will be used to evaluate the effectiveness of the structured teaching

program. Chi-square will be used to determine the association between selected

demographic variables and knowledge levels

7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR

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INTERVENTIONS TO BE CONDUCTED ON PATIENTS OR OTHER HUMAN

BEINGS OR ANIMALS?

The study will require interventions in the form of planned teaching programme

which will not have any harmful effect on the study participants.

7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM THE

INSTITUTION?

1. Yes, ethical clearance has been obtained from ethical committee of christian

college of nursing.

2. Permission will be obtained from the area selected for the study.

3. Informed consent will be obtained from the all the participant

8. LIST OF REFERENCES

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1. Minkin, et al. (1997), What Every Woman Needs to Know about Menopause, Yale

University Press, ISBN 0-300-07261-9.

2. North American Menopause Society. Menopause Guidebook: Helping Women Make

Informed Healthcare Decisions Around Menopause and Beyond. www.menopause.org

Accessed 3/14/2011.

3.Poole KE, Compston JE (December 2006). "Osteoporosis and its management". BMJ

333 (7581): 1251–6. doi:10.1136/bmj.39050.597350.47

4. Davis S, Oliver A, Goeckeritz B, Sachdeva A (2010). "All about osteoporosis: a

comprehensive analysis". Journal of Musculoskeletal Medicine 27 (4): 149–153.

5. WHO Scientific Group on the Prevention and Management of Osteoporosis (2000 :

Geneva, Switzerland) (2003). "Prevention and management of osteoporosis : report of a

WHO scientific group" (pdf). Retrieved 2007-05-31

6.From Tracee Cornforth, former About.com Guide Updated December 28, 2003.

7.Cockayne, S; Adamson J, Lanham-New S, Shearer MJ, Gilbody S, Torgerson DJ

(2006). "Vitamin K and the Prevention of Fractures: Systematic Review and Meta-

analysis of Randomized Controlled Trials". Archives of Internal Medicine 166 (12):

1256–1261

8. Riancho JA, Hernández JL. Pharmacogenomics of osteoporosis: a pathway approach.

Pharmacogenomics. 2012 May;13(7):815-29.

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9. Aggarwal N, Raveendran A, Khandelwal N, Sen RK, Thakur JS, Dhaliwal LK, Singla

V, Manoharan SR. Prevalence and related risk factors of osteoporosis in peri- and

postmenopausal Indian women. J Midlife Health. 2011 Jul;2(2):81-5.

10. Roux C, Wyman A, Hooven FH, Gehlbach SH, Adachi JD, Chapurlat RD, Compston

JE, Cooper C, Díez-Pérez A, Greenspan SL, Lacroix AZ, Netelenbos JC, Pfeilschifter J,

Rossini M, Saag KG, Sambrook PN, Silverman S, Siris ES, Watts NB, Boonen S; for the

GLOW investigators. Burden of non-hip, non-vertebral fractures on quality of life in

postmenopausal women : The Global Longitudinal study of Osteoporosis in Women

(GLOW). Osteoporos Int. 2012 Mar 8. [Epub ahead of print]

11.Paul TV, Thomas N, Seshadri MS, Oommen R, Jose A, Mahendri NV. Prevalence of

osteoporosis in ambulatory postmenopausal women from a semiurban region in Southern

India: relationship to calcium nutrition and vitamin D status. Endocr Pract. 2008

Sep;14(6):665-71.

12. International Osteoporosis Foundation (IOF) http://www.iofbonehealth.org/patients-

public/about-osteoporosis.html.

13. Ungan M, Tumer M, “ Turkish Women’s knowledge of Osteoporosis”, Family

Practitioner;18(2):199-203, April 2001.

14. Nadia ME, Nazrun AS, Norazlina M, Isa NM, Norliza M, Ima Nirwana S. The Anti-

Inflammatory, Phytoestrogenic, and Antioxidative Role of Labisia pumila in Prevention

of Postmenopausal Osteoporosis. Adv Pharmacol Sci. 2012;2012:706905. Epub 2012

Mar 15.

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15. Reymondier A, Caillet P, Abbas-Chorfa F, Ambrosi V, Jaglal SB, Chapurlat R,

Schott AM. MENOPOST - Calcium and vitamin D supplementation in postmenopausal

osteoporosis treatment: a descriptive cohort study. Osteoporos Int. 2012 May 16. [Epub

ahead of print]

16. Ringe JD, Fardellone P, Kruse HP, Amling M, van der Geest SA, Möller G. Value of

a new fixed-combination pack of bisphosphonate, calcium and vitamin D in the therapy

of osteoporosis: results of two quantitative patient research studies. Drugs Aging.

2009;26(3):241-53. doi: 10.2165/00002512-200926030-00005.

17. Malochet-Guinamand S, Chalard N, Billault C, Breuil N, Ristori JM, Schmidt J.

Osteoporosis treatment in postmenopausal women after peripheral fractures: impact of

information to general practitioners. Joint Bone Spine. 2005 Dec;72(6):562-6. Epub 2005

Mar 19.

18. Birkhäuser M. [Selective Estrogen Receptor Modulators (SERMs) for prevention and

treatment of postmenopausal osteoporosis]. Ther Umsch. 2012 Mar;69(3):163-72.

19. McClung MR, Wasnich RD, Recker R, Cauley JA, Chesnut CH 3rd, Ensrud KE,

Burdeska A, Mills T; Oral Ibandronate Study Group. Oral daily ibandronate prevents

bone loss in early postmenopausal women without osteoporosis. J Bone Miner Res. 2004

Jan;19(1):11-8

20. Wimalawansa SJ. Prevention and treatment of osteoporosis: efficacy of combination

of hormone replacement therapy with other antiresorptive agents. J Clin Densitom. 2000

Summer;3(2):187-201

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21. Miller E, Kalin MF. A review of combination regimens for osteoporosis--prevention

and treatment. Int J Fertil Womens Med. 2002 Sep-Oct;47(5):198-204.

9 SIGNATURE OF THE

CANDIDATE

10 REMARKS OF THE

GUIDE

11 NAME & DESIGNATION

OF GUIDE :

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SIGNATURE:

12 HEAD OF THE

DEPARTMENT:

SIGNATURE:

13 REMARKS OF THE

PRINCIPAL:

SIGNATURE:

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