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:

Simon Kipersztok, MD, OBGYN.net Osteoporosis Editorial Advisor

 

and

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

 

Click here to see Previous Ask the Expert Questions and Answers

Q:  I am a 35 year old mother of 2 and have had back pain for over six months.  My doctor sent me for a bone density and it showed moderate bone loss. Am I a candidate for medication?  I am on 1800 mg of calcium a day. Thanks.

A:  I do not know if you are a candidate for medication since I do not have full information about your bone density study. Nonetheless, your doctor should be able to determine the following based on the study and on a complete medical evaluation: 1. If you are at increased risk of fracture because of osteopenia and osteoporosis. 2. If your bone density is low, then why, and 3. Offer you treatments or recommendations that could help reduce any possible increase in your risk of fracture. The daily use of calcium as you are ingesting is more than adequate.
 
Q:  My new test results from DEXA is -2.69 and -2.66.  Three years ago they were -2.49 and -1.95. Although I took Fosomax 5mg each day and ran and lifted weights I did not have a supplement Calcium.  So now I currently take Fosomax once a week 70 mg and added 1500 mg supplement with Vitamin D and magnesium and changed my diet.  Will I be able to hold the line? My mother had severe osteo and my sister has Paget's disease. My gyn wants to also put me on HRT.  Will that help?  I want to try diet and exercise first.  What do you think?
A:   The new test results you referred to show that you suffer from osteoporosis. Therefore, the Fosamax that you are taking, in addition to the calcium, vitamin D and weight bearing exercises should help you to raise your bone mineral density and decrease your risk of fracture. Please be aware that lifting heavy weights could apply excessive pressure to your spine and cause a compression fracture. So I suggest you discuss your exercise regimen with your physician or a physical therapist.

The addition of HRT could be beneficial if you are having symptoms related to low estrogen levels. These symptoms include hot flashes, dryness in the vagina and urinary discomfort. It may also help improve your lipid fraction in a favorable way and maybe decrease your risk of cardiovascular disease although many debates are ongoing with regards to this particular issue. Estrogen replacement could also help in decreasing the incidence of colon cancer, blindness and possibly Alzheimer's disease. As far as your bones are concerned, Fosamax can produce a larger degree of bone mineral density gain than estrogen.
 
Q: There was a recent article about a new drug, Forteo.  It was described as "A natural bone-building hormone."  Last year, I had four spontaneous fractures (three pubic and one sacral) due to use of Prednisone for three years for Lupus.  I am unable to tolerate Fosamax or Actenol.  Could you please give me more information about Forteo?  The article stated that the manufacturer hoped to have the prescription drug available by the end of this year.

A: Forteo is the trade name of recombinant parathyroid hormone (rPTH). Parathyroid hormone is normally produced by the parathyroid glands, four small glands located underneath the thyroid gland in the neck. The glands produce parathyroid hormone (PTH) which is involved in the metabolism of calcium in the body. The term "recombinant" refers to the fact that the hormone was not extracted from actual human glands but rather produced in the laboratory through what is now considered to be acceptable and standard genetic technology.

All of the drugs thus far approved by the Food and Drug Adninistration for the prevention and treatment of osteoporosis such as estrogen (HRT/ERT - many brands), alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista) and calcitonin (Miacalcin) work by slowing the process of bone resorption. Resorption is coupled to the process of bone deposition. Both processes are necessary for bone remodeling a vital, ongoing process necessary for bone maintenance. When the two processes are balanced bone competency is maintained. After menopause, when estrogen production drops to very low levels, resorption exceeds deposition and bone mass can be lost leading to osteoporosis and to an increased risk of fracture. The FDA approved drugs work by slowing down resorption and thus improve bone mass to one degree or another.

rPTH works mostly by promoting bone deposition although it can also increase the rate of resorption. The initial trial of the drug in patients with osteoporosis who had previous spine fractures showed that Forteo can reduce the incidence of new fractures by 65-70% with minimal side effects. Bone mineral density also increases with Forteo. The new drug has to be administered daily by subcutaneous injection and is not yet available in pharmacies.
 
Q:  I have a 16yr. daughter who over the course of  the past year and a half or so  has been overexercising and limiting intake of particular foods.  She is working with a nutritionist on her diet which has greatly improved.  The exercise is still just about daily for a few hours(2-3).  Her physician had her get a bone density test because her periods became irregular and then stopped although she had not actually had it for very long. She considered her to have subclinical anorexia since her weight was stable at 105lbs.  Her height is 5'1". The bone density test came back with 20% loss.  There was some question about the sample used to compare her test to. I spoke with the radiologist who did the scan.  He was confident with the results and said that she had 15 years to improve her bone health through better diet.   Her physician started  her on Allese (birth control) pills , added calcium and a multivitamin in addition to her nutritional counseling. She is now getting her period. She was told to repeat the scan in a year to see if her score was improved.  She will be taken off the hormone for a month to see if she can get her period on her own shortly.  Have we received good advice?
A:   The answer is yes. Some young women, usually as a result of excessive exercise, an eating disorder or both, may develop menstrual irregularities or have no periods altogether. Under those circumstances, their ovaries stop producing estrogen and they can have the same risks to their bones as menopausal women. Unlike menopausal women, their condition is reversible once the exercise level is reduced or the eating disorder treated.
 
