osteoporosis, women's health, obstetrics, gynecology, infertility, pregnancy, hysterectomy, fibroids, and more

 

Print this page
OBGYN.net Advertisement
Osteoporosis Ask The Expert

Osteoporosis Ask The Expert
Questions this month have been answered by:

Harvey S. Marchbein, MD, FACOG, FACS, 
OBGYN.net Osteoporosis Chairman and Editorial Advisor

and

Michael Kleerekoper, MB, BS, FACP, FACE, OBGYN.net Editorial Advisor

Q: I am a student midwife with a keen interest in osteoporosis. Are you aware of any literature investigating links between pregnancy and osteoporosis? I am particularly interested regarding breastfeeding/parity/nutrition in pregnancy/hyperemesis gravidarum?

A:  There are many answers to your question. 

1)There is a rare complication of otherwise normal pregnancy called “osteoporosis of pregnancy”. It presents with back pain and vertebral fractures during pregnancy. It appears to be a short-lived condition in that the osteoporosis does not progress after pregnancy. Unfortunately the problems caused by the initial fractures persist. The cause of this condition is unknown. It is unclear whether it is aggravated by subsequent pregnancy because, not surprisingly, women who have experienced this once are reluctant to chance experiencing it again. Remember this is a rare complication of pregnancy. 

2) Many epidemiologic studies have addressed the issue of a link between pregnancy, breast-feeding and osteoporosis but there is no consensus opinion. Pregnancy and lactation are periods of negative calcium balance for the mother as she is nourishing her baby from her own body stores of calcium. This results in transient loss of bone much of which is regained after weaning. Some have suggested that this contributes to osteoporosis later in life but as I noted, there are conflicting opinions on this. 

3) One thing on which everyone agrees is that pregnant and nursing women should take in more calcium, at least 1500 – 2500 mg per day from diet and supplements. Vitamin D 400 units should also be taken daily. I am not aware of specific studies relating hyperemesis gravidarum to osteoporosis but this is not good for the health of mother or baby. As the hyperemesis comes under control it would be wise to make sure that intake of vitamin D and calcium is maintained.
 
Q:  I'm 21 years old I found out I have endometriosis. I have had laparoscopy twice to determine it. The doctor had suggested that I take a shot called lupron depot. I was on the shot for approximately nine months. My family care doctor wanted me to have a bone density test done, it showed that I had  12% bone loss which was considered osteopenia. I don't know the other results of the testing. Also I for about 6 months I was taking a shot called depo-provera three months per a shot. Should I be taking one of those medications for bone loss? Is there anything you can do besides, taking calcium pills which upset my stomach? Thank you for any information, I greatly appreciate it.
A: Your doctor may have been misinformed when he told you that you had any bone loss at all. Since your bone density had not previously been measured,  it is not possible to know whether you have ever had any more bone than you now have. It's a matter of "Never Gained" bone as opposed to "Lost" bone. Doing bone density tests in 21 year old women has limited value since you can still be accumulating bone and probably will do so until somewhere between 25 and 35. Lupron depot and depo-Provera may have some bad effects on bones but not all the answers are in yet. Some doctors are using a combination of estrogen, progesterone or both, with the lupron which does protect the skeleton. For now I would focus on your endometriosis which is clearly causing you problems. You have already had one bone density test and you should have a repeat one a year after that first one. In all likelihood you will get peace of mind when the result comes back that you have not lost any bone during the year. Regarding calcium tablets upsetting your stomach, try a diet rich in calcium - ice cream, milk, chocolate milk, cheese, yogurt, lots of good stuff. The tablets are for those who truly can't get calcium from their diet.  
 
