RISK FACTORS FOR OSTEOPOROSIS IN POSTMENOPAUSAL WOMEN – 
FROM THE POINT OF VIEW OF PRIMARY CARE GYNECOLOGIST 
Damir FRANIC1*, Ivan VERDENIK2
1Outpatient Clinic for Obstetrics and Gynecology, Celjska cesta 10, 3250 Rogaska Slatina, Slovenia
2University Clinical Center Ljubljana, Department for Obstetrics and Gynecology, 
Zaloska cesta 7, 1000 Ljubljana, Slovenia
Received: Jun 11, 2017
Accepted: Nov 27, 2017
Original scientific article
Introduction: Osteoporosis is a highly prevalent public health problem with osteoporosis-related fractures that 
account for high morbidity and mortality. Therefore, prevention strategies and early detection of osteoporosis 
should be carried out in primary gynaecological care units, so as to substantially reduce the risk of fractures 
and allow the best treatment option for a particular woman.
Methods: From 2002 to 2011, we recruited 2956 women. Of the total number of women, we additionally 
extrapolated 1274 women aged 60-75 years, assumingly, the group of women at higher risk of osteoporosis. 
Demographic and anthropometrical data as well as the information regarding risk factors for osteoporosis were 
collected using a questionnaire.
Results: The odds ratio for osteoporosis increased by 8% (p=0.001) with each additional year of life. The OP 
prevalence increased with age from 24.9% in 60-64 years to 37.4% in 70-75 years. In non-smokers the odds ratio 
for osteoporosis was 0.424, which was statistically significant (p<0.05). BMI <18.5 increased the odds ratio for 
osteoporosis by 2 times, which was not statistically significant. In women 60-75 years old (N=1274), the risk 
of fractures increased with increasing age, considering previous fractures in the last 5 years (p<0.001), hip 
fracture (p=0.001), wrist fracture (p=0.002) and observed height loss (p<0.001). Hormone therapy (HT) use 
decreased the prevalence of OP by 25% in comparison with non-users.
Conclusion: Primary care gynaecologist with a DXA centre has every opportunity for a holistic approach to 
the management of postmenopausal women, including the prevention and treatment of postmenopausal 
osteoporosis.
Izhodišča: Osteoporoza je zelo pomemben zdravstveni problem, povezana je z zlomi, ki povzročajo veliko 
obolevnost in umrljivost. Zaradi tega preventiva in zgodnje odkrivanje osteoporoze pri ginekologu na primarni 
ravni vplivata na značilno zmanjšanje tveganja za zlome in omogoča najboljšo možnost zdravljenja za vsako 
posamezno žensko.
Metode: V raziskavo je bilo vključenih 2956 žensk v obdobju 2002–2011 v DXA centru v sklopu ginekološke 
službe na primarni ravni. Od skupnega števila vključenih žensk smo dodatno obdelali 1274 žensk, starih 60–75 
let, kot skupino z večjim tveganjem za nastanek osteoporoze/zlomov. Demografski in antropometrični podatki 
ter podatki, povezani z dejavniki tveganja za osteoporozo, so pridobljeni s pomočjo vprašalnika.
Rezultati: Razmerje obetov za nastanek osteoporoze se poveča za 8 % (p=0,001) za vsako dodano leto starosti. 
Pri nekadilkah je razmerje obetov za nastanek osteoporoze 0,424 (p=0,05). Indeks telesne mase (ITM) <18,5 
poveča razmerje obetov za osteoporozo za dvakrat, kar pa ni statistično značilno. Pri ženskah, starih 60–75 let 
(N=1274), tveganje za zlome narašča z leti glede na predhodne zlome, pridobljene v zadnjih 5 letih (p<0,001). 
Hormonsko zdravljenje (HZ) zmanjša prevalenco osteoporoze za 25 % v primerjavi z neuporabnicami HZ.
Zaključek: Ginekolog na primarni ravni, ki premore DXA center, ima dodatno možnost za celosten pristop k 
ženski v pomenopavzi, kar vključuje preventivo in zdravljenje pomenopavzne osteoporoze.
