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Q: What
alternative treatments are available to aid in the healing of a broken rib?
I have a good friend who recently broke a rib. She is not very active and
is 54 years old. After 6 weeks, she feels her rib is not healing well. She continues to have pain and difficulty
breathing.
She has tried many calcium supplements and cannot tolerate them through her digestive tract. She has been diagnosed
as having osteoporosis.
What alternative treatments are available to her to aid in the healing of her rib?
Thank you for your help.
Regards,
Rebecca
Answer from Dr. Kipersztok
Dear Rebecca:
It is difficult to judge from your question what caused your friend's rib fracture. It is possible for any person,
even those without osteoporosis, to sustain a fracture if enough force is applied to any bone in the body. Also,
many factors can affect the healing process following a fracture.
The best advise I can offer is that your friend should discuss her situation and concerns with her family physician
or primary care doctor.
Simon
Kipersztok, M.D.
OBGYN.net
Osteoporosis, Editorial Advisor
Q: Livial Tibolone and Calcium tablets vs. Tamoxifin
I am on Tamoxifin. I have been taking this for four years. This summer I was diagnosed with severe osteoporosis. A doctor prescribed LIVIAL TIBOLONE 2.5 and Calcichews D3, three tablets a day. Another doctor has reservations about my taking Livial because I had breast cancer in 1995 and still on Tamoxifin and was estrogen positive on a test back in 1995. I am very confused. I did try Fosamax for three week and developed a rash. Can you please help by telling me what I can take in my condition. I am 58 years old.
Answers from Dr. Kipersztok and Dr. Barentsen
Your question raises some very important concerns common to many women.
I would like to start my reply by indicating to you that the best way to address the health needs of post-menopausal
women has not been determined and, therefore, care for that population of patients has to be highly individualized.
In addition, given the many different health situations that can be encountered among the menopausal population
it is extremely important that each woman become as knowledgeable as she possibly can about her condition and the
available treatments. Estrogen replacement therapy (ERT) is the most comprehensive treatment available to post
menopausal women today. ERT not only relieves the common symptoms associated with the menopause such as hot flashes
and vaginal dryness but also protects women from the ill effects of many other conditions that could affect them
in later life. These include cardiovascular disease, osteoporosis and bone fractures, Alzheimer's disease, colon
cancer, tooth loss and macular degeneration (visual condition that can lead to blindness). When women have a uterus,
ERT alone can substantially increase the occurrence of uterine cancer so to eliminate that particular risk another
hormone called a progestin must be administered. At that point ERT is called Hormone Replacement Therapy or HRT.
With the administration of a progestin menopausal women can experience vaginal bleeding which is often considered
a nuisance and is unacceptable to many menopausal women. One other possible risk associated with ERT or HRT is
that of breast cancer. However, many authorities consider the increased risk associated with ERT/HRT to be of a
magnitude similar to that associated with other common activities women usually engage in. For example, the increased
risk of breast cancer among ERT/HRT users is similar to the breast cancer risk found in women who have their first
child after 30 or the risk of breast cancer acquired by women just because they had the opportunity to attend college.
For women who either will not take or can not take ERT/HRT, drugs such as alendronate (Fosamax) can not only prevent
the development of osteoporosis but also significantly decrease the risk of fracture at anatomical sites that are
common for fractures in menopausal women. These sites are the spine and the hip. However, alendronate and other
compounds similar in structure provide no other benefit aside from that in the bone. Also they are absorbed poorly
and must be taken in a peculiar way. Raloxifene (Evista), in contrast, affords protection from estrogen
receptor positive breast cancers,
reduces the risk of fracture in the spine (not the hip), improves some of the lipids in the blood and will not
cause vaginal bleeding but it does not relieve hot flashes or vaginal dryness and can increase, like estrogens,
the risk of clots in the lower extremities. So with all this information, how can a woman decide what is best for
her? It is for the patient and her physician to have an open discussion about the options available given the history
and physical situation of the patient. This is one situation where the patient must be actively involved in her
care after careful assessment of all the risks and benefits. Good luck!
Simon
Kipersztok, M.D.
