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Osteoporosis Ask The Expert

Osteoporosis Ask The Expert

Q: I had a hysterectomy with ovary removal 2 years ago, am still taking premarin. I have grown fatter, am lethargic and have muscle aches with difficulty exercising. I am also quite flabby. I know that post-menapausal women quit producing adequate testosterone as they age. Is this something I should also be taking? What is the usual dosage for a 63 yr old who weighs 160 pounds? Why hasn't my own gynecologist suggested this to me? Can you help?

 

A: The long term use of estrogen has been called into question with the results of the Woman's Health Initiative study which was halted in July 2002. However, there is little data on the use of postmenopausal testosterone and excess risk, nor has the estrogen-only portion of the WHI study been stopped. In your case, my might benefit from estrogen/testosterone therapy in that some of your symptoms might suggest androgen deficiency. The most practical way to take this would be a product called Estratest HS. This is the lower of the two doses and contains an estrogen and a small amount of methyltestosterone. This would be empiric therapy as levels are difficult to accurately measure and probably only then in a research laboratory. If you feel better, that is the goal. This is probably best as short term treatment--perhaps several years, or at least until there is compelling data to suggest a benefit from longer therapy after symptoms resolve. There is some evidence that testostero! ne may augment the effects of estrogen on bone. It may increase lean body mass (as opposed to fat mass) and may enhance libido and quality of life.
Hope this helps.


Q: My doctor has advised me to take didrocal. I am confused. I know that the white tablets must be taken two hours after eating and no eating for another two hours. What about the blue tablet? Can that be taken anytime or does the eating restrictions apply?

A: The disodium etidronate tablets should be taken as a single, oral dose at bedtime, preferably on an empty stomach. However, should gastrointestinal disturbance occur, the dose may be divided. To maximise absorption, patients should avoid taking the following within 2 hours of dosing: Foods, especially those high in calcium, such as milk or milk products. Vitamins with mineral supplements or antacids which are high in metals such as calcium, iron, magnesium or aluminium. Intermittent Cyclical TherapyTwo white tablets of disodium etidronate (400 mg/day; 5-10 mg/kg/day) for 14 days followed by a 76 day period of calcium (the minimum recommended supplement is 500 mg/day of elemental calcium). It is recommended that patients maintain an adequate intake of dietary calcium and vitamin D. However, calcium can reduce the absorption of disodium etidronate. Therefore, supplemental calcium should not be given on the same days as the tablets of disodium etidronate and foods high in calcium should be avoided within 2 hours of taking the white tablets.

This is the best information I can find. This drug is not approved by the Food and Drug Administration for treatment of osteoporosis, but I do not have experience with it. Hope this is helpful.


Q: I am 43 years old and just completed 8 rounds of chemotherapy for breast cancer last month. Last week I got diagnosed with severe osteopenia. I'm amazed. What could have caused it? Can chemotherapy chemicals leach calcium from bones? Does the suppression of white and red blood cells during chemotherapy affect calcium absorption or bone production?

Here are a few more details about my case, in case this helps. I had a lumpectomy on 1/24/02 for a 2.5 cm tumor that was estrogen-positive, grade II/III. Seven of 13 lymph nodes were involved with tiny micromets. I started chemotherapy on 3/6/02 and had 4 rounds of Epirubycin and Cytoxan, followed by 4 rounds of Taxoterere. My last chemotherapy treatment was on 8/28/02. I started Tamoxifen (20 mg/daily) immediately after chemotherapy, and am currently in the middle of 6-1/2 weeks of radiation (I'm taking no chances!!). I took 1000 mg calcium plus Vitamin D daily throughout chemotherapy and walked one hour 3-4 times a week during treatment. I quit alcohol and caffeine the day I was diagnosed. I gave up junk food, and started eating a lot more veggies, fruit, soy shakes, chicken, salmon, and other healthy foods. I lost 25 pounds during treatment, so I'm down to a happy 135 lbs at 5 foot 6 inches. I was pre-menopausal ! ! before chemotherapy, but my period stopped after the second month and I'm currently experiencing strong hot flashes with no period in sight (yet). I've never had children. I've always been extremely healthy and there is no history of osteoporosis, hip fractures, dowager's humps, or even broken bones in my family.

In addition to eating more spinach and doing more weight-bearing exercise, which drug do you think would be most effective to treat my osteopenia? I need to avoid estrogen-like drugs because my tumor was estrogen positive. Does Fosamax act like estrogen? Is it possible to reverse osteopenia completely?

I'm completely determined to be 100% healthy, happy, whole and beautiful, and I plan to live to be 100 years old. Many thanks for your time and expertise to help me get there!

 

A: Your bone mineral density is a "snapshot" of today. It doesn't explain how you got there. The comparison is between you today and yourself in your 20's--based on a database model of what your peak bone mass would have been. If you had it and lost it, that is a problem. If you never had and are not losing bone mass, we would expect you to have normal bone quality and little fracture risk. Fosamax and Actonel are non-hormonal drugs that may be helpful. Since you seem to be experiencing a regrettably early menopause, these drugs might be advisable. Chemotherapy can cause bone loss but it is unlikely to do so quickly. It might be appropriate to repeat a bone density in 1 to 2 years to look at rate of loss. It is important to have the repeat test on the same equipment. Treatment other than calcium and vitamin D is seldom an emergency.


Q: I AM A 46 YEAR OLD FEMALE WITH WILSON'S DISEASE. I AM CURRENTLY BEING TREATED WITH SYPRINE AND ZINC . RECENTLY I HAVE BEEN DIAGNOSED WITH OSTEOPENIA AND TAKING FASOMAX. I AM AWARE OF THE FACT THAT ESTROGEN ELEVATES COPPER LEVELS AND THAT IS CERTAINLY IS NOT WHAT I NEED DUE TO MY CONDITION. THEREFORE DOES FASOMAX HAVE THE SAME EFFECT AS ESTROGEN WHEN IT COMES TO COPPER LEVELS IN THE BODY? CAN I TAKE ANY OTHER HRT COMBINATIONS WITHOUT IT AFFECTING THE WILSON'S DISEASE?

A: I have tried to search any contraindication of estrogen in Wilson's Disease. There are truly few contraindications to taking Fosamax. If you are only 46 years old, do you really need it? Osteopenia at age 46 may reflect lack of reaching predicted peak bone mass, and may not mean you have metabolic bone disease.


Q: I have been taking actonel once a week for three weeks. I have a history of carpal tunnel and ever since I started the actonel this condition has become more severe. I have had to take medication for pain. Two or three days before my next dose is due the pain eases off. Could this be caused by the Actonel? I do need some type medication for osteoporosis. I am 66 years old and have been on hrt for 20+ years.

A: Very interesting question.... Some patients have muscle pain or even some bone pain. It is obscure and seems to go away. I cannot really explain a relationship of Actonel t worsening of carpal tunnel symptoms.


Q: I am a 52 year old woman who was diagnosed with osteoporosis 5 months ago. I have been taking Fosamax 70 mg. once a week. I also am taking dilantin and topamax for seizures. I have been on dilantin for 23 years, which I think is a very long time, but when you need it you need it. I have tried other medicines but they didnt work. I started menopause a year ago October and have not had one seizure.The seizures when I did have them ranged from 14 to 18 a month, petit-mal with some grand-mal also. Menopause seems to be a blessing, the start of it anyway for me and my husband. The dilantin has really warped my memory which is side effect. I was never told to go for a bone density test or to take calcium, which might have prevented the bone loss that I have and I have seen many top notch Doctors. Do you think I can go off the dilantin like I said I! have been seizure free for one year with his permission. I do wish Doctors and pharmacies would advertise.

A: Dilantin has been associated with an increase in bone loss, described as secondary osteoporosis. You may well need dilantin and I would not want to be the one to tell you to stop. Remember that bone density testing does not reflect bone loss, as you are being compared to your predicted peak bone mass at age 20-30, which may have never been reached. The decision is to decide if your low bone density reflects ongoing bone loss vs. never having had it in the first place. Depending on your bone density and risk of fractures, therapy may be appropriate. Fosamax is effective therapy. Calcium and Vitamin D, as well as exercise are all important over a lifetime, not just once one has reached menopause. You need 1200 mg of calcium daily, hopefully obtained in diet, but supplementing if needed. Good news is that you are aware of the issues and doing something about it. Hope this helps.


Q: I have been on prednison since march for lupas and myositis, 60 mg down
to 4 mg. I have 4 compression fractures that were very very painful. My dr. has me on actonal and miacalcin. Will this help with the compression fractures or do I have to be off prednisone before the fractures will heal?