ABSTRACT
Keywords: 
osteoporosis, 
risk factors, 
DXA measurements, 
the prevention of 
fractures
IZVLEČEK
Ključne besede: 
osteoporoza, 
dejavniki tveganja, 
DXA meritve, 
preprečevanje 
zlomov
*Corresponding author: Tel: + 386 40 565 958; E-mail: damir.franic@guest.arnes.si
10.2478/sjph-2018-0005 Zdr Varst. 2018;57(1):33-38
DEJAVNIKI TVEGANJA ZA NASTANEK OSTEOPOROZE PRI POMENOPAVZNIH 
ŽENSKAH – ZORNI KOT GINEKOLOGA NA PRIMARNI RAVNI
Franic D, Verdenik I. Risk factors for osteoporosis in postmenopausal women – from the point of view of primary care gynecologist. Zdr Varst. 2018;57(1):33-38.
doi: 10.2478/sjph-2018-0005.
33
© Nacionalni inštitut za javno zdravje, Slovenija. 
1 INTRODUCTION
Osteoporosis (OP) was last defined in 2001 as a skeletal 
disease with significantly decreased bone strength, with 
its consequences – an increased risk of bone fractures; 
ever since, there has been a movement in osteoporotic 
paradigm (1). According to the World Health Organization 
(WHO), 30% of women over the age of 50 and 8% of 
men suffer from OP (2). Oestrogen deficiency in the 
menopause and beyond seems to be the main cause of an 
increased risk of OP. After the menopause, a decrease in 
the trabecular bone width occurs, followed by decreased 
cortical bone thickness after the age of 70. Peak bone 
mineral density (BMD) is reached at the age of 30, after 
which bone resorption exceeds bone formation for about 
0.7% per year, and a woman loses 37% of trabecular bone 
mass and 6% of cortical bone mass before the age of 50. 
The most significant decrease in BMD, about 5% per year, 
appears in the first years after the menopause, followed 
by 1-1.5% per year in the following years (3).
Fractures due to OP are an important epidemiological 
as well as a socio-medical problem. After the age of 50, 
the risk of fractures due to osteoporosis is 40%, which is 
similar to the risk of coronary heart disease. In Europe, 
approximately 11.5% of women aged 50-54 years, and 
35% of those aged 75-79 years, suffer from at least one 
vertebral fracture (4). Therefore, the prevention of 
the first fracture should be one of the most important 
tasks of treating an osteoporotic patient. However, as 
OP typically has no symptoms, patients go undiagnosed 
until a fracture occurs. Hence, the disease prevention and 
early diagnosis are particularly important. Dual-energy 
X-ray absorptiometry (DXA) is still the gold standard 
to diagnose OP using BMD measurements. It should be 
noted that before the introduction of FRAX, there were 
no effective diagnostic tools available to assist primary 
care physicians, especially primary care gynaecologists, 
in detecting individuals at risk for developing OP and 
associated risk for fractures (5). 
This study sought to assess the prevalence of risk factors 
for OP in a large sample of women randomly assigned 
to the DXA measurement in a primary care gynaecology 
office in Slovenia. 
2 MATERIALS AND METHODS
2.1 Study Design
An observational, retrospective study was designed to 
analyse the prevalence of different OP risk factors and 
their influence on the incidence of OP. The study was 
conducted at a Primary Care centre of obstetrics and 
gynaecology, associated with a DXA centre. From 2002 
to 2011, we observed 2956 women who were referred 
for DXA measurement by a general practitioner (GP), 
other specialists, or self-referred. A signed consent for 
the collection and use of clinical data in accordance 
with regulations regarding personal data protection was 
obtained from each woman prior to enrolment. 
Demographic, anthropometric and fracture data, and 
the risk factors for OP were collected from the women 
included in the study, in the form of the interview 
using a 13-item questionnaire providing the following 
information: date of birth, age at menopause, type of 
menopause, body weight, adult body height and body 
height on the day of the measurement, to see whether 
height loss exceeded 3 cm, BMI, bone fractures within 
the last 5 years (wrist, hip, lumbar spine), hysterectomy 
with or without ovaries, use of hormonal contraception, 
hormone therapy, and/or glucocorticoid therapy, disorders 
affecting bone metabolism and an increased risk of falls 
due to cardiovascular, kidney and thyroid gland problems, 
diabetes, blood pressure, alcohol abuse, smoking habits, 
problems with milk digestion, antiosteoporotic drugs use 
and family history of osteoporotic fracture (Figure 1). 
10.2478/sjph-2018-0005 Zdr Varst. 2018;57(1):33-38
34
Figure 1. The questionnaire to obtain demographic, 
anthropometric, and fracture data, and the risk 
factors for OP.