Q: I recently had my first baby, at 38.  Several weeks into the pregnancy, I was tested for ACA (due to 2 previous miscarriages), and was shown to have elevated levels of anticardiolipids (>150 IGM), although I have no indications of autoimmune disease such as arthritis, thrombosis, etc.  I took heparin and low-dose aspirin for the duration, and delivered (induction followed by c-section) a healthy baby a few days after term.  Pathology on the placenta showed infraction (explaining the deteriorated condition of the placenta and heart decelerations during contractions).  This history indicates that heparin would be indicated in any subsequent pregnancy.  A bone density test shows osteopenia (-1.55 & -1.60).  My mother has osteoporosis.  I am trying to decide whether to pursue another pregnancy, and I don't have a clear sense of the risk posed by using the heparin.  Can you shed some insight on the extent & magnitude of risk associated with heparin use and osteoporosis?

A:  There isn't much documented evidence to put any numbers on the risk to your bone health from heparin. My impression from more than 20 years in practice and from reading about this is that the effects are quite small. Don't worry for now about your bone density test results. Most experts agree that healthy premenopausal women don't need and shouldn't have a bone density test. Because of the way the T score values are derived, 16% of all perfectly healthy, normal premenopausal women will fit the criterion for having "osteopenia". Despite this label they are still perfectly healthy and normal. The time for you to worry about your bones is during pregnancy and breast feeding where you need extra calcium, and as you go through menopause where you should consider hormone therapy.
 
Q:  I am a 66yr. old woman whose recent bone scan of the hip had a t-score of -4 ( I was so surprised I don't remember the decimal). The dr. prescribed 10 mm. Fosamax, daily.  I have been on premarin for about 20 yrs., exercise, lift weights, and take 1200 cal.  My druggist told me about the weekly dose.  Is it as effective?  Also, how much coffee is considered detrimental?
A:  The weekly dose of Fosamax of 70 mg is every bit as effective as 10 mg once a day. You must still take it on an empty stomach with a full glass of water and nothing to eat or drink for the next 30-45 minutes and then you should eat breakfast. That 30-45 minute wait would be a good time to get in your daily exercise.

There is no firm data on how much coffee is too much. From the bones point of view it doesn't matter too much at all. For the rest of your health "too much of a good thing is no good for anybody". I would limit yourself to 2-3 cups a day but there is as much bias as evidence in that limit.

Your bone density numbers worry me quite a bit. If you have been faithfully taking your Premarin (what dose?) for 20 years or so, the T score of -4 something suggests that there might be a secondary cause of osteoporosis. Fosamax will almost certainly be effective but you should check with your doctor about causes for osteoporosis other than being a postmenopausal woman.
 

Q: I am a fifty-three-year old menopausal woman with osteopenia. I have been taking Actonel (5 mg per day ) for several months. Recently I read that a Dr. Epstein at the U. of Illionis (I think) believes Evista should be taken off the market because it increases the risk of ovarian cancer. From your responses to other women, I gather that you have no such reservations about the drug. Is that correct?

In my last conversation with my doctor, he suggested I take Evista and Actonel together--to increase the protection against osteoporosis. This is the first I've heard about combining these drugs and so far have not started Evista.

I'm generally in good health but should mention that I have a small thyroid nodule (benign) and have hypoglycemia (it didn't register until late in the five-hour glucose tolerance test). Because my mother had breast cancer, my doctor did not prescribe HRT for me. I am still seriously considering taking Evista (for possible protection of breast and heart), but would like your opinion before I make my decision. Specifically, if I take Evista, can it be combined with Actonel? Or would it be better to drop the Actonel?

One more question: Do I run any risks if I jog on a treadmill (not on pavement)? Lately, I have been combining walking on a treadmill with using a stair climbing machine, but before I got my osteopenia diagnosis I did some recreational jogging and I now miss that activity.

Thank you so much for any advice you can give.

A:  That's a lot to answer. There are no studies about combining Actonel with Evista and it doesn't make much sense. The potential added benefit is small, the added cost high, and you increase the potential to have side effects from two drugs rather than just one. For the bones Actonel is probably the more potent drug (although direct head-to-head studies have not been reported). Evista may decrease your risk of breast cancer but it is not approved by the Food and Drug Administration (FDA) for that  purpose and studies about Evista and breast cancer protection are ongoing. Tamoxifen is FDA approved for breast cancer protection. There's nothing about an "osteopenia" diagnosis that should limit your recreational jogging.
 
