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this month have been answered by:
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| Q: I have a 70 year old patient with osteopenia in her hip and osteoporosis in her spine with a moderate fracture risk. She has never taken hrt. If she is a candidate for hrt, should I start her on hrt and fosamax, or just hrt and repeat her DEXA scan in 6 months to 1 year? Also what is the recommended time to keep a patient in Fosamax? |
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| A: With
a patient with osteoporosis who is not on medication, the gold standard is
bisphosphonates. These include Fosamax and Actonel. Presuming the patient
has no desire for HRT, the bisphosphonates
alone are the treatment of choice. If she has concerns about
bisphosphonates, HRT can certainly be initiated first. In that case, get
an NTx (now available as a blood test) prior to therapy and after three
months. If there is not a significant drop in the NTx (at least 30%)
within 3 months, the HRT is not not helping her osteoporosis. It
has been shown that the anti-osteoporotic activity of bisphosphonates and
HRT are additive. DEXA scans should be done about every 2 years while following therapy. At this point, there is no optimum time to keep a patient on Fosamax. People have been on this therapy for over 7 years thus far. |
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| Q: I have read that coffee leaches out calcium. How much caffeine is harmful, how much calcium is lost? Is it preferable to take calcium supplements at a different time than the daily two cups of coffee? Requirements of daily calcium 1200 to 1500 mg, is this on top of any consumed through food? Besides the type of calcium supplement, can one maximize the absorption? Does intra joint injection of cortisone cause increase bone loss (19 in shoulder and back over 20 years)? Thanks. |
| A:
In "Caffeine
and bone loss in healthy postmenopausal women." Am J
Clin Nutr 1994 Oct;60(4):573-8, they showed that bone
densities were adversely affected by caffeine intake if the calcium
intake was suboptimal but not if the intake was adequate.
In "Interactions between dietary calcium and caffeine consumption on calcium metabolism in hypertensive humans." Am J Hypertens 1996 Mar;9(3):223-9 it was shown that caffeine consumption may contribute to hypertension since it increases urinary calcium excretion. "A morning caffeine dose of 6 mg/kg lean body mass increased urinary Ca/creatinine ratios similarly for 2 hours after beverage consumption...Caffeine consumption stresses calcium metabolism in hypertensive individuals, especially those consuming less than 700 mg calcium daily." In "Effect of caffeine on circadian excretion of urinary calcium and magnesium." J Am Coll Nutr 1994 Oct;13(5):467-72 it was shown that "Nighttime compensatory renal conservation was insufficient to offset morning caffeine-induced mineral losses, resulting in net 24-hour urinary increases of 0.32 mmol Ca and 0.16 mmol Mg." In "Interactions between dietary caffeine and calcium on calcium and bone metabolism in older women." J Am Coll Nutr 1994 Dec;13(6):592-6 showed that "Abstinence from moderate caffeine intake (mean 5.8 mg/kg lean body mass, 383 mg/day caffeine) raises ultrafiltrable Ca and decreases bone alkaline phosphatase in older women consuming < 600 mg Ca daily." A fascinating addition to this set of papers is a study done on college students, "Is caffeine associated with bone mineral density in young adult women? [In Process Citation]" Prev Med 2000 Nov;31(5):562-8" They showed that caffeine intake in the range consumed by young adult women (average 99.9 mg per day)is not an important risk factor for low BMD. In summary, caffeine in higher amounts causes increased urinary loss of calcium and it's associated with a net 24 hour loss of calcium. Taking calcium at different times of the day was not examined here. Total recommended calcium from all sources is 1000 mg per day in divided doses (prior to the menopause) and 1200-1500 mg during the menopause (again in divided doses). Vitamin D aids in calcium absorption. Although long term steroid therapy can increase the risk of osteoporosis, I could find no literature about steroid injections in joints and subsequent osteoporosis. |
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| Q: Can
you advise me, or refer me to information on Evista. How long is it
in use? What are the long-term effects? How long should it be
taken for? How does one go off it, if it is not good? How does
it work? I am 58, post-menopausal, and have a bone scan this fall of -.3. This was surprising because I do exercise a lot and take calcium. Evista has been recommended. As it is a hormone, I have concerns. If it is so safe, why are women still on HRT? Is this now used instead? Thank you for referring me to more information. |
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| A: Evista
has been around as long as Tamoxifen (used for breast cancer prevention
and therapy) and is a "chemical cousin" of Evista. As far as its
current use, it's been out there a few years. No specific long term
effects have been determined at this time.
