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EMAS Position Statement: Use of Vitamin D Among Postmenopausal Women

SUMMARY:

EMAS, an international society that promotes health in women and men at midlife and beyond, has produced a position statement targeting the use of vitamin D in postmenopausal women. The literature suggests “an association between vitamin D deficiency and adverse health outcomes in postmenopausal women, although they cannot establish causality.” The document includes an extensive literature review.

‘Vitamin D’ Overview

What is it?

  • Group of lipophilic hormones
  • Regulates calcium homeostasis via kidney, gastrointestinal tract, skeleton and parathyroid
  • Critical for skeletal health but impacts multiple tissues
  • Two major forms
    • Vitamin D2 (ergocalciferol)
    • Vitamin D3 (cholecalciferol)
      • Major source through cutaneous synthesis through exposure to sunlight
      • Small amount from animal diet (fatty fish, eggs and milk)

Measurement

  • Vitamin D status: Measure serum 25-hydroxyvitamin D levels
    • <20 ng/ml (<50 nmol/l): Vitamin D deficiency
    • <10 ng/ml (<25 nmol/l): Severe Vitamin D deficiency

Vitamin D Deficiency and Associated Health Outcomes

  • Skeletal
    • Increased fracture risk
  • Menopausal Symptomatology  
    • Evidence is inconsistent
    • Some studies have demonstrated increased risk
      • Hot flashes | Depression | Sexual dysfunction | Sleep disturbances
  • Cardiac
    • Increased prevalence for CVD risk factors
      • Metabolic syndrome | Type 2 diabetes | Atherogenic dyslipidemia
    • Increased incidence for CVD events
  • Cancer
    • Increased risk for cancers: Colorectal | Lung | Breast
    • Overall and cancer-specific mortality rates are increased in postmenopausal women
    • No evidence for ovarian or other gyn cancers
  • Infections and Inflammation
    • Increased risk for respiratory infection
    • Increased risk for autoimmune disorders

Vitamin D Supplementation Recommendations for Postmenopausal Women

Skeletal Health

  • No vitamin D deficiency or low fracture risk
    • No evidence to support vitamin D supplementation
  • Vitamin D deficiency with osteoporosis and/or high fracture risk (FRAX model)
    • Vitamin D: 2000 to 4000 IU (4000 to 6000 IU in obese patients)
    • Calcium: 1000 to 1200 mg of calcium (dietary or supplements)
    • Encourage Vitamin D and calcium use for minimum 3 to 5 years
    • Check vitamin D levels 3 to 6 months with target above 20 ng/ml (<50 nmol/l)

Menopausal Symptomatology

  • Vitamin D supplementation is not recommended to improve menopausal symptoms

Cardiovascular Disease

  • No effect of vitamin D supplementation on decreasing CVD risk

Cancer

  • No effect of vitamin D supplementation on cancer incidence although some studies identified a small reduction in cancer-related mortality

Infections and Inflammation

  • Vitamin D supplementation may ‘modestly’ decrease the risk for acute respiratory tract infections including COVID-19
  • Concerns regarding study design such as “heterogeneity in design, duration, population and vitamin D dosage among studies must be underscored”

KEY POINTS:

  • Typical daily dose of 1000 to 1200 mg of calcium is not associated with increased risk for cardiovascular disease or nephrolithiasis
  • Studies on vitamin D supplementation have significant limitations due to heterogeneity regarding dose, inclusion of calcium and baseline vitamin D status
  • More research needed to
    • Discriminate between vitamin D replacement and supplementation
    • Determine the need for universal vitamin D screening in postmenopausal women

Learn More – Primary Sources:

EMAS position statement: Vitamin D and menopausal health