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Questions answered by Harvey S. Marchbein, MD
Osteoporosis Treatment Options
I am 59 and have been diagnosed with osteoporosis. I had a total hysterectomy at age 42 and was unable to tolerate hormone replacement drugs at that time. So this diagnosis (through a bone scan) is not a surprise. There is a history of cancer, both male and female in my family. My primary care physician is recommending Climara patch as treatment, along with calcium I am already taking. I am worried about taking hormone replacement - mainly with the risk of breast cancer. Are there any better or safer treatment options - such as Evista or Fosomax? The research on both drugs seems to be good. Is one better than the other? Thank you very much for your response.
ERT has been questionably implicated in an increase in breast cancer but, from studies of HRT, there is no consensus as to whether or not hormones increase the of breast cancer. Many studies do show an increase but also show breast cancer being diagnosed at an earlier stage with a higher cure rate. The are many other advantages of ERT including reduction in heart disease, reduction in Alzheimer's disease, reduction in colon cancer and reduction is vision loss associated with macular degeneration.
Evista is not recommmended for the treatment of osteoporosis but rather for the prevention of osteoporosis. With a diagnosis of osteoporosis already, this would not be a first choice. ERT by patch is highly recommended but approximately 18% of women are gentically incapable of increasing bone density with estrogen and need medications such as Fosamax. An option for many would be starting ERT and doing a urinary NTx pre treatment and 3 months later. This test measures bone turnover and with adequate decrease after 3 months of therapy, it is reasonable to assume that bone density will increase.
How much calcium should you take as a supplement?
Depending upon the age of the individual, this varies. Calcium can be taken in appropriate foods and or supplements. Nutritionists point out that the body will not absorb more than 500-600 mg at one time, so larger amounts (1000 mg) will have to be split into smaller doses (500-600 twice a day). Teenagers need about 1500 mg per day. Adults need about 1000 mg per day. After menopause, 1000 mg per day if on hormones, 1200-1500 mg per day if not. After age 65, 1200-1500 mg per day. This presumes there are no medications or medical problems that would accelerate bone loss. In addition, Vitamion D 400IU per day until age 65, when many experts recommend 800IU per day. These same experts also feel that after age 65, at least half of the requirements should be by supplement, not just food.
Is it appropriate to compare DEXA results from say "Hologic" with results from "Lunar"?
Kathleen Griffin, M.D.
Maui, HI
It is difficult to compare DEXA results from machines from the same company much less from different companies. Another problem is what set of normals each practitioner uses. The T scores will vary depending upon the company, the machine and the updated (or not) set of normals upon which comparisons are drawn.
After having radiation theraphy in 1970, I had a pituitary tumor removed in 1974 (I was 29 years old then, I am 53 years old now).
I had my periods by hormone treatment (Premarin and Provera) all these years. Aproximately two years ago my periods became irregular (somethimes just dark spotting and others very light bleeding). My doctor put me on PREMPRO, supposedly to stop the periods completely. I took PREMPRO for several months, but I still bleed (dark spotting and very light bleeding) almost every month at different times of the month. I went back, and I was given a prescription for PREMPHASE this time. Well, I took PREMPHASE for several months and the same thing happened. A week ago I went back to the doctor and this time I was instructed to take a doble dosage of PREMARIN (1.25mg daily, PREMPHASE has .625mg) for the rest of the month of December, then in January to start with 10mg of PROVERA, days 1-14, and 1.25mg of PREMARIN from day 15-to the end of the month. The same day I took this double dosage I started cramping, and then bleeding. I stopped taking the double dosage, and decided to take just the regular PREMPHASE dosage.
At the last appointment (when the doctor asked me do do the double dosage), she indicated that if the above therapy (double dosage) didn't work, she would take me completely out of the hormones. My main concern is osteoporosis. If I stop the hormones now, could I develop osteoporosis?
If one were to be a responder to estrogen with respect to bone formation, discontinuation would tend to decrease bone overall.
Approximately three months ago I attended an Osteoporosis Seminar, and at that time I was given a right heal bone density test, which the doctor indicated was OK at that time, even though I seem to be a high risk person (my mother developed osteoporosis, I take daily cortisone, synthroid, diuretic and potasium (DYAZIDE and SLOW-K), consume little milk products, and have very sedentary life - always tired, little energy).
It is unknown as to whether or not "OK" indicates normal bone or osteopenia without osteoporosis. The risk factors noted above are considerable.
Is there any other way that I could continue with my hormone therapy, to avoid developing osteoporosis?
