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Questions answered by Harvey S. Marchbein, MD
Q. I developed Osteoporosis from taking Lupron for seven months. (To treat Endometriosis. I took 3.75mg monthly). My doctor put me on Fosamax, 5mg daily for the first month, and then 10mg daily for another 5 months. Is this treatment adequate, or should I have taken Fosamax for a longer period? If so, what is recommended? Also, at what point should the bone density test be repeated?
Robin
A. My first thought is as to whether or not add back therapy was used to prevent the osteoporosis that can accompany prolonged GnRH therapy. The reason for therapy with Lupron was not mentioned so the point is one of academic interest but not practical at this time.
Fosamax 10mg daily is an adequate dose but the duration of therapy has to be customized to the level of osteoporosis and the speed of return to normal density levels. This is variable. During therapy, a urinary NTX could have been done to insure reduced bone turnover and it can still be done now, after therapy, to confirm premenopausal NTX levels if you, indeed, are premenopausal (not mentioned above).
Osteoporosis is frequently reversible in premenopausal women with adequate Calcium supplementation and weight bearing exercise because endogenous circulating estrogen should be helpful in and of itself. An important point is that we don't know your pre-treatment bone density or physical exam or family history which may also impact on your recent bone density.
The duration of therapy can not be determined in advance so that question is unanswerable. The repeat bone density should not be done earlier than 12 months and many experts recommend 24 months at a minimum due to variability of measurements even in the same person on the same machine on the same day (2-3% variation noted).
Harvey S. Marchbein, M.D. FACOG, FACS
Q. I have been diagnosed with Osteoporosis. I am a 60-year-old Caucasian female. I have not had a hysterectomy. I have been talking Ogen and Provera for the past five years. Can/should Fosamax be used in conjunction with HRT to help rebuild bone density?
A. If this is your first bone density, we have no way of knowing if there has been a decrease in bone density despite HRT (18% of women are genetically incapable of building bone from being on HRT) or if your bone density was always low and the HRT is keeping it stable.
Fosamax can be used in combination with HRT although there are very few papers in the literature at this point, indicating this. Anecdotally, this has been a very effective combination.
Another option is to get a urinary NTX prior to adding medication to determine the bone turnover and see if additional therapy is warranted at this time. Therapeutic modalities will also depend upon the severity of osteoporosis shown on the bone density.
Some small amount of literature speaks about HRT with the addition of small amounts of androgen to increase bone production. Pros and cons of adding this therapy should be discussed with your physician.
Harvey S. Marchbein, M.D. FACOG, FACS
Q. I have an 81 year old female patient who is taking Calcium, ERT (Premarin, .625mg), (s/p hysterectomy), and has taken Fosamax for 3 years for a history of lumbar compression fractures. I ordered her first bone density study, DEXA, which showed Z-scores (compared to young adult) of lumbar: -0.83, hip: -1.87, and radius -3.54. Should her therapy be changed?
Kathleen Griffin, M.D.
Maui, HI
A. T scores are compared to young adults. Z scores are compared to patients of the same age. I wonder if there is degenerative joint disease along with compression falsely increasing the lumbar reading because that is not consistent with osteoporosis causing vertebral fractures.
Due to history of vertebral fractures, treatment should be maintained. A urinary NTX can be obtained to determine bone turnover to insure adequacy of therapy.
Harvey S. Marchbein, M.D. FACOG, FACS
Q. Should Fosamax be used longer than 3 years?
Kathleen Griffin, M.D.
Maui, Hawaii
A. No reason why it can't. May depend upon the bone density and what it changes to in that 3 year period.
Harvey S. Marchbein, M.D. FACOG, FACS
Regarding the reporting form for DEXA Densitometry , specifically the LUNAR brand
Q. What is the significance of >2.5 S.D. over young adult values at the distal radius, if the 33% value is normal, and why is this reported?
A. Have never seen it. Don't know.
Q. For the spine, is the L1-L4 the best marker? Is this an average? Are all values given, in case 1 or 2 are markedly different from osteoarthritis or other disorder, and we should thus not use them in our interpretation?
A. Both the separate values and the average are important. With osteoarthritis, the value will be abnormally elevated, making an osteoporotic vertebra appear better than it is and a normal vertebra may have a positive T score indicative of degenerative joint disease.