A: Actonel is an approved drug for your condition. Miacalcin has an effect of relieving pain in symptomatic vertebral fractures although it is not as effective a drug as Actonel for the treatment of osteoporosis. Your dose of 4 mg is a small one. You may well need it to treat your underlying illness. In addition to the medications, make sure you get the recommended daily intake of calcium (1000 mg under the age of 50, 1200 if over 50, and 1500 if over 65 years) as well as Vitamin D (600 to 800 units). If you smoke, STOP! Try to exercise, but be careful of injuries. It might be helpful to see a physical therapist familiar with osteoporosis to help with an exercise program. Hope this helps.


Q: Medical History: I am a 33 year old, premenopause, 5 ft, 11 inches, 135 lbs. I was diagnosed hypothyroid approximately 3 years ago, otherwise healthy. I recently had a bone density scan (spine -1.8, hips -1.4). I am continuing laboratory testing in an attempt to determine the underlying cause.

Questions:
What is the most common cause of osteopenia in younger women?
What treatments are safe for women while trying to conceive?
What special precautions or testing are recommended during pregnancy?
Will pregnancy worsen the osteopenia?

Any information would be greatly appreciated?

A: This is a case where getting a bone density may well be a detriment. The bone density most likely reflects never having reached the predicted peak bone mass and NOT have a metabolic bone disease with loss of bone density. It might be a different story if you have been severely hyperthyroid, or on repeated doses of steroids, or have had other major medical problems. None of the medications would be appropriate in pregnancy or in someone trying to conceive. I would be careful to not carry a diagnosis of osteopenia in terms of being insurable. Having lower than predicted bone mass does not necessarily increase your risk of having fractures. It is likely that the bone quality is normal. Appropriate calcium intake (1000 mg per day) and Vitamin D (400 units per day) as well as exercise is the best bet for maintaining bone density and strength. Avoid tobacco and excessive alcohol. Hope this helps.


Q: I am 32 years old and still get my period. I had osteopenia since I was 26. We found out when I broke 2 ribs coughing. with in the last 2 1/2 years I lost 8.6% of bone mass in my hip and 8.3% in my spine. My spine is now -2.3. I am concern with the percentage of bone loss in such a short period of time and my age. It is significant? What could happen when I am postmenopausal? My doctor has put me on Actonel weekly. How long do I have to be off of the medication before I can have a baby and what is the average percentage of bone mass gained per year? What could be causing the bone loss at such a young age. I have been tested for RA, GI problems, kidney problems, and endocrine problems. Blood work has always been normal. Help if you can.

A: You raise some very good questions. First of all, tussive fractures (coughing) may not be due to bone loss. There are some extreme forces developed with severe coughing. Your bone density at age 26 was probably your peak, not necessarily a reflection of loss. The problem with repeat testing is that one must be sure that the data is truly comparable--same machine, software, database, technique, and that there exists precision data to know if a difference in bone density is real or artifact. This is very important because apparent loss of bone density may reflect imprecision in measurements rather than real loss.

Actonel is approved for treatment and prevention of POSTmenopausal osteoporosis and steroid induced osteoporosis. We would rarely if ever use it in otherwise healthy premenopausal women, especially if they plan to conceive.


Q: I am a 51 year old woman dx'd with mild osteopenia 2 years ago (T-score -1.4
hip and spine). The dexa was done because the year prior, my dentist was
concerned about excessive bone loss on x-ray unrelated to dental health. At
that time, I was having regular, albeit, excessive periods. I increased my
calcium from 1000 total (diet plus supplement)(which I had been taking since
my mid-thirties) to 1800, continued with multi vit which contained 400 D.
Later that year, I was dx'd with persistant asthma that is only controlled
with high dose inhaled corticosteroids. Later that year I had TAH/bilateral
oopherectomy due to adenomyosis and started vivelle dot .05. Two months
later, rheumatologist consult for inflammatory polyarthritis started me on
fosamax 70 because of osteopenia with high dose inhaled corticosteroid.
Later that month I had outpatient foot surgery for ganglion cyst and was
limited exercise for another 2 months. I have been able to walk regularly
for the past 8 months (with brief hiatus's secondary to joint pain.) This
summer I had 2 short bursts of prednisone. I just had my second DEXA, on
the same LUNAR machine as the first, after 10 months after starting fosamax.
I had assumed that with the fosamax and estrogen, I would have gained at
least a little bone despite the steroid. I not only did not gain bone, but
lost, from T =1.4 to T -1.69 (which I believe is more than than margin of
error for reproducibility of results/)

Is this just a temporary setback due to lack of activity from hysterectomy
and foot surgery or side effect from inhaled steroid (they are supposed to
not have systemic effect, but I have petecchiae on my forearms, bruise like
a son of a gun and have new hair at my hairline. Also, rheumy mailed me
journal article detailing bone loss on ICS). And second question, I
remember somewhere, some specific high impact exercises for osteoporosis but
cannot locate the source - do you know what these exercises are? (If my
joints will tolerate them, that is.) I don't think there is anything else I
can do, but would like your opinion re if I'm missing something?

A: Excellent questions. First of all, inhaled steroids seem to show a slight impact on bone loss. Not nearly as much as high dose systemic steroids. Fosamax for a T-score of -1.4 is a bit aggressive. Studying the change in bone density in 10 months is too soon. I would wait two years, the use of high dose steroids the exception. One study showed that in the first year of treatment some people do lose bone mass. If you look at them at the end of the second year, they seem to have gained it back and are on the predicted slope of improvement in BMD. I am not sure that comparing T-scores is the answer. I would look a the percent change in bone mineral content. One last point, if you have low bone mineral density (T-score in osteopenic range) and do not have ongoing bone loss due to excessive resorption of bone, you might not expect to see a change in bone density with treatment. The lower then desired T-score may reflect bone mass never there, not bone mass lost. Long-winded to be ! sure, but not an easy question.


Q: I received results of my bone density test today &was told there was minimal bone loss. I am 69 years old. My doctor recommended Actonel 30mg. Unfortunately, the way health insurance is going my prescription will run $160 a month. I have never taken a calcium supplemement. Could I take one instead of starting this Actonel? I have not been diagnosed with osteoporosis.
Thank you for your time.

A: I certainly share your concern. If you have close to normal bone density, does it make sense to take an expensive drug. I would have to know about the results of the test. If your bone density, expressed as a T-Score is better than -1.5, no specific treatment is warranted even with risk factors. If it is better than -2.0 without risk factors, treatment is not needed at this time. Calcium and Vitamin D are important in any case. Your calcium requirement is 1500 mg per day and you need 600-800 units of Vitamin D. You should strive to exercise daily. Walking is helpful, as well as exercise to improve strength, balance, and endurance. Again, it would be helpful to have more complete information regarding your bone density testing. Hope this helps.s


Q: Two month ago I begun a treatment with Fosamax 70 (Alendronate Sodium). I am 52 years old and in my last Densitometry I have Osteopenia 2% and lumbar Osteoporosis 89.3. A week ago I had an acute renal colic (Nov 8th). The renal ultrasound revealed very little stones. Now I am ok, but I would like to know if any of you have had experience with Fosamax 70 in patients presenting renal calculus (stones). Thanks for your information.

A: I did a literature search and could not find anything about renal calculi and Fosamax. The bisphosphonates have been used to treat malignant hypercalcemia. Since hyperparathyroidism is associate with elevated serum calcium and is a cause of renal stones, perhaps Fosamax would be be beneficial.


Q: I am a 24-year-old caucasian female just diagnosed with osteopenia after a
Dexa scan indicated that my L3 vertebrae exhibited 11% bone loss (or, more
accurately, that it was 11% under what a normal 30 year old woman's bones
should be.) I suffered a compression fracture in my T12 vertebrae as a
result of a fall last June and thus requested the scan. My doctor has
prescribed 35 mg of Actenol taken once a week. I am also on Mircette, a
birth control pill. My questions are this: Has there been significant
research done on premenopausal osteopenia and osteoporosis? If I intend to
become pregnant in the next five to six years, will Actenol interfere or
cause problems with the pregnancy? Will I still be able to breast feed my
children? On a secondary order, Actenol seems to be causing some nausea for
me. Is there anything that I can do to prevent that kind of a side effect?