Q: I am a 44 year old female that has advanced osteoporosis which was discovered 10 years ago.  I have increased my weight bearing exercise as much as possible and increased calcium, etc.  But only got some bone density increase in my spine none in my hip.  I am still regularly menstruating.  I just went on fosamax 5 weeks ago on the 70 mg. dose once a week.  I am having upper jaw pain ever since the day I started the fosamax.  I gained 4-5 lbs. that first week and have gas & bloating.  I know that the gas & bloating are normal side effects but what about the jaw pain? Should I discontinue?  Would a smaller dose 10 mg. a day 7 days be better? What causes this jaw pain?
A:  Healthy, regularly menstruating 44 year old women do not get osteoporosis - let alone advanced osteoporosis, unless there is something very unusual going on. I would have serious doubts about the diagnosis and the need for specific treatment. I know of no association between Fosamax and jaw pain.
 
Q:  I am taking weekly dosage of Fosamax - is there any possibility that this medication can cause aching in the lower back and hips?  I am a 52 year old female.
A:  There are uncommon reports of Fosamax being associated with joint pains but I am not convinced. I would suggest you stop your Fosamax for a few weeks (no harm will happen to you) and see if the pains go away. If they don't get better it was probably not caused by the Fosamax, and you should find out what the cause might be. Even if they do go away when you stop Fosamax you can't be sure that was the cause. You would need to re-start Fosamax and see if the pains come back. As I said, I doubt the two are related.
 
Q: I was diagnosed with RA 7 years ago, been taking prednisone, the highest dosage was 30 mg and been up and down since then. I had Dexa study about a month ago and was told that I had an early osteoporosis, so was put on Vioxx 25mg and Fosamax 70 mg, and I'm also taking Plaquenil. My Rheumatologist suggested a Remicade therapy, but I'm concerned since I'm prone to infection and I'm scared because of the side effects. I have to pay $400+ for every infusion, and I cannot afford that. I need your advice to what is the best to work this out. I've been suffering all those years, sometimes it's mild but sometimes it's debilitating.
A: I am not an expert in RA and suggest you follow your rheumatologist's advice about Remicade. While you are on prednisone, Fosamax is an appropriate and important drug to be taking.
 
Q: Please send me as much information as you can on "actenol" and the major side effects. I have been on Foxamax (causing closing of throat), Now I am on Miacalcin and Caltrate plus D. I have had three cracked ribs and the pain in horrendous. The doctor suggested actenol, but I have a very bad stomach and I have had heart bypass. Please advice. Thank you.
A:  Actonel has very few side effects when you take it properly - first thing in the morning on an empty stomach with a full glass of water. Nothing else to eat or drink for 30 minutes and don't lie down during that 30 minutes. Then you should eat breakfast.
 
Q: I am 74 years old and have never taken ERT.  However, at my recent annual physical my doctor said I should start taking Prempro 0.625 to prevent  Osteoporosis. He said I have Osteopenia.  My only bone density test was in l997.  After reading the information that came with the prescription I am hesitant to take the pills.  My attitude is "if it ain't broke, don't fix it."  Would I be out of line to request a new bone density test to see what has happened in the last 3 1/2 years before starting the ERT.  I don't like the sound of all the possible side effects of the pill.  I would appreciate your opinion.  Thank you.
A:  Prempro is good and safe but you would be wise to have a repeat bone density test before starting it. If the repeat test shows your bones are stable you might not need therapy.
 
Q: My 75 year old mother is on a treatment plan of Fosamax for 10 months.  She has been taking the drug for about 6 months.  In the last month she has been suffering from extremely painful toes.  The tips of her toes are so sore she can't wear shoes and has trouble walking.  Do you think this could be related to the Fosamax?  I was worried about her taking the drug because she has acid reflux, esophagus problems but she hasn't complained about any problem in that area.  She has a high tolerance for pain so her feet must be intensely sore for her to mention it.  I appreciate any information you can give me. Thanks.
A: I am not aware of any association between painful toes and Fosamax. I am glad she is not having any esophageal or other problems with Fosamax. She should see her doctor about her toes.
 
