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Guideline Issued on Vitamin D and Postmenopause

Clinical Context

According to the current study by Pérez-Lópeza and colleagues, vitamin D plays a pivotal role in maintaining skeletal health. There are 2 major forms of vitamin D: vitamin D2 and vitamin D3. The major source of D3 is cutaneous synthesis requiring sunlight exposure, and other sources include gastrointestinal absorption of foods such as fatty fish, eggs and milk. There are 3 categories of hypovitaminosis D: insufficiency, deficiency, and severe deficiency according to the respective cutoff values of 25-hydroxyvitamin D [25(OH)D] levels of 20 to 29.99 ng/mL, below 20 ng/mL, and below 10 ng/mL.
This is a review of hypovitaminosis D in postmenopausal women and recommendations to address low levels of vitamin D.

Study Synopsis and Perspective

A European Menopause and Andropause Society (EMAS) position statement on the role of vitamin D after menopause notes that the recommended daily allowance is 600 IU/day, or 800 IU/day for those 71 years of age or older. The new guidelines were published in the January issue of Maturitas.
"There is emerging evidence on the widespread tissue effects of vitamin D," write Faustino R. Pérez-Lópeza, MD, PhD, from the Department of Obstetrics and Gynecology, Universidad de Zaragoza, Spain, and colleagues. "Epidemiological and prospective studies have related vitamin D deficiency with not only osteoporosis but also cardiovascular disease, diabetes, cancer, infections and neurodegenerative disease. However the evidence is robust for skeletal but not nonskeletal outcomes where data from large prospective studies are lacking."
Based on a literature review and the consensus of expert opinion, the position statement panel concluded that the leading natural source of vitamin D is sunlight exposure stimulating synthesis in the skin. Dietary sources, which are not as significant as cutaneous synthesis, include animal-based foods such as fatty fish, eggs, and milk.
Measurement of serum 25(OH)D levels allows determination of vitamin D status, with optimal levels ranging from 30 to 90 ng/mL (75 - 225 nmol/L). However, different countries vary in their recommendations concerning optimal vitamin D levels. Factors affecting vitamin D levels include season of the year (lower in the winter), latitude, altitude, air pollution, skin pigmentation, use of sunscreens, and skin coverage by clothing.
Obesity; malabsorption syndromes; use of anticonvulsants, antiretrovirals, or various other medications, skin aging, little sun exposure, and living in residential care facilities have been associated with low serum 25(OH)D levels.
The recommended daily allowance of vitamin D is 600 IU/day, but this should increase to 800 IU/day in those patients at least 71 years of age. Postmenopausal women can generally achieve healthy levels of vitamin D though exposure without sunscreens to regular midday sunlight for 15 minutes, 3 to 4 times a week. Ingestion of vitamin D–fortified foods does not necessarily provide sufficient amounts.
When supplementation is needed, either vitamin D2 (ergocalciferol) or vitamin D3 (cholecalciferol) may be appropriate. Depending on the dose used and the presence of renal disease or other comorbidities, monitoring may be indicated.
Specific summary recommendations include the following:
  • Clinicians should recognize that vitamin D deficiency and insufficiency are widespread, affecting up to 70% of European populations (including those living in sunny regions).
  • Healthy postmenopausal women may achieve adequate serum concentrations of vitamin D through either sun exposure (15 minutes per day, 3 - 4 times a week) or supplementation with 800 to 1000 IU/day.
  • To achieve adequate levels, women with low serum 25(OH)D may need doses ranging from 4000 to 10,000 IU/day.
  • Specific tailored doses of vitamin D supplements are needed for women with morbid obesity, both before and after gastrointestinal bypass surgery, malabsorption syndromes, and/or hepatic or renal diseases.
  • Adequate amounts of vitamin D and specific bone-conserving therapies are indicated for women with vitamin D deficiency, osteoporosis, and/or previous incidental fractures. If there are no associated risk factors for low serum vitamin D levels, doses should be from 800 to 1200 IU/day.
The authors have disclosed no relevant financial relationships.

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