10.2478/sjph-2018-0005 Zdr Varst. 2018;57(1):33-38
35
2.2 Methods of Measurement
All the women enrolled in the study underwent a DXA 
measurement using the HOLOGIC QDR-2000 Explorer 
DXA machine. After performing the daily quality control 
(QC) using a spine phantom on the table at the position 
indicated by the laser, all the women underwent a DXA 
measurement of the anterior-posterior (AP) lumbar spine 
and left hip. In women with an artificial hip, left or 
right forearm examination was additionally performed. 
According to the diagnosis in the questionnaire, osteopenia 
is the condition of a bone that is slightly less dense than 
the normal bone (from -1.0 SD), to the degree of BMD 
defined as osteoporosis (-2.5 SD). Bones are considered 
normal with BMD up to -1.0 SD, and osteoporosis is a 
condition where BMD is below -2.5 SD from the normal 
young Caucasian.
2.3 Statistical Analysis
Out of all the items included in the questionnaire, only 
those which were statistically significant were analysed. 
The second reason was the possibility to act in the 
preventive manner for BMI, smoking habits and usage of 
HT. Moreover, other confounding variables, like age and 
observed decreased height, which definitively influence 
OP, were analysed in particular.
For the comparison of different ordinal categorical 
variables between age groups, chi-square test for linear 
associations was used. For numerical variables, Spearman 
rank order correlation was used. For determining the 
effect of different factors on osteoporosis, multiple 
logistic regression was performed. Model fit was tested 
with Hosmer-Lemeshow goodness-of-fit test. An IBM SPSS 
Statistics v21 was used for all calculations. The p value 
<0.05 was considered statistically significant.
3 RESULTS
Total of 2956 women were enrolled in the study, in the 
period of 9 years (2002-2011). General characteristics are 
summarized in Table 1.
The descriptive data concerning using of HT and anti-
resorptive agents are presented in Figure 2 and 3.
HT use significantly decreased the incidence of OP; HT 
users had 50% lower odds for OP than non-users. Also, 25% 
of HT users had normal bone mineral density in comparison 
to 10% of non-users. Altogether, 75% of HT users vs. 50% of 
non-users were OP-free. 
Of all the women included in the study, 1274 were aged 
60-75 years. We extrapolated these women because of 
increased risks of OP and fractures in this age group.
Figure 2.
Figure 3.
The incidence of osteoporosis concerning HT 
use (N=2956).
The use of anti-resorptive therapy by age groups 
(N=1274).
Table 1. General characteristics of the women (n=2956).
*Some data were missing, hence differences in totals
2810
2486
2942
2299
2906
2896
19
20
35
135
129
16.0
98
64
164
182
180
46.0
61.0 ± 11.0
49.0 ± 4.7
71.0 ± 12.9
162.3 ± 5.9
158.8 ± 6.3
28.1 ± 4.9
Age (years)
Age at onset of 
menopause (years)
Weight (kg)
Height 
before measurement
on measurement (cm)
Body mass index (BMI)
N* Min. Max. Mean ± SD
10.2478/sjph-2018-0005 Zdr Varst. 2018;57(1):33-38
36
Vitamin D was the most prescribed drug in the age groups 
60-64 and 70-75 years, whereas the use of bisphosphonates 
(BP) increased in the age groups 65-69 and 70-75 years. 
The expected decreased use of HT and selective oestrogen 
receptor modulators (SERMs) was expressed in the age 
groups 65-69 and 70-75 years.
Table 2 shows important changes occurring with increasing 
age: statistically significant increase in all osteoporotic 
fractures, height loss (cm), and bone mineral content 
(BMC).
For the entire investigated group of women, the odds ratio 
for OP concerning established and independent risk factors 
was highly important. The results are shown in Table 3 
(uni- and multivariate regression). The multivariable 
model fit the data well, as proved by Hosmer-Lemeshow 
goodness-of-fit test (p=0.11).
Table 2.
Table 3.
The prevalence of osteoporosis and fracture risk factors regarding age (N=1274).
Odds ratio for osteoporosis concerning risk factors (N=1274) (univariate and multivariate regression).
Statistically significant odds ratios are written in bold.