It can be used as long as the advantages of the therapy are warranted. Some take it for osteoporosis therapy, some for prevention, some for the as yet unproven reduction in breast cancer. It has been shown to be favorable to lipids but long term follow up is necessary to get a better idea of what that means. If side effects warrant discontinuation of the medication, it can just be stopped. Evista is a SERM (selective serotonin reuptake inhibitor). It has both estrogen and anti-estrogen activity. Estrogen activity on bone, possibly cardiovascular and some lipids and anti-estrogen activity on uterus, breast and vagina. Other actions are still be investigated. Some women don't wish to tolerate the potential side effects of Evista which may include hot flashes and vaginal dryness. In addition, HRT is reported to be helpful in heart disease reduction (certain circumstances), reduction in colon cancer, reduction in Alzheimer's (not once it's started however) and reduction in macular degeneration. Other potential advantages are being discussed even today. The one major concern is increased risk of breast cancer and that seems to be limited to dosing when progesterone is used for half the month rather than daily progesterone which has no such increase risk. Please check-out this article "What are
'designer estrogens'?" from Judith A. Norris, Ob-Gyn, RNP, |
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| Q: Recently I was diagnosed with osteoporosis in my hips, with a score of -1, and osteopenia, in my spine. I am only 30 years of age, and would like to have a child in the next few years. My Ob Gyn believes my osteoporosis is from poor nutrition at an earlier age (in my later teen years). I am also on Fosamax and 1500 mg of calcium per day. When I decide to try to conceive, what advice can you give me? |
| A: A T score of
-1 is indicative of mild osteopenia, not osteoporosis. The two
possibilities are bone loss and bone never gained. Presuming your problem
is bone never gained, it can be poor nutrition or inadequate absorption
for a variety of reasons. Fosamax has not been approved for premenopausal use with the exception of steroid induced osteoporosis. Even with that, the recommended dose of Calcium while on Fosamax is 1000 mg. per day in divided doses along with adequate Vitamin D. Adequate estrogen or birth control pills (to give a sustained, adequate level of estrogen) may be as good or better than Fosamax in the premenopausal period. Give the discrepancies noted above, an osteoporosis specialist may need to be consulted for a full evaluation. With osteoporosis in the hip, fractures are indeed possible with or without pregnancy. If pregnancy is contemplated, a rheumatologist may need to consult with your obstetrician. |
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Q: I am 56 years old and last December I was diagnosed with DCIS and had surgery to remove the cancer. As a follow-up, I completed 30 rounds of radiation treatment. For several years my GYN had been encouraging me to take HRT but I had declined. My mother died from Breast Cancer and my sister had two breasts removed. I have had a several cyst aspirations. Because of this history, I chose to bypass HRT. I just had a bone density test done and have been diagnosed with Osteoporosis. I have a -1.6 femur neck and -2.6 in the lower back. My GYN wanted to put me on Evista but suggested I speak with my Radiation Oncologist. When I called by GYN back to tell him that she would prefer Fosamax, he was a little huffy about it and said it wouldn't give me the cardio benefit Evista would. He then decided that the would put me on Actonel instead of Fosamax because it wouldn't cause as much of an irritation to the stomach and esophagus. Why would my GYN be so against anything but Evista? Why is Actonel better than Fosamax, and should I be checking somewhere else? If you can help I would greatly appreciate it. |
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A: You
have a very complex problem. It sounds as if there is a genetic
issue in your family. Have you undergone genetic testing for the
breast cancer gene? These are the issues I hope I can clarify.