A: If your fall caused the fracture, it is probably not osteoporotic in nature. Getting a bone density is unwarranted. The comparison of your bone density at age 24 to someone at age 30 would indicate that you have not yet reached your peak bone mass and NOT that you have a bone disease. Actonel is not appropriate and should be stopped. The rare exception of using Actonel in normally menstruating women would be in the case of steroid (such as high doses of prednisone) induced osteoporosis. The use prior to pregnancy is unknown, untested, and should be discouraged. I would suggest adequate calcium and Vitamin D intake, exercise, and not smoking as the best way to be kind to your bones. Oral contraceptive users tend to have higher bone mass than nonusers, so if you are trying to delay pregnancy, that may be an added benefit. Hope this helps.


Q: I just had a DEXA bone density scan and my T scores are -1.6 for spine and 0.0 for hip. I am 42 and have been on prednisone for asthma. Are those T scores low? Should I be on medication?

A: The use of predisone for over 6 months at a dose of 7.5 mg daily or greater may make the use of Fosamax or Actonel reasonable. One issue in young women is what might happen if you become pregnant while on or after taking these medications. Your bone density is very close to normal and may not represent any loss at all. I would make an effort to take adequate calcium, Vitamin D, exercise and about smoking, excess caffeine and excess alcohol.


Q: I have a 69 year old female patient who presented with the following test
results:

1996: DEXA hip T-score:-2.39
1997 DEXA hip T-score : -2.22 Increase of +7.94%

1999 CT spine T-score: -2.59
2000 CT spine T-score: -2.54
2002 CT spine T-score: -3.27 A decrease of 19% since 2000!!!

She has been taking Fosamax faithfully for the last 5 years. How common is this degree of deterioration, and what should be done now?

A: I think you need to compare percent gain/loss in bone mineral content--grams/square centimeter. I am not conversant with CT, presumably quantitative CT, results and cannot comment. The change noted in one year may reflect the regression to the mean. In other words, patients who appear to lose bmd in the first year tend to gain and be on the predicted slope after two years. In your patient's case, she gained bmd and we would be happy with that. The next problem is precision. These tests are very accurate, but precision (reproducibility) is totally unknown in most department doing BMD testing. That is subject to personnel and equipment calibration. Are the techs certified? Do they calculate precision? Are these results known to clinicians? I would make sure your patient is getting adequate amounts of calcium and vitamin D as well as avoiding tobacco, etc. Has she been evaluated for secondary causes, such as hyperparathyroidism? Is she on steroids? Hope this helps.


Q: Take Evista for osteopina, but get severe leg cramps in the middle of the night. Also, I have lots of bruising on my legs. Is this common? I've stopped taking it. Now what?

A: Leg cramps are a known adverse effect of Evista. They may subside with time. I cannot explain the bruising. The most serious risk of Evista is that of abnormal blood clotting, such as clots in the leg veins or lungs. The cramps most likely do not represent blood clots. You should discuss your symptoms with your physician.


Q: I have been on Fosamax for 1 1/2 years and have increasingly elevated liver function tests (SGPT and SGOT). I went from 5 mg daily to 70 mg weekly and the liver functions are worse. I have been tested for hepatitis and many other liver diseases and everything, thankfully, is OK. The only difference is the Fosamax. Has this been reported as a side effect? If it hasn't, how does one report it.

A: Fosamax is not metabolized in the liver or by the body. It is excreted in urine. There is no evidence nor any reason to suspect that it would affect liver enzymes. There are many causes of increase in liver enzymes, but Fosamax is unlikely to be one of them. You may wish to consult a gastroenterologist.


Q: Hi...I am a 66 yr old woman...Ihave been diagnosed with ostioporosis after a bone density test I have it in my spine and not in my hips..my doctor wants me to take medication.My question is this....since I ran nearly four hundred miles in the past 2-1/2 yrs.and have gone to yoga every day for th past yr and 1/2 I am a jogger for the last 20 yrs and eat very healthy ...orange juice with calcium ,yogurt,cheese, fish,take 1200 milligrams of calcium..although not every day ...no fried foods.I am a little surprised at the diagnosis.My sister is 70 yrs old and was diagnosed with osteoporosis also and she has been running every day for six to nine miles a day. for 20 years.also she is an avid walker,she always ate a lot of cheese and had to stop because her cholesteral was too high.What are we doing wrong.?..we thought we were doing the right ! thing.Please respond if you c! an thank you.

A: One word of caution. Bone density testing measures your bone density on one day of your life. If it is lower than predicted by the computer model of comparing you at age 66 to yourself in your 20's, we cannot differentiate those who reached the predicted peak bone mass and lost it from those who never reached it. The definition of osteoporosis is really more than just low bone density. It reflects loss of bone quality. However, we do not have easy ways of assessing quality. Depending on the level of bone density compared to predicted peak bone density (know as the T-score) it may be appropriate to offer medications to prevent further loss. This decision is made on bone density as well as risks for fractures, of which bone density is only one. Your exercise and good lifestyle changes should be applauded. The peak bone density any of us achieves is based in part on genetic and other factors beyond our control.


Q: Are there any clinical studies supporting the use of plant based estrogen to improve bone density? Do you recommend plant based estrogen to improve or maintain bone density?

A: I think you are confusing two issues. Many commercially available estrogens, both oral and by patch, are derived from plant sources. These include Mexican yams and other plants. The precursor molecules are made into 17 beta estradiol, identical to the major estrogen of the premenopausal ovary. Phytoestrogens are derived from plant sources, most notably from soybeans. There are compounds that exert mild estogenic effect. The source is using soy as a food, not soy extract which may not contain active hormonal effect. The most common sources of soy would be soy flour, soy milk, tofu, miso. In fact, all beans may have this effect. The problem is that the amount needed to be consumed is far greater than the usual American diet. Studies of Phytoestrogens have shown mixed results--perhaps some reduction in hot flashes, maybe some increase in bone density, but no fracture data.


Q: I'm 58 years old and just started taking Actonal on a weekly basis. 24 hours after I took the first pill, I was terribly sore from head to toe. The second pill was worse. After 24 hours, I couldn't lift a glass and my wrists and arms bacame swollen. I had severe back pain and I was unable to move my hand enough to make a fist. The neck area was so tight I could only move it a matter of inches either way. I had a headache centered in the back of my scull. It has had a total debilitating affect on me. Am I having a reaction to the medication or is this normal? Will these symptoms go away after time? I am 5'3" and weigh 135 pounds. My Grandmother, Mother and now my sister and I have all been diagnosed with osteoporosis. Please help.

A: Obviously, these are not normal symptoms from taking one dose of Actonel. In studies presented to the Food and Drug Administration, most side effects were similar to placebo. I suggest you consult your physician.


Q: I am female, age 55, and recently had a bone mineral densitometry exam with results of T= -3.0 for lumbrosacral spine and T= -2.5 for femoral neck. My physician prescribed Actonel 35 mg, one tablet per week. He also recommended a calcium supplement with magnesium and vitamin D. Five days ago, I took the first Actonel pill as directed. The first day I had mild nausea and flu like symptoms that went away. On the second day, I developed back pain which ranges from moderate to severe, day and night. When the pain is moderate, I can function with some restrictions as long as I keep my back perfectly straight. When the pain is severe, if I move just right (or wrong) or take a deep breath, the pain is unbearable. I have not had a good night's sleep since taking the Actonel. Will this side affect go away as my body! adjusts to the medicine?

A: The symptoms you report are very unusual for Actonel or Fosamax. I would discuss them with your physician.


Q: I know I need to see my gynecologist, I have made an appointment. Until then can you give me any possible reasons for the below symptoms?

I am 42, 7 yrs ago when I was 35 I had a total hysterectomy due to severe endometriosis. I know everyone has a different opinion about that, but it is a mute point now! The problem is this: before I had a hysterectomy I was having the same symptoms I am having now. I have been free of these symptoms for 7 yrs! I don't have mood swings, although I am depressed quite a bit, I have gained 15#s, have cravings for sweets, my hair is thinning, my skin is itching and dry, my scalp is oily and my hair is dry, my face is washed out and ashen, I am exhausted and have intermittent mild hot flashes, I am constipated beyond belief and feel water logged. I take estratest FS. What is going on? Is there a certain supplement I should take? Is there anything I can do? Is it thyroid? Do my hormones need to be tweaked? Any thoughts or anyone with the same problem? Thanks very much

A: The very best advice I can give you is to get to your gynecologist for your scheduled appointment. Your symptoms could represent several conditions, none of them serious, but with different treatment options. Only by taking more details of your history and completing a physical examination can your doctor decide what is most likely and begin appropriate investigations and treatment.