Q: I would like to know a general program with exercise to prevent osteoporosis and fractures?
A:  Total inactivity, such as paralysis, results in rapid bone loss, and any physical activity slows down bone loss. However, no studies have demonstrated unequivocally that any specific exercise program slows down bone loss to a point where no other therapy is needed to prevent osteoporosis and fractures. Exercise is good for you for many reasons. From a fractures point of view, if you can maintain your muscle strength and balance you will minimize your risk of falling and be better able to protect yourself from injury if you should fall.
 
Q: Please send me as much information as you can on "actenol" and the major side effects. I have been on Fosamax (causing closing of throat). Now I am on Miacalcin and Caltrate plus D. I have had three cracked ribs and the pain in horrendous. The doctor suggested actenol, but I have a very bad stomach and I have had heart bypass. Please advice. Thank you.
A: In general Actonel is safe, effective, and well tolerated. If you have rib fractures while taking an effective drug like Fosamax it is important that you see a specialist to see if something might be going on other than osteoporosis.
 
Q: I've been taking Actenol since last Christmas.  I thought it would be a good present for myself.  I haven't really noticed any of the side effects that were listed.  However, recently I have noticed a weird one.  Every day one of my ears will get red and hot.  It lasts for about an hour and goes away.  It is so annoying and embarrassing.  Do you think this has anything to do with the Actenol?  I've started taking it every other day.  Is this ok?
A:  I can find no reporting of this very interesting complaint nor can I give any logical answer as to why it would be on one ear and last one hour. I would suggest calling the company (Proctor and Gamble AND Aventis) and see if anyone has reported this. As to taking it every other day, the FDA only has it approved for daily use at this time.
 
Q: How much testing and side effect observations have been made on "younger" women?  I am 43 and am more active than most women of any age. I experienced many side effects from Fosamax.  I went into this believing that there were NO side effects except the chance of stomach and esophagus irritation if not taken properly.  After wondering what was wrong with me, I stopped the drug for a few days and felt like I did 2 months ago.
A:  These drugs go through extensive testing in many age categories as well as both sexes. As with all medications, some people have more side effects than others. Yours is not a typical story and cannot be related to age based upon previous information and studies.
 
Q:  Could you summarize the data on the effectiveness of HRT and also that of OCP for the treatment of osteoporosis in young women associated with hypothalamic amenorrhea?
A: The summary is best found in the few journal articles I refer you to for further analysis. There appears to be little consensus on this topic. 

Bone mineralization, hypothalamic amenorrhea, and sex steroid therapy in female adolescents and young adults.
J Pediatr 1995 May;126(5 Pt 1):683-9    (ISSN: 0022-3476)
Hergenroeder AC Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston 77030-2399, USA. Conjugated estrogen, in doses that improve bone mineralization in postmenopausal women and in combination with medroxyprogesterone, has not been shown to improve BMD in young women with hypothalamic amenorrhea. The role of orally administered medroxyprogesterone at a dose of 10 mg per day, 10 days per month, in improving BMD in teenage girls with hypothalamic amenorrhea or oligomenorrhea remains to be established.  Treatment with OCP may have a beneficial effect on BMD in young women with hypothalamic amenorrhea, but this has not been established in a double-masked, randomized, controlled trial. Doing a double-masked trial using OCP will be difficult because estrogen-deficient subjects treated with OCP will be likely to have menstrual bleeding, whereas those treated with placebo will not. In addition, the risk of pregnancy in a sexually active subject, who does not know whether she is receiving OCP, is too great for some subjects.