* Chi-square for linear association
** Spearman correlation
*** Chi-square
132 (24.9%)
46 (10.0%)
2.57 (2.4)
25 (5.4%)
72 (15.7%)
31 (6.7%)
5 (1.1%)
15 (3.3%)
54.0 (11.5)
31.1 (5.8)
58 (12.6%)
1.07 (1.04 - 1.11)   p<0.001
1 (ref)
1.86 (0.35 - 9.8)   p=0.462
0.37 (0.27 - 0.52)   p<0.001
0.19 (0.13 - 0.28)   p<0.001
0.12 (0.07 - 0.20)   p<0.001
0.42 (0.24 - 0.74)   p=0.002
1.02 (0.77 - 1.36)   p=0.864
0.31 (0.13 - 0.73)   p=0.008
1.11 (0.87 - 1.41)   p=0.392
1.08 (1.05 - 1.11)   p<0.001
1 (ref)
2.32 (0.40 - 13.5)   p=0.350
0.38 (0.27 - 0.54)   p<0.001
0.19 (0.13 - 0.27)   p<0.001
0.11 (0.07 - 0.19)   p<0.001
0.55 (0.29 - 1.01)   p=0.055
1.15 (0.84 - 1.59)   p=0.373
0.26 (0.10 - 0.65)   p=0.004
1.13 (0.86 - 1.47)   p= 0.377
102 (34.2%)
38 (10.3%)
3.05 (2.8)
15 (4.1%)
80 (21.6%)
40 (10.8%)
9 (2.4%)
23 (6.2%)
52.9 (12.9)
30.4 (6.2)
38 (10.3%)
166 (37.4%)
60 (13.5%)
4.30 (3.9)
14 (3.2%)
114 (25.7%)
57 (12.8%)
20 (4.5%)
18 (4.1%)
51.1 (11.6)
29.3 (5.7)
49 (11.0%)
<0.001*
0.097 *
< 0.001 **
0.088 *
< 0.001 *
0.002 *
0.001*
0.107 ***
0.001 **
< 0.001 **
0.551 ***
Osteoporosis prevalence
Low calcium intake
Observed height loss in cm (SD)
Smokers
Osteoporotic fractures in the last 5 years
Wrist fracture
Hip fracture
Corticosteroid use
BMC (g/cm2) - L1-L4
BMC (g/cm2) - hip
Family history of osteoporosis
Age
BMI 18.5-25 (ref)
BMI<18.5
BMI=25-30
BMI=30-35
BMI= > 35 
Non-smoker
Hormone contraception (ever user)
HT (ever user)
Height loss >3 cm
60-64 years (N=460)
OR (95%CI) univariate OR (95%CI) multivariate
65-69 years (N=370) 70-75 years (N=444) p-value
10.2478/sjph-2018-0005 Zdr Varst. 2018;57(1):33-38
37
Age as an independent risk factor for OP increased the 
odds ratio for OP by 8% each year, which was statistically 
significant. BMI <18.5 as an independent risk factor for OP 
increased the risk of OP for more than 2 times, although 
this increase was not statistically significant. Smoking 
also proved to be the risk factor for OP: non-smokershad 
significantly lower odds for OP than smokers. HT as a well-
known preventive agent against OP, was shown to decrease 
the odds for OP by almost 50%. Hormonal contraception 
seemed to have no influence on the OP incidence.
4 DISCUSSION
The analysis of risk factors for OP clearly shows that 
besides age and BMD<18, the most important, statistically 
significant risk factors are decreased height increasing 
with age, low BMC either in the lumbar spine or in the 
hip, and previously sustained fractures. All these factors 
influence the prevalence of OP, which increases with age 
from 24.9% in the age group 60-64 years to 37.4% in the 
age group 70-75 years. Nevertheless, low calcium intake, 
family history of OP, cigarette smoking and corticosteroid 
use are not statistically prevailing factors for the OP 
prevalence.
In Slovenia, a significant decrease in hip fractures in the 
last 10 years has not been observed, although Slovenia has 
almost twice the recommended number of DXA machines 
per one million inhabitants (20 vs. 11 in EU) (6). The reason 
might be that DXA measurement was not reimbursed by 
the Slovenian health insurance, therefore the selection 
of women is not by the OP risk factors, but by the ability 
to pay the procedure. Hip fracture is definitely one of 
the most important consequences of OP, causing death in 
30% of cases within the first year after the fracture (7,8). 
Therefore, the prevention of hip fracture is one of the 
main tasks of the OP prevention strategy. 
We have analysed the incidence of hip fracture among 
women aged 60-64, 65-69, and 70-75 years. The incidence 
of hip fractures as well as all fractures increased 
statistically significantly with increasing age: from 1.1% 
in the age group 60-64 years to 4.5% in the age group 
70-75 years for hip fractures, and from 15.7% to 25.7% 
for all fractures, respectively. A recent study (9) has 
emphasized the importance of using different sites of 
BMD measurement to evaluate the frequency of vertebral 
fractures. The odds ratio for osteoporosis increases with 
increasing age, smoking, height loss, low calcium intake 
and BMI<18.5, which is in agreement with the Spanish 
study (10).