Q: HELLO, I KNOW YOU PROBABLY DON'T HAVE AN ANSWER FOR ME, BUT WAS WONDERING IF YOU KNEW ANY DOCTORS IN NY THAT ARE AWARE OF THE SIDE EFFECTS OF LUPRON. I HAD 5 INJECTIONS BECAME VERY SICK AFTER MY 4TH. DIZZINESS, TREMORS,BLURRED VISION,SEVERE JOINT AND MUSCLE PAIN AND BRAIN FOG. I HAVE SPOKE TO AN ATTORNEY WHO WILL BE REPRESENTING ME AND ANOTHER CLIENT. I HAVE BEEN TO MANY DOCTORS AND HAVE HAD MANY TESTS DONE AND THEY CANT DIAGNOSE ME WITH ANYTHING AT THIS POINT. I FEEL VERY FRUSTRATED BECAUSE I KNOW THE LUPRON WAS THE REASON FOR MY SICKNESS. I WAS VERY HEALTHY ASIDE FROM THE ENDOMETRIOSIS THEY TREATED ME FOR.. I AM VERY SICK AND KNOW THERE ARE THOUSANDS OF OTHER WOMAN OUT THERE WITH THE SAME PROBLEM BUT I CANNOT FIND A DOCTOR IN NY THAT REALLY KNOWS WHATS GOING ON. ANY INFORMATION WOULD BE GREATLY APPRECIATED.

A: Since this case is in litigation or heading that way it would be foolhardy to offer any comment other than to follow the recommendations of your attorney.


Q: My doctor recently suggested I start Actonel, 35mg. once a week. The
first pill, taken according to all instructions, caused a very unpleasant reaction in my stomach--not pain, but a high degree of acidity, such that I could only tolerate a little bland food. I sought help from the doctor on call, who suggested an antacid. I took several Tums at several periods throughout the day and got some relief, but
still felt very unwell. The next day I spoke with my doctor, who ultimately urged me to try again; but I am unwilling to do this without some kind of protection for my esophagus and stomach--perhaps an antacid taken the night before, and then again some hours after the pill. Do you know if there is anything available that will relieve symptoms, that will also not interfere with absorption of the Actonel?

I might add that my second bone scan, taken over a year ago after increasing my calcium and vitamin D intake, showed a slight improvement in my T-score--not statistically significant, my doctor said, but "moving in the right direction." I don't remember if it was -1.8 or +1.8. Even so, with the discouraging news coming out about estrogen (I take estrogen alone and have done so for 17 years--I had my uterus removed but the ovaries were left intact), I think the doctor felt estrogen alone (plus calcium, etc.) might not be sufficient against osteoporosis; hence the Actonel.With a family history (mother) of severe osteoporosis, I would like to do whatever I can to avoid her fate. I am 67, exercise several days a week, walk, work with weights, eat well. Thank you for your advice

A: I may be the only MD who still feels this way (I hope not) but the news coming out about estrogen is not really news to most of us who have followed the use of estrogen for 10, 15, or 20 years. If you have been comfortably, and clearly safely, on estrogen for 17 years why stop? The major new study was in women using a combination of estrogen plus progesterone and the part of the study for women taking estrogen alone is continuing. It makes a huge difference if your T score was -1.8 or +1.8. I suspect it was -1.8 which is very good and expected for a woman on estrogen for 17 years. Regarding Actonel, if you can’t tolerate it you shouldn’t take it. There are other good osteoporosis drugs available. I am surprised, however, that you had such a bad reaction to Actonel. Most patients tolerate this 35mg once a week dose very well.


Q: Please explain why loss of bone contiued while taking HRT (Fem HRT). From age 42 to age 49 took Fem HRT. Is the dose not proper or am I in the 18% of females not responsive to estrogen's bone effects? Can you recommend an estrogen in my case?

A: The first thing to do is to make sure that you are indeed losing bone on your HRT. Let’s focus on the spine values where you have most results and is in fact the best place to monitor bone mineral density (BMD) during the early menopausal years.

If all the studies were done on the same DEXA machine it is likely you are losing bone despite HRT. This simply means that the dose of HRT you have been taking has not been enough for you. For too long we have treated HRT as “one size fits all” and that is clearly wrong. An alternative explanation is that you have some other cause for bone loss in addition to the menopause. I would have your doctor measure one of the biochemical markers of bone resorption (available as blood or urine tests) and see if they are normal or high. If they are high then you need further evaluation to look for one of the many causes of bone loss besides menopause. If no other cause is found it is time for you to add a bone drug to your HRT.

If the studies have been done in different offices with different machines then we cannot conclude that you are losing bone. Even if exactly the same model of DEXA machine is used in different offices, unless the two instruments have been carefully cross-calibrated, there are sufficient differences to make comparisons between successive readings extremely difficult. This is a huge problem as people switch health plans, doctors, etc. and they have no control of where they are sent for the BMD test. If you have been measured on different machines see if you can get your insurance to cover yet another test, this time going back to one of the places where you had an earlier study. You may be pleasantly surprised that you have not lost bone.

You have asked a very important question and I hope you and other readers fully understand the implications of making sure that, to the maximum extent possible, follow-up bone studies should be done where the first one was done.


Q: I am a 53-year-old female and have been taking evista for osteoporosis for
over 3 years. My recent bone scan showed a change from -3.2 to -2.4 in the spine, but my hip has gone from a -1.3 to a -1.8. Do you think the increase in the spine could be real, or only due to osteoarthritis?(My doctor seems to think it is real). I am now also on didrocal in addition to the evista because of my decreased hip measure. My legs ache during the night and this goes away only when I get up and walk around a bit. Anything to be concerned about or a reason to get off the medication? My doctor didn't pay much attention to this problem when I mentioned it to him. I am concerned about possible blood clots forming or would I get a different symptom from them

A: The change in the spine is probably real. You are too young to be really worried about osteoarthritis of the spine. The change in the hip is probably not real and not worth acting upon. Adding Didrocal adds expense without any evidence that it adds benefit (or harm). The leg pains that go away with walking do not sound typical of the symptoms of blood clots but that is easy to exclude by examination (by your doctor) and a simple ultrasound test if he/she has any concerns.


Q: I am now 43 and I had a hysterectomy double oopherectomy at the age of 24 and took Premarin for about 14 years. I led a very healthy lifestyle with exercise, excellent diet of organic foods, lots of greens, dairy etc. I wasn't aware that doing all these things would not prevent Osteo with the history of surgery I had, but I recently found out quite the opposite and that most women who have had this surgery will develop it at sometime. I just had a positive reading for Osteo and don't have those readings. Last year I was diagnosed with a kidney growth benign that is 1 cm. in size and was told it posed no health risk to me, however, I have been experiencing severe kidney pain, blood in the urine and cloudy milky urine with fever on a regular cycle type basis. They did a CT scan two times with no radioactive dye because I am extremely allergic to it, one ultrasound, and a cystoscopy and I was informed that the growth is not causing any of the symptoms I am experiencing. The urologist said if it continues that in the next year I will undergo the same testing, and I informed him it is still continuing so he said I should see a kidney specialist that there could be a possible rupture in a blood vessel in the kidney causing it that cannot be detected on imaging. I have seen my GP and he requested a blood analysis first and then we will decide where to go from there.

In the meantime, recently, I had the OSteo diagnosis, so what I am wondering is because my risk/history I am wondering if there is a bone medication for ostoe on the market that is not contraindicated with kidney disease.

Also, I went off the Premarin because it made me so sick all those years and I was also aware that it had no protective effect after so many years use so rather than being sick all the time I opted off of it. I also have a history of Lupus that started shortly after Premarin use and suspect that it was the culprit for the autoimmune. My Lupus has been in remission for the majority of the time I have been off the Premarin, my immune function has strengthened tremedously.

Thanks for your time and sorry for the long message but I wasn't sure how much info you would be needing.

A: Lot’s to discuss. Let’s clear up one thing. I am unaware of Premarin being associated with an increased likelihood of Lupus.

Next, if you really felt that Premarin was making you sick for the 14 years you were taking it you should have asked your doctor to prescribe something else. There are some circumstances where the benefits of the medicine so far outweigh the side-effects that the patient is asked to put up with the side-effects. One such example might be chemotherapy. I can’t think of too many others. If the medicine prescribed to make you “better” actually makes you “worse” – something’s wrong with that picture.

I cannot get a clear handle on your kidney problem from your description. However if the kidney is functioning normally (which it probably is even though you may have a cyst on your kidney) there should be no problem with taking drugs for bone health.