Firstly, Evista is FDA approved for the prevention and treatment of
osteoporosis. It has excellent fracture reduction data for the spine
where you have osteoporosis. It also has good safety data from the
MORE Trial supporting a reduction in breast cancer incidence in those
women who used Evista in the trial. As such the NCI-NIH is
supporting a trial comparing the efficacy of Tamoxifen and Evista in
reducing breast cancer incidence. This trial is called the STARR
Trial and information will be available in about 2007. Therefore, to
date, we don't have the final answer on Evista and Breast Cancer.
Evista appears to reduce lipids in a cardioprotective direction, but we
have yet to prove that it actually reduces the incidence of heart attack.
However, it does provide this extra benefit over the bisphosphonates (fosamax,
Actonel). Fosamax and Actonel are similar medications. Proctor
and Gamble, in their phase three clinical trial was able to show a reduced
incidence in GI side effects compared to Fosamax in their clinical trials.
Of course these were different studies so I'm not sure you can compare
them. All in all your choices for bone management are Evista or one
of the bisphosphonates. Of course you need to look at lifestyle
issues and correct risk factors you can control.
This question answered by R. Wayne Whitted, MD, OBGYN.net Editorial Advisor. |
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Q:
What is the purpose and after effects of using Actonel. What
are the dangers of long term usage?
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| A: Actonel is used to treat osteoporosis and osteopenia. Most people have no adverse effects. The medication has been used for a few years so long term "dangers" are, at this point, unknown. |
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| Q: I am 65 years old and went through menopause at 52. I was diagnosed with Breast Cancer in 1998 and have been taking Tamoxifin. I have had two dexa scans, one in 1999 and one in 2000. There has been no change in a year. My doctor is asking me if I want to take Fosomax. I have a problem with some acid reflux and wonder if the meds would make that worse. I take 600 mg of calcium and a soy product. I walk, swim and ride a bike. I would rather not take any more meds, however I don't want a broken bone. Can you help me decide if it is important at this time to begin the Fosomax? |
| A: It would be important to know the results of your two bone density studies. I would suggest a total of 1500 mg of calcium daily. In addition, if you live in the northern United States, making sure you get Vitamin D-this is contained in most multivitamins. Taking soy in large doses is controversial. There is conflicting evidence concerning bone protection, and some real question concerning the risk or safety of phytoestrogens in breast cancer survivors. |
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| Q: I have recently had a bone density test that showed -1.0 in the spine and -1.6 in the hip. I am 59. No periods for 7 years. I am small frame (5'3" and 120 lbs), caucasian, never smoked or drank. Not noticed osteoporosis in other women in the family. Taking 25 mcg levoxyl for the last 3 years. I have never taken hormones. I was encouraged to, but felt that I had no symptoms to address, therefore it did not seem prudent to take them and put myself at risk for other problems. I have taken calcium tablets for 15 years (now 1200 mg per day), a vitamin each day for 20 years and enjoy great health. I am quite active but my 3 or 4 walks weekly are really strolls rather than brisk walking. Now my doctor wants me to take Fosamax "to prevent further bone loss". My question -- is there any natural way for me to increase bone density? Are those figures of -1.0 and -1.6 not really bad for a woman my age? (I have read that the standards are compared with a 30 year old women.) Since I am 7 years into menopause would I have already lost the bulk of bone density since I read that most of that occurs early? I would prefer some other prudent, logical option other than Fosamax but would consider medication if that really seemed necessary. Thank you for your advice. |
| A: You may be correct in that you have passed the most rapid period of bone loss already. Also, that osteoporosis (or osteopenia) is a comparison of your bone mass with the expected peak bone mass, i.e. a person in the 30's. The bone density test (DEXA) is a static measure of bone mass at given point in time, and doesn't reflect failure to reach peak bone mass vs. having reached it and lost it. It is not unreasonable to repeat the study in 2 years, assuming that you do not have other medical risk factors for osteoporosis or to consider the use of estrogen and progestins (if appropriate) or Evista (raloxifene). I would be a little concerned about Fosamax in that the length of time it is effective is unknown and it may be best to not use it for relatively little bone loss as opposed to an older individual where a "hit" of bone increase may be more important in reducing fractures. |