OBGYN.net
Osteoporosis, Editorial Advisor
Tibolone is a compound derived from norethisterone with estrogenic, progestogenic
and androgenic properties. It works mainly through metabolites. The metabolite mainly formed in the uterus is the
"delta" form with progestogenic activity. Let us say: local progestogen. The other metabolites are essentially
estrogenic. In breast tissue (in vitro) with Tibolone the estrogen is mainly bound to sulphate and with Tibolone
the enzymatic step to convert estronsulphate to oestradiol is inhibited. Theoretically Tibolone has advantages
above oestrogens in breast cancer. So I choose Tibolone instead of estrogens for women with heavy vasomotor complaints
after treatment for breast cancer. I have no information on combination of Tamoxifin and Tibolone. Trials with
a combination of Tamoxifin and progestogens are under way (mainly for uterine Tamoxifin effects). For that part
the combination is useful, but for the breast it is completely unknown.
Ronald
Barentsen, MD, PhD
OBGYN.net
Osteoporosis, Editorial Advisor
I am a 62 yr old Caucasian female who has not been on HRT. I just had my first dexascan, and my primary care physician, who is also a rheumatologist, put me on Evista in conjunction with the Fosamax, which was prescribed to me by my OBGYN. Apparently the dexascan was positive for osteo but I do not have any more info than that. Would I just be better off throwing in the towel and giving up on my heretofore rejection of HRT therapy? Looks like some of the side effects of Evista could be just as scary (blood clots, stroke)-- and how long has Fosamax combined with Evista been studied vs. HRT therapy? Am I too late for HRT? Mother Nature has been taking good care of me all along except for this newly diagnosed osteo, so I was never anxious to go the HRT route. (Also I have been taking Zestril which controls hypertension for about 10 or so yrs). I understand the benefits of HRT but still hesitate due to some of the breast cancer fears I have (one biopsy for a benign lesion about 20 yrs ago).
Answer from Dr. Kipersztok
Raloxifene is a prescription medication in the U.S. and is not sold over
the counter. It belongs to a class of compounds called Selective Estrogen Receptor Modulators (SERM) or Tissue
Selective Estrogens (TSE). In some tissues in the body Raloxifene, and other compounds like it such as Tamoxifin,
can have an estrogen like effect whereas in other tissues it has an antiestrogen effect. Raloxifene is effective
in decreasing the incidence of breast cancer, it decreases fractures in the spine but not the hip and it causes
some improvements in the lipid levels that may improve cardiovascular health. Unlike estrogens it does not relieve
hot flashes and does not cause vaginal bleeding. Like estrogen, it increases the risk of thromboembolism (clots
in the veins).
Simon
Kipersztok, M.D.
OBGYN.net
Osteoporosis, Editorial Advisor
Q: What is the best way to combat osteoporosis?
I am 65 years of age and have recently found out I have some osteoporosis in my left hip. I am not on estrogen at this time. What is the best way to combat this.
Answer from Dr. Kipersztok
There are many factors that have to be taken into account when deciding
on how to treat osteoporosis. Your best option is to discuss your situation with your physician and become as knowledgeable
as you can about all the recommendations your physician makes. Some of the common drugs available in the US to
treat osteoporosis include: estrogen, bisphosphonates, Raloxifene and Calcitonin. The use of calcium and vitamin
D, and frequent exercise can also be helpful
Simon
Kipersztok, M.D.
OBGYN.net
Osteoporosis, Editorial Advisor
Q: Treatment of osteoporosis in the face of possible pregnancy
I need to pose a difficult question to you all. I am a 28 year old woman
with one child, age 2. I was diagnosed with severe osteoporosis 2 years ago. I am on fosamax, vitamin D and calcium.
I was diagnosed after suffering through several spinal fractures. The cause of the osteo is unknown, I have gone
through all imaginable tests. My husband and I want to have another child and am seeking council on this matter.
Here are some of the questions that we hope you can answer for us:
1. How would weight gain be maintained?
2. Would a special diet have to be followed?
3. Are there any aids that could help in support of the weight?
4. If I were to fracture, what would be the medical course taken for the rest of the pregnancy? bed rest?
5. Would I be able to continue on the fosamax?
6. What type of exercise would be recommended?
7. How often would I have to visit the doctors?
8. How much calcium should be taken in this type of pregnancy?
9. Is there such a thing as calcium shots that can be administered to ensure extra calcium right into the blood?
10. Could a baby fracture me from the inside out with kicking?
If there are any other questions that you come up with during the research for this question please let me know.
I understand that this is not a very common thing and I would appreciate any advice that you could give on the
topic.
Regards
Answer from Dr. Kipersztok
You raise the issue of treatment of osteoporosis in the face of possible
pregnancy. I am enclosing a copy of the package insert of alendronate (Fosamax) that describes some of the effects
the drug can have on pregnant animals and its use in nursing mothers. Please note that alendronate is a Category
C drug. This means that risk of the drug to pregnant women can not be ruled out and that human studies are lacking.