As for the “Osteo” diagnosis I must say that I have not heard it described quite that way before and it doesn’t sound quite right to put it that way. Do you have osteoporosis? What is your T-score? Those are the things we need to be talking about. The National Osteoporosis Foundation is now mounting a campaign to “Know yourself to a T”. Once more doctors and patients get used to the terminology in osteoporosis and bone density testing a lot of unnecessary anxiety will go away. Drop us another line with your T score and we’ll give a more specific answer for you.


Q: I am 50 years old and was started on eivsta today to treat osteoporosis
in my neck area. I took fosomax and it seemed to make me hurt but, I am concerned about the side effects o f evista forming blood clots. I live and active life. I do have fibromyalgia and I hurt on certain medicines. I try to stretch and run daily on a treadmill. My mother died with a stroke last year. So I have a great fear. I wonder what is the best for my problem. I never had problems with the fosomax going down. Just after a few weeks I started to hurt. I would like some imput on the side effects and what I should look for.

A: I have not heard of osteoporosis being diagnosed in the neck area so I question the diagnosis. How was it made? If you don’t have osteoporosis you don’t need either Fosamax or Evista. Please get back to us with more specific information about your osteoporosis.


Q: I’m a nurse educator for a bone health/osteoporosis program and saw a patient who had questions about taking Evista. I told her I’d write and ask your opinion about her situation. She’s 51 years old with a history of osteoporosis (mother, father, grandmother). She was on HRT for 2 years up until this summer (2002) when she discontinued it. She works (on her feet), but has no regular exercise program and doesn’t have a diet rich in calcium or Vitamin D, nor does she take supplements. She has no other risk factors for osteoporosis. Her DEXA results were normal in her spine (T=0.43) and showed osteopenia in her hip (T= - 1.5). She is not having hot flashes or menses, and her serum hormone levels indicate that she is in menopause. Her OB/GYN ordered Evista 60mg/day (because of her history) and she is wondering if she needs to start taking it now, or if she should wait a couple of years and repeat the DEXA.

I have encouraged her to take calcium (1500mg/day in divided doses) and 800 IU of Vitamin D, along with starting a regular exercise program. Yet, I understood that the recommended treatment threshold for using medications was a T-score of – 2.0 with several risk factors present, and – 2.5 with no other risk factors present. I also thought that Evista was to be used 5 years after menopause. Would you recommend treatment with Evista now, because of her family history, or wait?

A: She can certainly start Evista now, or Actonel or Fosamax which may be better drugs for the bone.

She could also well afford to wait 2 years and repeat the DEXA. She could save herself, or her insurance carrier two years worth of therapy, with very little risk of fracture in the next two years.

Another approach would be to have her serum NTX measured. NTX is the abbreviation for N-telopeptide of collagen cross-links and is a measure of bone resorption. There was a very good study from Europe indicating that women early in the menopause who had low levels of NTX or other markers of bone turnover lost very little bone density during four years of follow up. Those with high levels of markers (i.e. higher than the normal range for premenopausal women) lost more bone during the four years. Serum NTX is available in many commercial clinical chemistry labs around the country, is not very expensive (about the same cost as one month of Evista for example), and may help you make decisions about patients such as this.

Not every expert in the osteoporosis field is as convinced of the benefits of these measurements as I am but I certainly use them routinely in my practice.


Q: I am a 64 year old female and was on Hrt until recently. My Dr has put me on 60 mg Evista once daily and also 70 mg Fosamax once weekly. Is it safe or wise to be taking both these drugs? When I questioned him about the necessity of taking both he said he was thinking 10 years down the road in preventing major injuries. I have several friends who are only one or the other and their ob Dr's have told them to be on both at the same time.

A: It is certainly safe to be taking both drugs but it is unnecessary. Fosamax is the more potent of the two drugs as far as osteoporosis is concerned.


Q: I have just started taking actonel 35 mg and started spotting. Can there be a connection?

A: If you mean vaginal spotting there is no connection to Actonel and you should discuss this spotting fairly soon with your gynecologist. If you mean a skin rash, any drug including Actonel can cause an allergic skin reaction and you should immediately stop Actonel and the rash should clear within a few days. Let your doctor know and try something else for osteoporosis.


Q: I am 66 yrs- recently diagnosed with Osteoporosis -- Dexascan score minus 2.02. Gyn doctor recommended Evista-but I told him I had surgery for an abdominal aneurysm 8 yrs ago--and I still have 2 aneurysms which were inoperable (one fusiform at the neck of the artery to the liver & the other inside the liver. I also told him I normally take no drugs- trying to not disturb the liver.

He suggested Fosamax 70 mgm---the day after I took the drug, I became profoundly weak, I was panting instead of breathing, chilled, diarrahea, nausea-----I could not function. No one else in the house is ill-(do not suspect virus infection). I was perfectly full functioning before I took the Fosamax 70mg tablet-( I walk up to 4 miles several times a week)-and I did follow the directions on how to take this drug --step by step.

The doctor's office suggested I not take the 2nd dose--I won't! I'm basically very well- & love to eat--(not junk food) I'm 5'10"-153lbs--weight has been stable all my life. I am a retired RN. I do occasionally get Sinusitis--therefore I hesitate to take any drug nasally to irritate that tissue. I was not taking a calcium supplement because my blood level calcium was 9.3 and my phosphorus blood level is above normal 4.7--cholesterol 189--LDL Cholesterol 100. I have 2 questions--which supplement should I be taking if any--and how can I stop the osteoporosis from progressing?

A: Many things to discuss. Firstly with a T-score of -2.02 you do not have osteoporosis, just low bone mass. By definition osteoporosis is diagnosed when the T-score is -2.50 or lower. That does not mean you might not need therapy to prevent fractures because many factors besides the T-score must be considered when assessing fracture risk.

Regarding Evista I cannot see why your aneurysms would be a contra-indication to using that drug but that’s your personal choice.

Regarding Fosamax you sure had an un usual and marked reaction. I don’t know if it was the cause of the symptoms but agree you shouldn’t try it again.

You could try Actonel, Miacalcin nasal spray, or an estrogen skin patch. Alternatively you could wait two years and see if your bone density is stable or is decreasing. With your T-score your risk of fracture in the next two years is really quite low.

Your blood calcium of 9.3 is not a reason to avoid calcium supplements, and I don’t care which brand or type you use. Just don’t spend too much money and take 1000 to 1500 mg each day. Dairy products are also a great source of calcium – milk, cheese, yogurt, ice cream etc.You should also take a multi-vitamin with 400 units of vitamin D.


Q: I have been taking Fosamax for one year due to osteoporosis and 3 fractures of my spine. I have heard that Actonel is less expensive than Fosamax with the same if not better benefits. I would like to see a comparison in order to ask my doctor if I should change prescriptions. I will soon be on Medicare and Fosamax will eat up my allowance for RX each year alone.

A: There are no studies directly comparing Actonel and Fosamax and they cost about the same.


Q: I am a 63 year old Caucasian woman. Last year I requested a bone density test to obtain baseline and was appalled to learn that I have osteoporosis in my hips and osteopenia in my spine. At that time I rejected medication recommended by my doctor and opted for increasing calcium intake by natural means and supplementing with Tums. I also began a regime of weight bearing exercise.

Recently I requested another bone density test. I was disappointed with the results. While there was no change in the bone density in my hips, there was a slight decrease in density in my spine. My doctor has again recommended that I consider taking Fosamax. I am reluctant to take this medication.

I am on HRT; I am continuing with a weight bearing exercise program. Specifically I lift weights three times a week. I have added swimming three times a week to my physical program. I consider myself to be in good health.

In searching the internet to find a natural alternative to Fosamax, I came upon an entry from a woman who reported positive results in increasing bone density through the use of vitamin B6. I cannot find any collaborating data to this regime. Can you offer any information on the use of vitamin B6 in the treatment of osteoporosis? Can you recommend an alternative natural treatment for this condition.

A: If you are on HRT I am quite surprised that you have osteoporosis and before making further recommendations I would like to know a lot more about your HRT. How long after menopause did you start HRT? How long have you been taking it regularly? Do you indeed take it regularly? What form, what dose? HRT is very effective treatment to prevent bone loss at menopause and on the right dose very few women lose bone while taking HRT. Before doing anything I would check that the “slight decrease” in bone density in the spine was in fact any change at all from baseline. If the change was indeed significant (the person doing the test should know how much change is “significant”) your doctor needs to do some tests to find out why you are not responding to HRT as expected.