Q. For the hip, I have been told that the Wards triangle value is useless, and the only one to pay attention to is the neck value. If so, why are 3 values reported?
A. Wartd's traingle is of limited value because there is no agreement on *exactly* where on the bone densitometry Ward's triangle is. The neck has been shown to be the most reliable value. The 3 values are reported as a matter of custom and hopefully, in the future this will be changed by the NOF (National Oseoporosis Foundation or another governing body.
Q. What do I tell a patient who has very discrepant values from radius to hip to spine, for example, +.09, -2.5, and -0.85, and what is the significance of which bone is the lowest in density?
A. You tell the patient she has osteoporosis evident in the hip and considering the mortality associated with hip fracture, treatment is recommended.
Q. If I have a bone density value in g/cm2 from a SPA study can I compare that value to a subsequent DEXA value?
A. My understanding is that only DEXAs can be compared to DEXAs and even that is not completely true due to variations from one machine to another.
Questions by Kathleen Griffin, M.D. Maui, Hawaii
Answers by Harvey Marchbein, M.D. Great Neck, New York
Q.
I have an 81 year old female patient who is taking Calcium, ERT (Premarin, .625mg), (s/p hysterectomy), and has
taken Fosamax for 3 years for a history of lumbar compression fractures. I ordered her first bone density study,
DEXA, which showed Z-scores (compared to young adult) of lumbar: -0.83, hip: -1.87, and radius -3.54.
Should her therapy be changed?
Kathleen Griffin, M.D.
Maui, HI
A. T scores are compared to young adults. Z scores are compared to patients of the same age. I wonder if there is degenerative joint disease along with compression falsely increasing the lumbar reading because that is not consistent with osteoporosis causing vertebral fractures. Due to history of vertebral fractures, treatment should be maintained. A urinary NTX can be obtained to determine bone turnover to insure adequacy of therapy.
Harvey S. Marchbein, M.D. FACOG, FACS
Osteoporosis & Catamenial Epilepsy
Q. I am a 58 yr. old cauc. woman whose epilepsy began at onset of menses: age 12 I am Gravida 2 Para 2 I took oral contraceptives 34 yrs. ago after the birth of my daughter, but instead of a period, I had a seizure once a month. I took o.c. for 4 months. Last year at age 57, I had a bone scan which showed some osteopenia. My Gyn. says HRT or Fozomax My Neurologist says to go a natural route, with soy, exercise, calcium, & other supplements. I have not had a seizure for many years, but both Neurologist & I agree, "if it ain't broke, don't fix it" My mother is 88 yrs. has never had hysterectomy, (I still have uterus & ovaries, too) she has never taken any medication for osteo. or HRT. She is now MUCH shorter than she used to be, had a wrist fracture at age 75. My LMP was age 52. I am concerned about HRT & breast ca. (there is no history in my family) I am concerned aboutbleeding. But my primary concern is: NO ONE can guarantee there will be no seizures if I begin HRT.
A. If there is concern about potential side effects from HRT, it would be prudent to stay away from this therapy. Although isoflavones and phytoestrogens including soy may alleviate many menopausal symptoms, they have never been proven to reverse osteopenia nor at the very least stabilize it.
There is much to say for the recommendations of the neurologist but it is unlikely that it will help the bones and with a mother having an apparent history of osteoporosis (and family history being a great risk factor), I might consider Fosamax 5mg as a preventative daily dose.
A urinary NTX (a urine test to determine bone turnover) would be most helpful - to be done prior to therapy and 3 months later to determine adequacy of therapy and whether or not a change in therapeutics is necessary.
Harvey S. Marchbein, M.D. FACOG, FACS
Q. I am 48 years old, had a hysterectomy a few years ago, am taking estrogen, and have osteoporosis/osteoarthritis. I have a lot of pain in my left hip, knee, and left great toe. My feet hurt, and also the joints of my fingers. My shoulders and neck are also very stiff and painful. My hip is so painful that I have a very difficult time trying to sleep at night and wake up several times a night because of the pain. My question is: What can I take for the pain?
Marian
A. Osteoporosis does not cause pain unless it is associated with fractures. Presuming no fractures, the pain is osteoarthritis and can be treated with NSAIDs. If this is insufficient, a visit to a rheumatologist may be helpful. Other diagnoses to be considered are sciatica and gout.
Harvey S. Marchbein, M.D. FACOG, FACS
**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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