As you can read, some of the information obtained from animals indicates that there is the potential for risk.
In situations such as yours you should weigh the potential benefits and risks of your treatment with your obstetrician
gynecologist or primary physician. They can take into consideration all the pertinent information they have about
your health and help you make a decision.
Pregnancy Category C:
Reproduction studies in rats showed decreased postimplantation survival at 2 mg/kg/day and decreased body weight
gain in normal pups at 1 mg/kg/day. Sites of incomplete fetal ossification were statistically significantly increased
in rats beginning at 10 mg/kg/day in vertebral (cervical, thoracic, and lumbar), skull, and sternebral bones. The
above doses ranged from 1 times (1 mg/kg) to 9 times (10 mg/kg) the 10 mg human dose based on surface area, mg/m
2 . No similar fetal effects were seen when pregnant rabbits were treated at doses up to 35 mg/kg/day (50 times
the 10 mg human dose based on surface area, mg/m 2 ). Both total and ionized calcium decreased in pregnant rats
at 15 mg/kg/day (13 times the 10 mg human dose based on surface area) resulting in delays and failures of delivery.
Protracted parturition due to maternal hypocalcemia occurred in rats at doses as low as 0.5 mg/kg/day (0.5 times
the recommended human dose) when rats were treated from before mating through gestation. Maternotoxicity (late
pregnancy deaths) occurred in the female rats treated with 15 mg/kg/day for varying periods of time ranging from
treatment only during pre-mating to treatment only during early, middle, or late gestation; these deaths were lessened
but not eliminated by cessation of treatment. Calcium supplementation either in the drinking water or by minipump
could not ameliorate the hypocalcemia or prevent maternal and neonatal deaths due to delays in delivery; calcium
supplementation IV prevented maternal, but not fetal deaths. There are no studies in pregnant women. FOSAMAX should
be used during pregnancy only if the potential benefit justifies the potential risk to the mother and fetus.
Nursing Mothers
It is not known whether alendronate is excreted in human milk. Because many drugs are excreted in human milk, caution
should be exercised when FOSAMAX is administered to nursing women.
Simon
Kipersztok, M.D.
OBGYN.net
Osteoporosis, Editorial Advisor
Q: Question about DEXA results
I am 49 year old. Had my first DEXA scan and got results today. I was told that I have osteoporosis in the femoral neck region and the total hip region shows marked degree of osteopenia. Z 8.58 T -.12 I was told that I am pre-menopausal and just started having hot flashes which do not bother me. My periods have been irregular for the last 10 months and now I am late by about 10 days which never has happened. I presume that estrogen would be the way to go along with calcium, and weight bearing. Is this disease going to make me an invalid? Am I looking towards being in a wheelchair? Sorry, but I am upset, being a healthy active person. Please help me with anything I may need. thanks
Answer from Dr. Kipersztok
With the development of different technologies for measurement of bone mass
we have the ability to assess patients who are at increased risk of fracture. A T- score is a comparison of your
bone mineral density to that of individuals who are at an age when they reach their peak bone mass. It predicts
your risk of fracture fairly accurately. The Z-score compares your bone density to other individuals who are 49
years old. It can indicate if factors other than age may be causing changes in your bone density. As long as the
T and Z score are within 1 standard deviation (SD) or more than 1 SD from the mean you are considered to be bone
competent. If the T, or Z score, are less than 1 SD from the mean you may have bone thinning (osteopenia) or bone
loss (osteoporosis). Bone mineral density can be measured at different anatomical sites such as the spine, the
hip, the wrist, etc.
You are reporting a T score of -0.12 which is within 1 SD from the
mean so you are not at increased risk of fracture. If your T score was -1.12 your bone density would be less than
1 SD from the mean and a diagnosis of osteopenia could be made. If the T score was -3.12 a diagnosis of osteoporosis
would be appropriate. Similarly, you report a Z score of +8.58 which I presume was mistakenly reported or typewritten
because it would mean that your bone mineral density is more than 8 SD above the mean when compared to other individuals
your age. I have never encountered such a high value but if correct it would mean that your bones are very thick.
Such value is also inconsistent with the T score you report. I suggest you ask your physician to explain to you
how to interpret your bone mineral density results. Good luck!
Simon
Kipersztok, M.D.
OBGYN.net
Osteoporosis, Editorial Advisor
**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.