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| Q: I was recently diagnosed with osteopenia. I am a 57 year old woman who has been postmenopausal for 3 years. I chose not to take estrogen replacement as my mother had breast cancer. I am quite physically active, always drank a lot of milk etc and there is no history of osteoporosis in my family. My T-score is 1.24 spine and +.22 hip. I have had a history of GERD and have heard that Fosamax causes esophageal problems. Do you think if I take 1500 mg of calcium and Evista daily, it should help me restore bone mass? |
| A: I am a little confused by your numbers. I assume your spine is -1.24. If your hip as a T-score of + 0.22, congratulations! I would agree that Evista is appropriate. In fact, there is data to suggest the reduction in Estrogen Receptor breast cancers diagnosed while on Evista, answering another of your concerns. |
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| Q: Please explain how to properly advise a patient about her hip T-score. I have heard it said that the TOTAL T-score is the most meaningful. I have a patient that has T-scores of -3.35 at the neck, and -1.02 at the trochanter, and -0.65 at the intertrochanter, for a total of -1.03. Does she have osteoporosis and is therefore at risk for fracture or does she barely have osteopenia? |
| A: The World Health Organization defines osteoporosis as T-score of >2.5 SD below the young adult mean a the femoral neck. I would be very concerned about the T-score at the femoral neck you describe. |
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| Q: I am no longer on Premarin after having taken it for 18 years (surgical menopause). I do have some osteoarthritis as well as osteopenia. My doctor put me on Fosamax (5 mg.) for prevention of osteoporosis. I have been experiencing more muscle and bone pain and am wondering whether it could be due to the Fosamax as well as no longer being on Premarin. I have read that hormone replacement therapy often relieves symptoms of rheumatoid arthritis and assume it would also help with osteoarthritis. Could you comment, please? I am seriously considering Premarin again and discontinuing Fosamax? |
| A: The symptoms you report are possible with Fosamax. You may also feel better while taking estrogen. It appears that the beneficial effects of estrogen upon bone mass may wane with time, and if so, changing to Fosamax might be a very good idea. You might try the weekly 35 mg dose to see if you have fewer side effects, or try risedronate (Actonel). I suggest you discuss this with your physician. |
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| Q: I am 61 years of age and have been diagnosed with postmenopausal osteoporosis. my doctor advised me to take actonel, the new drug on the market. I want to use my estrogen patch as well. Is there any evidence that says if actonel and ERT, taken together are more beneficial than either of them alone? Or is this actually harmful to do. I know that studies have shown that fosamax and ERT taken together have demonstrated better response. Also how do you compare the bone building effect of actonel versus fosamax? I know about gastrointestinal discomfort caused by Fosamax but as far as osteoporosis alone, will one surpass the other or are they both about the same? |
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A: If
you are on estrogen and in spite of that, losing bone mass, then adding a
drug
like Actonel might make sense, if other causes for continued bone loss
are
ruled out. There is some evidence that estrogen and Fosamax (and probably
Actonel) together are better than either alone. This does not mean a combination
is appropriate for most women. Actonel may be less harsh in its effects on the upper gastrointestinal tract. You might want to consider weekly therapy to decrease the exposure to the esophagus. This is approved for Fosamax and many of our colleagues are using the 30 mg dose of Actonel on a weekly basis. |
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| Q: I am a 50 year old female diagnosed as menopausal and with osteopenia. My doctor and I decided on Evista as a treatment, but after reading the side effect warnings that came with the prescription, I am reluctant to take it. Since this is a relatively new medication, do you know of any long-term users that have had success without the side effects? Also I bought a bone health supplement to take in the meantime. Can I use this instead of Evista to prevent any more bone loss? |