Dr. Mischell, in California, is reported to use combination therapy in some patients, 5 days on and 2 days off. This helps some. A new HRT patch, Combipatch may also be helpful to some. Still others change from Prempro and Premphase to other estrogens and progesterones, including Estratab and Estrace (E) and Prometrium (P). There are other options in compounded medications including Bi-Est and Tri-Est from Women's International Pharmacy in Madison Wisconsin.
Another option is preventative therapy in patients with osteopenia in the form of Fosamax.
I am a 49 yr. old on HRT for 1 year and have been suffering from mild to severe chronic mid back pain for almost 3 yrs. My Gyn. Dr. thought it was due to osteoarthritis & that it might subside somewhat w/ HRT but it has not. I still get occasional hot flashes also. I was wondering if slightly higher doses than standard Prempro were ever used to alleviate either of these conditions. ( I am also seeing a Rhemetologist and have been diagnosed w/ osteoporosis and have just started taking extra calcium supp. plus Calcetonin spray as I have a sensitive stomach).
The only other advice the Rheumetologist has given is to take an exercise class (although I'm fairly active and not overwieght) and just take anti-inflamatorys (although even w/ buffers this still upsets my stomach at times..) Any suggestions?
Several points -
1) HRT has recently been shown to be somewhat helpful in the symptomatic relief of
osteoarthritis.
2) Occasional hot flushes can be normal with adequate HRT but it might be appropriate to consult your physician about an Estradiol level. Depending upon the HRT used, the Estradiol level may be reflective of your supplemented estrogen level and indicate either adequate therapy or suboptimal therapy. Higher doses will not necessarily be more helpful with your osteoarthritis and higher doses are usually associated with higher risk rates and side effects. With respect to hot flushes, one may wish to consider herbal therapy, most notably Black cohosh. The major caveat is to be sure your liver chemistries are normal.
3) With respect to osteoporosis, depending upon the severity, estrogen can halt and/or reverse osteoporosis in about 82% of patients. Using urinary NTx (a chemical showing bone turnover - high NTx is not good and lower NTx 3 months after therapy is initiated can indicate response to therapy) may be helpful in delineating these patients who are estrogen "responders". For those who don't show lowering NTx, there is Fosamax (many with sensitive stomachs can take it although this is not universal). Fosamax is far superior to Calcetonin (*Miacalcin* - brand name) in efficacy and calcetonin is noted to be most effective at least 5 years after menopause but may still meet your needs. Didronel, an older medication, is making a comeback in some circles for patients sensitive to Fosamax who are less than 5 years from initiation of menopause.
4) For osteoarthritis and osteoporosis, exercise is extremely
important. Stretching, aerobics and weight bearing exercises are crucial for maintainence of flexibility, cardiac
conditioning and body strength. Exercise not only has these benenfits but, by increasing body strength and flexibility,
aids in maintaining balance, which reduces falls.
Miacalcin for premenopausal women
I'm having trouble finding information on studies concerning Miacalcin for premenopausal women diagnosed with osteopenia (lumbar spine only). I'm a 42 year-old physical therapist who has been taking salmon-calcitonin via nasal spray since September 1997. How long should I remain on the Miacalcin? Are there any side effects? Can I start a low-estrogen birth control pill and continue taking the Miacalcin? I'm currently chewing 3 Tums 500 with meals for calcium and take 800 IU's of Vitamin D at bedtime; the only other medication I use is a Proventil inhaler before aerobic exercise for ex-induced asthma.
I would appreciate any information you could send my way!
Having no personal knowledge of the use of Miacalcin in premenopausal women with either osteoporosis or osteopenia, I performed a literature search and came across only one article in the first 60 stating that calcitonin had no effect on premenopausal osteoporosis. there is no mention at all of calcitonin for the prevention of osteoporosis. There is some data to suggest that premenopausal changes in BMD may not be significant. The DEXA results are not listed so the discussion will be in general.
Presuming there are no other predisposing factors for osteoporosis, the birth control pill option mentioned is an excellent one if approved by your physician and the literature supports this.
In patients with adequate weight bearing exercise, adequate Calcium (1000-1500mg per day depending upon BMD status - maximum dose 500-600mg per dose - therefore 2-3 doses per day) and adequate vitamin D (400IU is recommended for the average person person under 65) miold osteopenia may be their norm and may not represent a loss.
The literature confirms the less than acceptable response from calcitonin for the treatment of osteoporosis (not osteopenia), and with that, best effect after 5 years of menopause (not premenopausal).
Harvey S. Marchbein, M.D. FACOG, FACS
Great Neck, New York
**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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