My guess is that there was no real change in spine density and you should continue what you are doing.

Sorry, can’t help you with the vitamin B6 story.


Q: I am a 55 year old woman with osteoporosis. I am post menopausal. My
doctor started me on Miacalcin when I was diagnosed with osteopenia 2 yrs.
ago but it didn't seem to help. After my last bone density test this year, she started me on Actonel which I have now taken for 3 weeks. I have read articles that state osteoporosis can be reversed with weight bearing exercises such as walking and lifting weights because you can build bone mass. Other articles state this is not true. I would appreciate your opinion. I have started an exercise program and will not have another bone density test until the middle of 2003 to see for myself. Thank you very much.

A: Osteoporosis cannot be fully reversed by exercise. Exercise can contribute
to the attainment of an optimal bone mass during growth and development, but
does not increase bone mass once it has been lost. Besides taking an anti-osteoporosis drug such as Actonel, there are three things you should do:

1. have a diet rich in calcium (for your age, at least 1200 milligrams a
day)
2. stay outdoor in the daylight: the UV rays will help you synthesize vitamin D in your skin. Vitamin D is essential for calcium absorption in the intestine and the correct mineralization of bone. If you can't stay outdoor, or if it's necessary for other reasons, ask your doctor if you should take a supplement of vitamin D or
one of its active metabolites.
3. have moderate but regular physical exercise. A 30-minute walk at least 5 days a week is very good for your bones. Every "mild" exercise where your skeleton supports your body's weight is good to keep your bone in good shape.

"Weight lifting" as a gym exercise in the presence of osteoporosis is absolutely contraindicated, unless you mean 2-4 lbs weights. However, do not lift any weight by bending your spine forward and then straightening up: this is a dangerous movement in the presence of vertebral osteoporosis.


Q: I have just had the results from my BMD scan, which indicates that I have the beginnings of osteporosis in my hip and osteopenia in my lower lumber region. My doctor wants me to take Livial.

However, I have alopecia androgenetica and wear a wig as my hair is diffficult to manage at the moment as it is too thin. In their report and also in one of your answers, it is mentioned that Livial has androgenic properties. Will this make my hairloss condition worse?

A: Unfortunately, there are no data about the effects of tibolone (Livial) on
alopecia in the scientific literature.


Q: I am 50 yrs old and recently went for my first bone density test. To my and the doctor's surprise the test score came back -4.9. I had polio when I was 2 yrs old which probably accounts for the high score. However I drive, work full time and have my own home. But now I am confused. With such a high test score should I be seeing a physician who specializes in osteoporosis? What does this test score really mean in terms of a life change? Am I at a VERY high risk of breaking a bone? I'm having a difficult time comprehending the consequences and seriousness of this disease and am not sure what else to do than take a pill, get enough calcium and continue to exercise. A: Polio may have had some effect on the accrual of your bone mass, but not so
relevant if you could have a substantially normal life.

I suggest that you verify with your doctor if you can have a form of secondary osteoporosis (i.e. osteoporosis caused by an underlying disease, such as intestinal malabsorption, coeliac disease, hyperthyroidism, hyperparathyroidism, idiopathic hypercalciuria, etc.). If this is the case, the primary disease must be treated. The other important thing, which you didn't mention, is if you had an early menopause (under 45 years).

Your bone mass value seems to be low (you don't tell me if it was a DEXA test or a QUS test) and you certainly should be aware that you have an increased risk of fractures. This means that you should be careful to avoid falls (e.g. pay attention to any obstacles, such as carpets, wires, etc.) and to avoid to lift or carry excessive weights (I'd say no more than 6-8 lbs). Never lift anything by bending your spine forward! I think your doctor has given you a specific therapy (you spoke about a
"pill", but didn't tell which one).

Calcium and regular exercise are an essential part of your therapy. After about one year of therapy, you should check your bone mass again (on the same machine to have a good comparison).

Q: I just returned from my doctor's, and it seems I am dealing with a kidney stone. I have been on Fosomax for 4 1/2 months, have no history of stones in my family, and have never had one myself before. Since I have been diagnosed with a high level of osteopenia, and am post menapausal, and did not want to do HRT, fosomax seemed a safe thing to do, but now, after doing some research, perhaps the fosomax is why I have the stone now. Please, what suggestions can you make? Also, my salivary glands appear to be swollen. What's the deal with research on fosomax now?

A: Kidney stones can occur at any age for the first time. As far as I know, alendronate (Fosamax) has not been reported to cause kidney stones or salivary gland enlargement. It generally reduces calcemia and calciuria, so it should not facilitate the formation of calcium oxalate stones (if this is your kind of stone - there are others not containing calcium).

Drinking too little water may favor the formation of kidney stones: at least 1.5 liters a day are recommended. A diet too rich in sodium and animal protein may do the same.

Finally, you don't tell me if you have been taking calcium supplements and vitamin D metabolites and for how long. An excess of vitamin D (particularly active metabolites) increases the urinary excretion of calcium, which could favor the formation of calcium stones.


Q: Can fosamax cause your sodium to lower? Mine was so bad I had to be hospitalized for 5 days. I quit it for 4 months and then started back on it because I was diagnosed with osteoporosis at age 45. Within two weeks my sodium was back down to 127. Is this the problem? They thought my gallbladder was causing the problem in the hospital and I had it removed. Now they say I actually had 2 problems, gallbladder and sodium. Can this cause low sodium? Once a week 70 mg.

A: The causes of hyponatremia are many. This effect has not been reported in the scientific literature on alendronate (Fosamax). In the hundreds of patients on long-term alendronate therapy that I saw over many years, I never encountered such a problem, and on the basis of alendronate pharmacology I cannot explain it. However, if all other causes of hyponatremia have been excluded, your hyponatremia could be subspected to be a first case of a very rare, not reported until now, side effect of alendronate. You don't tell me what was the problem with your gallbladder and if you have been taking other drugs like diuretics, NSAIDs, which could cause hyponatremia.


Q: I have osteoporosis in my spine, a -2.6 And Osteopenia in the hips, a -2.2. Theses are the drugs my Rheumy wants to put me on. I am very medicine sensitive anyway& these side effects listed with Zometa,Fortea& Evita sound horrendous. I know I can take Evista& if I have a problem, just not take it again, But what about Zometa? It is infused & according to Novartis, it must be infused no less than 15 minutes to prevent a common clinical problem they had, which was renal insuffiency& renal failure. One it's in , what can be done? I know it's not yet FDA approved til year ending, but my fear is having the severe chest pain, fainting, etc, altho the news declared it side effect free, maybe some minor flu like pains in the bones.

Also the Forteo... It has to be injected daily & they found that mice developed multiple myeloma, yet this seems to be the best thing for the bones& fastest. Which also scares me just because of that serious side effect & how fast it seems to build bone. A cancer is an overgrowth of cells gone wild, correct? It kinda makes sense this can cause a bone cancer if you are on it long term, even short term.
Please, I need advise on these drugs. I once had a blood clot& Evista can cause blood clots. Because I had one in my lung after a surgery, does that mean I have a ' History ' of blood clots, or is that considered more an isolated event?
My Gram& Mom both had invasive ductal cancer, so Hrts& Erts are not an option & because I have irrital bowel& Fibromyalgia& reflux, the Fosamax/Actonel are out. My Dr also mentioned Adrea or something like that for IV, I believe. I must make a choice for 2 drugs he said to build me up for 4-5 yrs. Those are my choices & I am here researching, but all that does is pose more questions for me. Another thing about Evista. If it's not an estrogen& won't affect me getting breast cancer down the road, why does the insert say if I experience breast enlargement or breakthru bleeding, call the Dr. I am not a health professional, but that kinda sounds contradictory.

A: I am sorry I can't cancel all your doubts. Drug therapies always imply some umpredictable risk. All drugs can have side effects in some patients, and benefits must be weighed against likely discomforts and harms. Your doctor is in the best position to evaluate your personal situation. Anyway, having osteoporosis, you should take care of it. A fracture is itself a risk for one's health and well-being.

Zometa is a bisphosphonate (as Fosamax/Actonel): These drugs have few side effects: the major ones are gastric problems. But the intravenous administration (as for Zometa) minimizes this problem. The risk of renal problems is low if the correct infusion procedure is followed. Some patients (not very often) may have flu-like symptoms (pain, moderate fever) initially.