| A: I am not sure what is in a "bone health supplement." I would suggest at the very minimum, at least 1200 to 1500 mg of calcium daily, best if in your diet, and use a supplement if necessary. A multivitamin would give you Vitamin D 400 units. I would be wary of any promoted supplement as many contain calcium from bone meal, oyster shell, and dolomite, and may contain lead and other heavy metals as contaminants. Evista is an appropriate drug for protection of bone mass, does reduce fractures, and has a cost and side effects. I suggest a careful discussion with your doctor to decide on how low your bone mass is, what your risks for fractures may be, and the possibility of other causes of low bone mass, including lifestyle, other drugs, and other illnesses. |
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| Q: Could you please tell me what are the side effects of Fosamax? |
| A: The major side effects of Fosamax are related to the upper gastrointestinal tract, especially the esophagus. They may include heartburn and gastritis, and less commonly, muscle pain. The best course is to take Fosamax with a glass of plain water, and remain upright for at least 30 minutes. The medication should be taken the first thing in the morning and only with water. The once a week dosing may help to reduce side effects and is far more convenient than daily dosing. It works just as well. |
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| Q: I am fourteen years old, and I have osteoporosis, having been born with it. I have been reading into it recently, and have been noticing that it usually occurs in older women. I was wondering is it abnormal for me to have osteoporosis at this age? Will it get worse when I'm older? Thanks a bunch. |
| A: I need a whole lot more information to answer your question. You are correct that osteoporosis is uncommon in 14 year olds. An exception may be in those who have received prolonged or repeated courses of cortisone or prednisone. Talk to your doctor. |
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| Q: My 64 year old mother was recently diagnosed with osteoporosis in her neck and was prescribed a daily dose of Fosamax. She took the medication as directed and by the 2nd day experienced an extreme headache, nausea, dizziness, and while walking out to get her mail she passed out, awaking covered in sweat. She takes premarin and synthroid, some information on Fosamax says not to take with HRT. Is this a side effect of this drug? |
| A: Nausea may be a side effect with Fosamax, but I am not sure I can explain the other symptoms. It is not dangerous to take Fosamax with Premarin, but the question would be...why? There is some evidence that those who experience documented bone loss in spite of estrogen many benefit from the combination, but for most individuals using estrogen and other drugs for osteoporosis at the same time does not make sense. I would suggest appropriate dietary calcium and Vitamin D, exercise, and avoidance of tobacco, excessive amounts of caffeine and alcohol. |
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| Q: I am a 59 year old female who began taking Didronel at age 50 then was switched to Fosamax (10 mg. daily). I have been taking Fosamax along with 1500 mg. calcium daily for approximately 4 years. During these years, I have lost an over an inch in height, have had a wrist fracture that did not heal properly and had to be followed up with surgery. The joint is irreparable in my wrist, so I am in constant pain. Also have had multiple fractures in my foot and toes. I know have learned that the bone loss in my spine had accelerated. My physician has mentioned changing to Actonel, 5 mg. daily or remaining on Fosamax but changing the Fosamax dosage to 20mg. daily. What is the difference between the Actonel and the Fosamax treatments? Is one superior to the other? I am having a difficult time discerning the information on both products. |
| A: Your question is a complex one. Osteoporosis does not affect joints and the pain and possibly poor healing may reflect the nature of the traumatic fracture. Both Fosamax and Actonel are effective drugs for osteoporosis. I see no need to change, and would say, there is more data on Fosamax as it has been available for a longer time. I am not sure that increasing the dose to 20 mg per day has any basis. I would be concerned about secondary causes of osteoporosis, and there are many, to explain your condition. I would suggest talking to your physician for further evaluation. |
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| Q: I just turned 45 and went for my physical and was measured at 5 ft 3 inches. As of my last physical (1998) I was still 5'4. I even had my son re-measure my height when I got home and sure enough I was 5'3. What do you suggest? |