The prevention of OP mainly includes calcium and vitamin D 
intake. The recent Slovenian guidelines for the prevention 
and treatment of OP (11)recommend daily calcium and 
vitamin D supplements intake: 1200 mg of calcium 
and 2000 units of cholecalciferol (Vitamin D3) during 
the first month of use, and 1000 units/day afterwards. 
Moreover, the supplements are also recommended as a 
supportive therapy with antiosteoporotic agents, such 
as bisphosphonates, denosumab and strontium ranelate 
(11). A recent meta-analysis of vitamin D and calcium 
supplements (12) emphasizes that calcium supplements 
have very small, non-progressive effects on BMD that are 
unlikely to translate into clinically significant effects on 
the occurrence of a fracture. Nevertheless, vitamin D has 
no additional effects on BMD when used as monotherapy 
or together with calcium. On the other hand, the HT 
“story” still remains a matter of interest because the 
WHI study has definitely confirmed positive effects of HT 
on bone resorption and decreased risk factors for either 
vertebral or hip fractures (13-17). 
In our study, we also have confirmed a positive impact of 
HT on the OP prevalence. On the other hand, confusion 
exists as to the benefit/risk profile of HT, limitations 
concerning the age of initiation of treatment; there is 
evidence that HT is the appropriate first–line treatment 
for women older than 50 years (18). In the age group 
50-60 years or within 10 years after the menopause, the 
benefits of HT clearly outweigh the risks. The initiation of 
HT after the age of 60 requires individualization for the 
benefit/risk ratio for a particular woman. After the age of 
70, HT should not be administered at all, OP treatment 
being no exception (19). The trends in prescription of 
antiresorptive therapy according to our analysis, show a 
decrease in the prescription of HT and SERMs as women 
grow older. On the other hand, the women aged >65 use 
bisphosphonates as the first-choice treatment.
Today, HT remains the treatment of choice for the 
prevention and treatment of postmenopausal OP in 
younger women with climacteric symptoms and low BMD 
(17). 
Analysing the risk factors for OP and targeting the 
patients for DXA measurement in a primary care setting 
seemed to be a hard work for doctors before the FRAX 
has been established. On the other hand, DXA equipment 
isexpensive, therefore FRAX seems to be a useful 
method for primary care settings. The major application 
of FRAX in osteoporosis is to direct pharmacological 
interventions to those at high risk of fractures (19,20). 
Thus, in the absence of BMD to identify those at high 
risk of fractures and consequent need for treatment, the 
use of FRAX seems to be a good option for primary care 
interventions. Nevertheless, the combination of FRAX and 
DXA measurements of BMD seems to be the best option for 
targeting women at increased risks of OP or for deciding 
on the best treatment for a particular woman. 
The limitations of this study might be its retrospective 
nature. Nevertheless, the results of this retrospective 
analysis might help a primary care physician when dealing 
with osteoporosis-related problems. 
10.2478/sjph-2018-0005 Zdr Varst. 2018;57(1):33-38
38
5 CONCLUSION
The role of the primary care gynaecologist, focused on 
menopausal medicine, should also be the prevention 
and treatment of postmenopausal OP (21). Therefore, 
a DXA centre provides a good opportunity for a holistic 
approach to addressing postmenopausal women. HT is 
the most appropriate therapy for fracture prevention 
in the early post-menopause. Lifestyle changes, such as 
smoking cessation, physical activity improvement, intake 
of food rich with calcium and vitamin D, should be part 
of the prevention as well as the treatment strategy. The 
choice of pharmacological therapy should be based on the 
balance of effectiveness, risks and costs. 
CONFLICTS OF INTEREST
The authors declare that no conflicts of interest exist. 
FUNDING
No funding has been received for the conduct of this study 
and/or preparation of this manuscript.
ETHICAL APPROVAL
The study is based on the retrospective analysis of registry 
data and is, as such, an exempt from ethical approval.
REFERENCES
1. Kocijančič A. Smernice za odkrivanje in zdravljenje osteoporoze. 
Zdrav Vestn. 2002;71:571.
2. Prevention and management of osteoporosis: report of a WHO 
Scientific Group. WHO Technical Report Series; 921. Geneva: World 
Health Organization, 2003.