Evista fully acts as an estrogen only on bone. It seems to reduce the risk of breast cancer. Like other drugs in the same class (SERM) it can cause endometrial hyperplasia. Any symptom on the breast and uterus must be reported to the doctor. We are all different and our reactions can be different, we learn about side effects thru the reports about them. Maybe only one person in a million may have a certain effect, but it's good to know that. Evista can increase venous thromboembolic episodes, so given your history you should re-evaluate your blood coagulation status with your doctor befossre choosing it.

Forteo (PTH) increases the bone mass more than the other drugs. It is still a relatively new drug (even if it's a normally produced human hormone, which regulates calcium metabolism). Indeed, in the first studies in animals at very high doses, there was a risk of bone cancer. We didn't observe anything like this in all the subsequent human studies, with much lower doses. Overall, bisphosphonates are the class of drugs which have been used for a longer time and those more widely used for osteoporosis.


Q: I am a 42 year old female with osteoporosis in my lumbar spine (-3.27) and osteopenia in my hips. I am currently taking Fosamax once-weekly. Can you tell me whether this is classed as severe osteoporosis. I am worried about losing bone density when I reach the menopause but I am not keen on HRT.

A: T-score -3.27 on spine at your age means severe osteoporosis. You are already treated for osteoporosis with a very effective drug (and HRT therapy is not more effective on bone than Fosamax). I hope that the cause of your pre-menopausal osteoporosis has been investigated to exclude a case of secondary osteoporosis. A complete treatment for osteoporosis includes also a correct diet, a
regular physical activity and the avoidance of possible risk factors (smoking, abuse of alcohol). A correct diet means at least 1200 mg of calcium daily. Reduce the intake of sodium (salt), animal protein (meat), fibers. A regular physical acitivity means at least a 30-minutes to 1-hour walk every day plus, at your age, some light aerobic activities, e.g. 2-3 hours per week.


Q: Like many other women who have posed questions to you, I have not found much information about treatment options for premenopausal women with osteopenia or osteoporosis. Your site has been the most informative and useful. Thank you.

I was diagnosed with osteopenia two years ago at the age of 41. Since then I've been taking 1500 mg of calcium and vitamin D daily, have decreased my caffene intake and have resumed weight-bearing exercise. I also take Ortho Tricyclen birth control pills, which I've been taking for many years. I'm premenopausal. My only risk factors are that I'm Caucausian and have a small frame.

A recent, second Dexa scan indicated my condition is worse but still in the osteopenia range. I'll be seeing my GYN soon to discuss these results and treatment options. Over the telephone he mentioned the drugs Fosamax and Actonel.

My question is: should I ask my gyn to perform other tests (blood/urine/?) to determine the cause of my bone density loss before starting Fosamax or Actonel. If so, what tests do you recommend and what do they measure?

A: Osteopenia can be seen also in premenopause, even if not frequently. A small frame is a risk factor for a lower bone mass. But it is also important to consider dietary habits (calcium, caffeine, fibers,...) and physical activity during the whole life, in particular the period of growth and development where the peak value of bone mass is reached.s

If your bone mass is consistently reduced, the possible causes should be evaluated with your doctor, first on the basis of clinical history/examination, then if necessary with some specific tests. In general, plasma calcium, phosphate, alkaline phosphatase, parathyroid homone, TSH, ESR and urinary calcium excretion are the first-line tests used.


Q: I am a 49 year old with t scores of -1.5 in lumbar spine and -1 in the hip. Although these scores are not terrible my doctor has recommended that I take Evista or Fosomax due to the fact that both my mother and maternal aunt have been crippled by osteoporosis, and that over a 2 year period I had lost 7.9% and 8.4% of bone density. I had a bone density test two years ago and just last month and so the two sets of scores could be compared. I have not had any periods for over a year and do not experience any menopausal problems other than bone losss. For at least 10 years I have taken calcium and Vit. D supplements, I excercise 5 or 6 days a week running and walking 30 minutes a day and doing weight bearing excercise (nautilus) three times a week. I have a good diet, don't smoke and never have and have always been active. So my question is which of these medications would prove more ef! fective for me? Is there a difference in the outcome when patients take different medications? Is one more effective than the other for the spine where I seem to be losing more bone density . My mother also has extreme problems with her spine and les with the rest of her bones. Could this be inherited- a loss of bone in a specific area? My sister is presently on fosomax due to diagnosed osteopenia as well. Evista or Fosomax?

A: Familiarity is one of the risk factors for osteoporosis. The daughters of osteoporotic women have a bone mass lower than daughters of non-osteoporotic women. The decrease in spine bone mass is the first one to appear (because of the prevalence of trabecular bone, the first to lose calcium) after menopause. Given your family history, your age, and the entity of your bone loss I think that your doctor was right to prescribe you a therapy.

Both drugs - Evista and Fosamax - are effective. Evista acts as an estrogen mainly on bone. It reduces bone loss, and mainly reduces the risk of spine fractures. Must be taken every day orally. Fosamax is a bishposphonate. This kind of drug acts exclusively on bones, reducting bone loss and the risk of both spine and hip fractures. It's generally taken orally once a week.

I think that your doctor is in the best position to evaluate the more suitable therapy with you (knowing your general clinical condition). Both a correct diet and a regular physical activity should be maintained also during therapy for osteoporosis.


Q: I am 49 years old. I had a partial hysterectomy at 45. Recently I was diagnosed with moderate osteoporosis. The reason I went for an ultra sound test was because of a family history of osteoporosis (Mother, aunts). When I went for a bone density test it should that I was quite a bit below the average for my age.

Would the hysterectomy have any thing to do with the fact that I have osteoporosis now? I never took any hormones after the surgery. And I have always eaten a healthy diet. And I don't smoke. The biggest factor is the family history of osteoporosis. Currently I am taking 5 mg of Fosamax. HRT was not considered as my estrogen levels are still quite within the normal range

A: If by partial hysterectomy you mean that your ovaries were left in place (and are still functioning as appears from your normal estrogen level), this hasn't had any influence on your bones. There are many reasons why a person can develop osteoporosis, including genetic factors (which may show as a recurrence of the disease in the family). Lack of calcium in the diet or poor calcium absorption from the intestine; lack of weight-bearing physical activity (e.g. walking - at least 30 minutes a day); chronic diseases (hyperthyroidism, hyperparathyroidism, chronic inflammatory disease treated wiuth corticosteroids, coeliac disease and other intestinal disorders; etc) are other risk factors. You should take at least 1200 mg of calcium every day (1 liter of milk is about 1200 mg of calcium, other dairy products are also calcium rich food) and have a regular physical activity. Fosamax will help to halt your bone loss and reduce your risk of fragility fractures.


Q: I want to know if osteoporosis affects teeth? Just recently I had to have 8 teeth remove and have to have more done. I am 44 years of age, and had a complete hysterectomy at 21.

A: Osteoporosis is a generalized reduction of bone mass (i.e. it affects all bones) . This means that also alveolar bone is reduced when osteoporosis is present. If you don't have osteoporosis your tooth problems may have another cause. The more frequent cause is periodontitis (bacterial infection in the dental plaque) which can induce a loss localized to alveolar bone and the loss of the soft-tissue attachment to the tooth. So the first question is to discover whether you have osteoporosis or not.


Q: I have osteo and am taking Fosomax and calcium supplement with Vitamin D. What is the best time to take calcium I have been taking it with meals but I read it is a good idea to take a calcium supplement at bedtime. I take caltrate 600+D three times a day. Am I doing what is most beneficial?

A: There is no rule about the best time to take calcium. It's probably better during meals, or just after, also to minimize the common side effects. Taking fractioned doses, as you do, is also probably better for an optimal absorption. The only other thing I'd say is: are you sure you must take a supplement of 1800 mg of calcium a day? The recommended dose for a woman in menopause is 1200 to 1500 mg of calcium per day (1500 mg over 65-70 years because of reduced intestinal absorption). And probably the food you eat will also give you some more calcium... (don't you take any milk, yogurt, cheese? ... about 200 mg of calcium are probably taken anyway, even without dairy products). A last word: you certainly know that you should not take your calcium for at least one hour after taking Fosamax.


Q: I am a 52 year old post-menopausal women. I have been taking estrogen since the onset of menapause, about 8 years ago. I just had my first bone scan and show signs of osteoporosis. I have begun Fosomax. My question is, is one estrogen any better than the next when it comes to bone health. I have been taking Cenestin but am anxious to be taking the one most likely to aid in bone health. Thanks for your time.