| A: It has been stated that a documented loss of over 1.5 inches in adult height is associated the finding of vertebral osteoporosis, heights are surprisingly difficult to measure. It requires careful and consistent measurements with a stable platform and a devise absolutely parallel to the floor to mark the top of the head. Because of fatigue during the day of the muscles extending the spine, morning and evening measurements may vary. At age 45, it is unlikely that you are rapidly shrinking. I would suggest assessment for any medical factors in your specific case that may accelerate bone loss, and would be careful to obtain adequate calcium and Vitamin D. |
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| Q: I have just had a bone density test and it was returned showing that I have some slight osteopenia. I am 66 years old, had a hysterectomy in 1974. I take premarin.625 and daily calcium, Calcet with Vit. D 500mg. I did not take calcium tablets for a lot of years, but I have continued taking Premarin for 30 days of the month. I have tried to go off Premarin, did not feel good. I have not taken testosterone for about 5 or 6 years. I will talk to my doctor about the fact that their is supposed to be hair loss with taking Premarin. In all the years that I have taken it, I never read anywhere that this condition would occur. Is this a true side effect and how severe is it? |
| A: "Mild osteopenia" may not reflect ongoing bone loss and I would need to know all the results of your bone density testing to make a comment. If you have had a prior study for comparison, done on the same densitometer, it would be helpful to compare your bone mass over time. I think you are confusing testosterone with progesterone (or progestins) in that progestational agents are appropriate if you have not had a hysterectomy. This is to protect the uterine lining, not the bones. Testosterone is another issue. Osteopenia reflects less than ideal bone mass and may result from many factors, of which lifetime poor calcium intake is one. Over the age of 65, 1500 mg of calcium daily is recommended. It is not too late to start, but calcium alone is not enough. You need 400 to 800 units of Vitamin D, depending on how much sunlight you get, and exercise. Also, I would discuss any medications and other medical problems with your physician, as they may impact your bone density, and risk of fractures. |
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| Q: I am a RN and a student midwife interested in the effects of pregnancy on bone mineral density. Are you aware of any research into links between parity/breastfeeding/nutrition in pregnancy/hyperemesis gravidarum/heparin use in pregnancy? I feel midwives are in an ideal position to educate women about bone health, but have no specific information to work with. |
| A: I recall seeing some studies regarding some bone loss during lactation, probably because it is often a hypoestrogenic state. I applaud your interest in getting information to pregnant and nursing women. The recommended calcium intake would be 1200-1500 mg daily. The prenatal vitamin should contain 400 units of Vitamin D. Also, it is a good time to stress the importance of lifestyle choices, especially avoidance of smoking. |
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| Q: This week I was put on actenol and folic acid since then my stool has been green is this a side effect of either of these drugs? |
| A: Cannot think of a connection there. Sorry. |
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| Q: I have been prescribed Activella. Does this help prevent bone loss, or would Fosamax be better? I have few symptoms of hot flashes, etc. - am primarily concerned about preventing Osteoporosis. Also, I read that one of the side effects is hair loss, and I certainly can't afford to loose any more hair. |
| A: Activella is a combined continuous estrogen/progestin. It contains norethindrone acetate as the progestin. There is some evidence that norethindrone acetate augments the protective effects of estrogen on bone. If you are experiencing hot flashes and do not have a reason why estrogen would be ill-advised, Activella would be a good choice for bone protection and relief of symptoms. |
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| Q: Is it advisable to be placed on estrogen replacement therapy during premenopausal phase? Female, age 44, with history of mother, grandmother osteoporosis. |
| A: If you are premenopausal, by definition, you are making estrogen. I would look to other causes of osteoporosis in a 44 year old. |
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**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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