3. Riggs BL, Melton LJ, Robb RA, Camp JJ, Atkinson EJ, McDaniel L, et 
al. A population-based assessment of rates of bone loss at multiple 
skeletal sites: evidence for substantial trabecular bone loss in young 
adult women and men. J Bone Miner Res. 2008;23:205-14.
4. Lindsay R. Prevention and treatment of osteoporosis. Lancet. 
1993;341:801-5.
5. Franić D. New aspects in diagnosis and treatment of osteoporosis. 
Zdrav Vestn. 2009;78:143-50.
6. Kocjan T, Preželj J, Pfeifer M, Jensterle Sever M, Čokolič M, Zavratnik 
A. Smernice za odkrivanje in zdravljenje osteoporoze. Zdrav Vestn. 
2013;82:207-17.
7. Bolland MJ, Grey A, Reid IR. Should we prescribe calcium or vitamin 
D supplements to treat or prevent osteoporosis? Climacteric. 
2015;18(Suppl 2):22-31.
8. Cauley JA, Robbins J, Chen Z, Cummings SR, Jackson RD, LaCroix AZ, 
et al. Effects of estrogen plus progestin on risk of fracture and bone 
mineral density: the Women’s Health Initiative randomized trial. 
JAMA. 2003;290:1729-38. 
9. Anderson GL, Limacher M, Assaf AR, Bassford T, Beresford SAA, Black 
H, et al. Effects of conjugated equine estrogen in postmenopausal 
women with hysterectomy: the Women’s Health Initiative randomized 
controlled trial. JAMA. 2004;91:1701-12. 
10. Rossouw JE, Anderson GL, Prentice RL, LaCroix AZ, Kooperberg C, 
Stefanick ML, et al. Risks and benefits of estrogen plus progestin in 
healthy postmenopausal women: principal results from the Women’s 
Health Initiative randomized controlled trial. JAMA. 2002;88:321-33.
11. Rossouw JE, Prentice RL, Manson JE, Wu L, Barad D, Barnabei VM, 
et al. Postmenopausal hormone therapy and risk of cardiovascular 
disease by age and years since menopause. JAMA. 2007;297:1465-77.
12. Kocjan T, Franić D. Osteoporoza in nadomestno hormonsko 
zdravljenje. Zdrav Vestn. 2008;77(Suppl 3):43-8.
13. de Villiers TJ. The role of menopausal hormone therapy in the 
management of osteoporosis. Climacteric. 2015; 18(Suppl 2):19-21. 
doi: 10.3109/13697137.2015.1099806.
14. Baber RJ, Panay N, Fenton A, IMS Writing Group. 2016 IMS 
recommendations on women’s midlife health and menopause 
hormone therapy. Climacteric. 2016;19:109-50. doi: 
10.3109/13697137.2015.1129166.
15. Kanis JA, Harvey NC, Johansson H, Oden A, Leslie WD, 
McCloskey EV. FRAX and fracture prediction without bone 
mineral density. Climacteric. 2015;18(Suppl 2):2-9. doi: 
10.3109/13697137.2015.1092342.
16. Kanis JA, Johnel O. Requirements for DXA for the management of 
osteoporoisi in Europe. Osteoporos Int. 2005;16:229-38.
17. Komadina R, Senekovič V, Dolenc I, Andoljšek M,Grabljevec K, 
Venišek K, et al. Priporočila za zdravljenje zloma kolka v Sloveniji. 
Zdrav Vestn. 2012;81:183-92.
18. Kocjan T. Zlomkolka – najpomembnejši zaplet ostoporoze. ISIS. 
2010;19:64-6.
19. Ilic Stojanovic M, Vuceljic M, Lazovic M, Gajic N, Radosavljevic 
D, Nikolic A, et al. Bone mineral density at different sites and 
vertebral fractures in Serbian postmenopausal women. Climacteric. 
2017;20:37-43. doi: 10.1080/13697137.2016.1253054.
20. Rentero ML, Carbonell C, Casillas M, Bejar MG, Berenguer R. 
Risk factors for osteoporosis and fractures in postmenopausal 
women between 50 and 65 years of age in a primary care setting 
in Spain: a questionnaire. Open Rheumatol J. 2008;2:58-63. doi: 
10.2174/1874312900802010058.
21. Thomas CC, Zeytinoglu M. Primary care endocrinology in the 
adult woman. Obstet Gynecol Clin North Am. 2016;43:325-46. doi: 
10.1016/j.ogc.2016.01.005.