A: Fosamax is a very effective drug against osteoporosis, and can be taken together with the estrogens. A correct calcium intake (about 1200-1500 mg a day) is also important, as well as regular weight-bearing physical activity (e.g. walking at least 30 minutes a day). Estrogens used ans an HRT for menopause are generally effective in preventing osteoporosis. If they are not enough, Fosamax can be added or substituted.


Q: I am a 28 year old woman who has a history of Crohn's disease and has been on prednisone intermittently for the past 7 years. I also have secondary amenorrhea and was without a menstral cycle for 3 years. I have recently had a bone density test with me being -2.8 standard deviations below normal. My physician wants me to start on an biphosphonate. Can you give me some insight as to which biphosphonate might be the best for me. Towards the end of this year, I was also planning on starting a family. As I realize that should not be on this kind of drug while trying to concieve or breastfeeding, could you tell me how long I would need to be off the biphosphonate until I was ready to conceive?

A: The action of bisphosphonates on bone is always the same. As you probably know, alendronate (and also risedronate in the USA) is available as a once-a week pill. Re pregnancy, all bisphosphonates cross the placenta and might induce alterations in the child's bones. It is generally recommended to suspend them at least 6 months before a possible pregnancy. It is most important in your case to take the correct dose of calcium (1500 mg / day) and vitamin D to optimize your intestinal absorption throughout pregnancy and breast-feeding.


Q: I've been on Arimidex for about one year, as adjuvant treatment for breast cancer. I'm 50, and post-menopausal. How often should I have my bone density measured?

A: It depends on your bone mass density at the last measurement. If BMD was satisfactory and there are no special risk factors, you should have a new measurement after 2-3 years. If the values were low or there are risk factors, check your BMD after about 1 year (no less than 1 year). In any case, do follow the standard prevention rules: correct intake of calcium (about 1200-1500 mg a day) and moderate but regular weight-bearing physical activity (e.g. walking 30 minutes a day).


Q: I have a patient, 40 year old male, current special forces paratrooper with hx of 1999 fx femur and hip. Radiological evidence of osteopenia in January. Is there any evidence of usefulness of Forteo for stimulating bone growth in an isolated area related to a previous injury? Any different side effects for Forteo for a male?

A: Radiographs are not reliable to diagnose osteopenia and evaluate its degree. A bone density measurement by DXA is the only reliable method to quantify it with precision.

Forteo (parathyroid hormone) is a normally produced hormone, both in men and women. There are no sex differences in its actions. It increases bone density in the whole skeleton, and this is why it is used for osteoporosis. In general, it is not used for simple osteopenia. Its use in your case should be evaluated with your doctor, also in relation to the degree of your osteopenia. Please remember that regular weight-bearing physical activity (e.g. walking) stimulates bone remodelling, and this mespecially at the hip.


Q: I am a 50 year old women that fell on my artificial knee over 1 year ago. I have been in pain since the fall. One doctor is saying that I have osteopenia of the lower femur and the upper tibia metaphisis. I had no pain prior to the fall and was wondering if the fall could have aggravated the Osteopenia. The bone scan does show some loosing of the artificial joint but xrays do not support this. Evidently the osteopenia was in evidence in previous xrays.

A: Some osteopenia is frequent in the bone regions around a prosthesis. The common form of osteopenia secondary to menopause is not influenced by a fall, unless there was prolonged immobilization. After a trauma it is possible to develop a chronic pain syndrome (reflex sympathetic dystrophy) secondary to a localized form of osteoporosis. In general, there are swelling, tenderness and reduced mobility accompanying pain. X-rays are not reliable to diagnose and measure osteopenia. Only bone density scans can evaluate it with precision.


Q: I have been recently experiencing muscle and joint pain, especially after rising from a sitting position. There have been times that I can barely walk. It quickly goes away after a few steps/movements. I am wondering if this could be a side effect of Fosomax. I have been taking Fosomax for about 4 years. I have just recently stopped taking my weekly dosage of Fosomax out of concern that this may be the cause. If this is indeed a side effect of Fosomax how soon can I expect this muscle/joint pain to subside? I will appreciate your answer.

A: The kind of pain that you describe is very characteristic of osteoarthrosis: there is pain at the beginning of movements after immobility, and pain disappears after getting in motion.

It's unlikely that your pain be related to Fosamax after 4 years of use. In very few cases bisphosphonates (the class of drugs Fosamax belongs to) can induce bone pain (not related to movements), but this is seen especially in the first months of use.


Q: I wonder if anyone taking Fosomax has trouble with their joints, knees, shoulders?

A: Which kind of "trouble"? In very few cases bisphosphonates (the class of drugs Fosamax belongs to) can induce some bone pain, but this is seen especially in the first months of use. It's also possible that you have a form of osteoarthritis/osteoarthrosis at these joints, unrelated to Fosamax.


Q: Does Evista improve bone density or only preserve the bone mass that is present.? I have been taking Evista for 2 years with no improvement in my bone density test. I also eat calcium rich foods, exercise,work 12 hour days several days a week and take calcium with Vitamin D- 1000 mg daily. I am wondering if Fosamex would be more beneficial for me.My body build is tall and slender. My mother suffered from severe osteoporosis. I have problems with gastritis already without aggravating them with a new medication. Thank you for your advice. A: All drugs used for osteoporosis should at least preserve the bone mass, preventing further losses. Sometimes, during the initial phase of therapy, some increase in bone mass -- about 2-3%, even up to 4-5% with Fosamax (alendronate) -- can be seen, but this is not the rule.

With both bisphosphonates (Fosamax and others) and raloxifene (Evista), even when there are no apparent increases in bone mass, the bone seems to become stronger, and there is a reduced risk of vertebral and hip fractures.

The use of bisphosphonates by mouth can determine oesophageal or gastric irritation, so in the presence of gastritis, their use must be evaluated with a doctor.
Calcium, vitamin D and exercise are always good for your bone, and are important also if you take a drug against osteoporosis.

Q: If foxamax goes to the reobsorption sites of bone and blocks the osteoclast activity, doesn't it also block the bone building activity of the osteoblasts? It appears to me if a persons bone density scores improved to acceptable levels for fracture risk and no longer wanted to take the drug, that eventually the bone density would be back to where it was origiinally with or without attention to other dietary supplementation. Just a comment...It seems to me that bone density testing should be done at much earlier stages of life especially with gastrointestinal disease, eating disorders etc. Thanks!

A: Yes, Fosamax blocks the activity of osteoclasts and consequently, also the osteoblast activity is reduced. But the overall balance is a reduced loss of bone mass or even a slight increase, particularly in the first 1-2 years.

These drugs should be taken for a long period. By suspending them, the original metabolic imbalance that caused osteoporosis will reappear, and the loss of bone mass will begin again. Bone mass measurement can be done at any age when a serious risk of osteoporosis is present.

Nervous anorexia and intestinal malabsorption (such as Coeliac disease or Crohn's disease) in adolescents are causes of a reduced peak bone mass (the maximum value of bone mass reached by a person). Of course, any osteoporosis in a young person must be thoroughly investigated to discover and treat the possible cause of it.


Q: I was diagnosed with ostepenia about 3 months ago. What prompted me to go get a dexa scan was the fact that I was having severe pain in upper and lower back. I can not sit for over a few minutes and then my back begins to hurt. If I stand for an hour or sit for an hour, my back begins to hurt severely. I was beginning to get muscles spasms too when I was working and standing all day. When I walk, my back feels better. I have been on caltrate for about 2 months now and I am not seeing any relief or changes in my back pain. My questions are: Do you feel that the bone density loss is causing the back pain? Have others experienced this terrible back pain associated with bone loss? If the bone loss is causing the pain, approximately how long will it be before I feel any relief or less back pain? Is it a very slow process to get better when taking the calcium pills? Thanks so much for your time.

A: There is no clear relation between back pain and the loss of bone mineral mass (osteopenia). Moreover, the pain of bone loss is usually getting worse after standing or walking, not after sitting or laying down. Serious back pain can be present after vertebral fractures, which are usually diagnosed with X-rays. However, it's impossible to feel better after walking if there is a vertebral fracture. Back pain is a common problem and can be thoroughly evaluated only with a direct examination by a doctor. Common causes of pain are osteoarthrosis/osteoarthritis. Calcium pill are important for the prevention of osteoporosis if there is not enough calcium in the diet. However, calcium is not a therapy for back pain.

References

**Note: Opinions expressed here are for educational purposes only and, as such, do not constitute a physician patient relationship. This information is not intended to supplant the need for you to consult with your physician prior to choosing therapeutic options and/or interventions.
 
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