Exercise and female adolescents: effects on the reproductive and skeletal systems.
J Am Med Womens Assoc 1999 Summer;54(3):115-20, 138    (ISSN: 0098-8421)
Warren MP; Stiehl AL Department of Obstetrics and Gynecology, Columbia University College of Physicians and Surgeons, New York City, USA. The most serious aspect of hypoestrogenism is its effect on bone growth of elite athletes; those with delayed menarche show a higher incidence of scoliosis, stress fractures, and osteopenia than do girls with normal menarche. The higher incidence of bone problems may be linked to a lower rate of bone accretion, which may lead to lower peak bone mass. Unfortunately, the loss may be irreversible. In addition to decreasing training and gaining weight, treatment for menarcheal delay may include oral contraceptive therapy.

Estrogen replacement therapy in the management of osteopenia related to eating disorders.
Ann N Y Acad Sci 2000;900:416-21    (ISSN: 0077-8923)
Bruni V; Dei M; Vicini I; Beninato L; Magnani L Department of Obstetrics and Gynecology, University of Florence Medical School, Italy. Data on the impact of oral contraceptive use on bone mineral density are controversial. We particularly discuss the question of long-term treatment with 20 micrograms ethinyl estradiol pills on peak bone mass acquisition during adolescence.

Effects on bone of oral hormone replacement therapy initiated 2 years after ovariectomy in young adult monkeys.
Bone 1998 Oct;23(4):361-6    (ISSN: 8756-3282)
Jayo MJ; Register TC; Carlson CS Department of Pathology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1040, USA, mjayo@wfubmc.edu. Oral estrogen replacement with CEE at doses similar to those taken by women leads to significantly increased BMC and BMD in monkeys, even when therapy is begun 2 years after ovariectomy. Most of the increase occurred during the first 16 months of treatment. The addition of MPA to the CEE regimen provided no additional benefit.
 
Q:  I am 32 weeks pregnant and about two weeks ago I started experiencing extreme pain in my knees and an MRI indicated aseptic bone necrosis.  I am wondering if this is due to my pregnancy, not enough calcium, osteoporosis, or could it be linked to my Graves Disease?  I am very worried about the future and my doctors mentioned vioxx after the birth of the baby.  Can I take this - does it help - can I take it if I am breastfeeding?  Any advice, information at all would be greatly appreciated.
A: Osteonecrosis (avascular necrosis, aseptic necrosis or subchondral avascular necrosis) is not a specific disease entity but the final common pathway of a number of conditions leading to bone death. The main predisposing factors (trauma, glucocorticosteroids, alcoholism and connective tissue disorders) should be carefully sought, but osteonecrosis can also be idiopathic (unknown) in origin. Its most common localization is to the femoral head, followed by the humeral head, the knee and the small bones of the wrist and foot. NSAIDs such as Vioxx are an option but some patients ultimately need surgery. As far as the Vioxx relating to breast feeding, safety of this drug is unknown in this regard and should be taken with caution. After delivery, you may wish to contact the manufacturer and learn of the experience data gained with respect to breast feeding mothers to date.
 
Q: Could you please tell me the difference between Opteopenia and Osteoporis? My test results were lumbar spine -2.27 and left hip -2.47.  What do I have?
A:  The simple answer is that you have severe osteopenia (verging on osteoporosis in the hip) and deserve treatment to prevent osteoporosis.  Please review this previous answer from Dr. Burstein: http://www.obgyn.net/osteo/ate_0201.htm#Question10
 
Q: My mothers arthritis doctor wants to change her from Fosomax to Actenol. Can you tell me, if she takes Actenol, can she eat and take it or does she
have to take it on an empty stomach?
A:  The instructions for taking Actonel and Fosamax are exactly the same. The only thing to be aware of is that Fosamax is now approved for once a week dosing whereas Actonel has not yet been approved for that scheduling.
 
Q:  I am taking about 2000 mg of calcium daily for my osteoporosis.  Does my daily intake of vitamin D need to be increased over the "daily value" to help the absorption of the increased calcium?  I also take fosamax.
A:  The recommended amount of Calcium supplementation with osteoporosis is 1000 mg for patients taking anti-resorptive medications such as Fosamax or Actonel. The Calcium should be in doses no greater than 500-600 mg per dose. The recommended amount of Vitamin D is 400 IU per day, but for patients over 65, due to decreased absorption, the recommended amount increases to 800 IU. Doses above 2000 mg may cause problems including kidney stones and should be discussed with your doctor.
 
Q: I have heard that Lipitor has been found useful in cases of osteoporosis. Any references?
A:  This was answered in a previous Ask the Expert question please see http://www.obgyn.net/osteo/ate_1299.htm#Question2.
 
Q: I am a 62 year old caucasian female who was recently diagnosed with osteopenia. My T score was -1.8 in the lumbar spine and -1.4 in the neck
of the left femur. While my remaining scores were in the minus column they were not highlighted by the reading physician. I currently take 1300 mg of hydroxyapetite combination, .625 Premarin, .1MG synthroid, Folic acid, and Vitamein E. I have been doing weight bearing exercises regularly for the last 20 years and weight training irregularly for the last five years. Blood work indicates:   T3 uptake 25, T4  15.4, FTI (17) 3.9, TSH .20. I understand that the above indicates that my thyroid dosage is a little high.

I am wondering if a small reduction in the synthroid, which I am taking for a thyroid cyst and resulting hypothyroidism will slow the progression of the osteopenia and ultimately osteoporosis. Also, is there anything more that I can be doing? My primary care physician was unimpressed with any of the above and told me I was just fine.
A:  With your bone density we come to the old story of "loss" vs. "never gained". We don't know if your -1.8 has been steady for 15 years or if it has been from a recent decline. As far as your Premarin goes, I'm presuming you've had a hysterectomy, or else you would also be on a progestational agent. Very recent evidence relates that adequate Vitamin C may also be helpful in bone metabolism as well as adequate potassium and protein intake. Now to the Synthroid. In our labs, TSH of 0.2 would be low, indicating a hyperthyroid state. This would seem to indicate a need to lower the Synthroid if a repeat blood level were to confirm the TSH. Although thyroid abnormalities can be associated with bone loss, this is not necessarily the case with you. If the bone density is repeated in 2 years and shows no change, you are doing fine. If there is a significant change, other medications such as bisphosphonates may be in order. A test that can be done right now is a serum NTx. If it's high, it indicates elevated bone turnover and the need for more immediate changes in therapy. Many rheumatologists would be osteoporosis experts as would many gynecologists who have taken an interest in this field of study.
 
Q: What are the ingredients in the medication Didrocal? Is it given for osteoporosis?
A:  In that a search of several sources did not show Didrocal, I presume you may have meant Didronel. This is etidronate and is taken daily for two weeks followed by 11 weeks off. It is the precursor of the bisphosphonates we use today, Fosamax and Actonel.
 
Q: I was wondering why osteo affects more older women than anyone else?  Is there anything women in this age group can do to more effectively prevent this disease? Thank you very much.
A:  Estrogen has been shown to be protective of bone mass. When the menopause comes and estrogen decreases, the protective effect also decreases. As in the archives of the Osteoporosis Ask the Expert section will attest to, adequate calcium intake along with Vitamin D (especially important prior to age 30 but also after), weight bearing exercise AND avoidance of caffeine, smoking and excessive salt. Once menopause comes, increasing calcium intake as well as a variety of medications can help as well.
Q: This answer is for Robyn.
A: As a healthy, regularly menstruating, 37 year old woman you can immediately stop worrying about osteoporosis just because your T score is –1.1 to –1.9. Without going into the statistical details, by definition 16% of all healthy, normal, premenopausal women will have bone density values in this range. Being petite will help put you at this low end of the normal range. That does not make you one bit less healthy or normal!! Experts in this field all agree that bone density should not be measured in healthy premenopausal women specifically to avoid causing any unnecessary concerns in healthy women.
Q:  Exactly what do these calculations mean? Bone Density of -3.5   Thank you.
A: A T score of less than -2.5 is indicative of osteoporosis. This would be classified as severe osteoporosis and requires therapy to reduce the risk of fracture.
Q: I'm a caucasian 60 year old woman. I am unable to take HRT because of a breast problem, atypical hyperplasia.  On a recent bone density test, the first one I've ever had, my lumbar spine  T score was minus 2.8.  Hips were a normal reading.  My GP doctor said because of my age, I was in no immediate danger of a fracture and he kind of left it up to me whether I wanted to go on Actenol or Fosamax or just go the extra calcium, exercise course.  I generally walk everyday and take 600 mg. of calcium  supplement daily.  I would rather not take medication if not needed but my concern is whether my condition will degrade over the coming years, improve or just stay status quo taking extra calcium and vit. D and repeating the bone density test  in a year or two.  Or do you feel Actenol or Fosamax is a better choice for me at this time.
A:  Based upon a T score of -2.8, you have osteoporosis of your spine. By definition, this puts your risk of fracture at higher than those without osteoporosis. It would be common to also have some bone loss in the hip as well and a "normal reading" may be normal or just not as bad as osteoporosis. Be that as it may, adequate calcium intake, adequate Vitamin D intake as well as weight bearing exercise should be IN ADDITION to anti-resorptive therapy, namely Actonel or Fosamax. Evista can also be a good choice here and may be suitable for women with issues of the breast.
Q: I am 52, post menopausal and take calcium and vitamin D in the recommended doses.  My physician recommended Evista today at my annual physical.  I have a strong family history of stroke and take medication for high blood pressure.  I read in the package insert that one of the risks with Evista is blood clots (however the incidence is low).  Blood coagulation research was my profession until recently and I am paranoid about developing clots from using Evista.  Are you aware of major problems in this area with Evista?
A: Evista, as well as hormone replacement therapy, increases the risk of deep vein thrombophlebitis three fold over non users due to increased coagulability. You are correct to point out that the incidence is still low. As far as your family history of stroke, if it is secondary to hypertension, that is a separate item. If, on the other hand, it is related to increased incidence of clotting, you may need a hematologic workup for several factors involved with this increased risk such as Factor V Leiden mutation, Protein S, Protein C and others.
Q: I would very much like your opinion of the nasal spray Miacalin for Osteoporosis.  Is this safe to use and what are it's side effects?  Does using this cause cancer of the breasts?  I would appreciate any information you can offer.
A: Calcitonin (Miacalcin©) has been shown to possibly reduce osteoporosis of the vertebrae but appears to have little or no effect on the hip. It has also been used in reducing back pain associated with vertebral fractures. It is a relatively safe medication but commonly listed side effects include nasal irritation, rhinitis, back pain, arthralgia, epistaxis (nose bleeds), headache, sinusitis, dizziness, nausea, vomiting, flushing and rash. Since it is not a "female hormone" there should be no relation to breast cancer.
Q: What is your knowledge of Black Cohosh's effectiveness as estrogen replacement, and how significant is cigarette smoking to bone loss?
A: Black cohosh is an herb commonly used to prevent or treat menopausal symptoms. It has been reported to be the number one menopausal treatment in Germany. It certainly has some estrogen-like effects but one study showed the inhibition of certain breast cancer cell lines. With respect to smoking, it has been shown to be a major risk factor in osteoporosis.
Q: My endocrinologist (I am 70 y/o with a T-score of 3.3) has placed me on Fosomax (10mg) and Evista (60mg) per day.  My gynecologist thinks that both together are not helpful.  I thought that the Evista was more of a preventive and Fosomax was a bone builder.  Please give me your opinion on this matter.  Thanks.
A: Both Fosamax and Evista are approved for prevention and treatment of osteoporosis. Although a study has shown that the effects of Fosamax and HRT are additive, a study regarding the use of Evista and Fosamax has not been formally published according to a recent literature search. Some physicians may be using combinations of medications without formal studies based upon unpublished data that, in the future, may become part of the standard of care. Time will tell.

**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.

Click here to see Previous Ask the Expert Questions and Answers