The Alesse your daughter received is a "low dose" birth control pill. In your daughter's case it is being used as a source of estrogen to protect her bones and regulate her periods. Some authorities may suggest that at 16 a pill formulation with a slightly higher dose of estrogen (35 micrograms compared to 20 micrograms in Alesse) could not only offer better bone protection but also improve or enhance your daughter's secondary sexual characteristics such as breast development. The added calcium and a multivitamin, which hopefully contains 400-800 international units of vitamin D, will also help her bones.
 
Eating disorders in young women can be life threatening. I read in your message that your daughter is under professional supervision and I encourage you to continue such care until her condition improves. The advise of a nutritionist can also be very helpful in monitoring her intake and weight gain. 
 

Q:  I am 51 years old, and just had my first bone density test.  My spine is --2.4 and my hips are --2.0.  This is not quite but almost osteoporosis.  In addition, I have been taking HRT daily for the last two years.  I know this has not stopped my bone loss because I am shorter in height now than I was a year ago.  Also I have what I call "hip pain" that never goes away but is especially apparent when I lie down.  I am close to menopause, with an occasional period every four or five months for the last year or so. My mother, who was only 69 when she died, had severe osteoporosis, a huge dowager's hump, and had lost height from 5'2" to 4'10".  I used to be 5'2" and am now 5'1".  I am also extremely fair skinned, light eyed, the whole "at risk" bit.  I literally had to fight with my HMO to get them to even schedule a bone density test for me because of my age, and it took nearly a year to be scheduled.  I want to present my OB-GYN with as much information as possible in order to be active in the treatment process.  What would your experts suggest as far as treatment goes?  (The HRT dosage I currently take is .6 of Premarin and I don't know what proportion of the Progestin is.)  Please help.  I don't want to end up like my poor mother!

A:  Assuming that the bone density scores you report are the "T" - scores you indeed have osteopenia. The  T score compares your bone density to that of individuals similar to you who are at peak bone mass and accurately predicts an increase in the risk of fracture.

HRT is helpful to bones after the menopause. However, some women may continue to loose bone even though they take estrogen. One common reason for it is that they do not take their medication. Another reason could be that they may have a medical condition that causes bone loss in addition to being menopausal. Smoking and alcohol abuse can also cause bone losses despite HRT use. Low weight is also a risk factor for low bone mass. It is, therefore, important that your physician evaluate you fully to rule out the many causes for osteoporosis other than menopause.

If all causes for osteoporosis, other than menopause, have been ruled out one way of telling if the HRT is working to your bone's benefit is by performing a urine test called N-telopeptide. Menopause thins bones by causing an acceleration of a natural process called resorption. N-telopeptide levels can reflect the degree of resorption taking place in your bones. If HRT is working then the N-telopeptide level should be in the normal range. If it is increased despite the HRT then you may need the addition of another drug that can slow down the accelerated bone resorption.
 
Q:  I am a breast cancer survivor with estrogen positive receptors, no node involvement.  After taking tamoxifen for about four years, I was diagnosed with osteopenia, and placed on Fosamax for about five years. My family has a history of osteoporosis.  Recently I received a letter from my drug plan provider stating that Fosamax would no longer be on the Preferred Medication List, and that I should have my new prescriptions written for Evista or Actonel. I have tolerated Foxamax well.  I am due for a DEXA scan next month.  Is there a great difference in the results of the two drugs, Evista and Actonel, and given my history which one would be best suited to me?
A:  It would be ideal if there was a drug that offered you protection from breast cancer recurrence while giving you protection from the risk of fracture particularly to the bones in the spine and the hip. Such drug, unfortunately, does not exist.

Raloxifene (Evista) has been shown to prevent the occurrence of breast cancer in osteoporotic women although, unlike tamoxifen, it has not yet been shown to prevent the recurrence of breast cancers. It can also decrease the incidence of fractures in the spine but not in the hip.

Conversely, risedronate (Actonel) can decrease fractures in the spine and hip but has no beneficial effect on the breast. Both risedronate (Actonel) and alendronate (Fosamax) are compounds that belong to the same family (bisphosphonates). One of the main differences between the two is that alendronate can be taken once a week while risedronate has to be ingested as a daily pill.

I suggest you discuss this matter with your physician who should be able to advise you which aspect of your health requires greater attention, your breasts, your bones or both organs. If breast protection is a priority then perhaps raloxifene (Evista) should be better suited than risedronate (Actonel). If bone protection is the priority then risedronate (Actonel) should be chosen. If both organs are equal priorities both drugs can be considered. There are reports indicating that raloxifene (Evista) was used effectively with a bisphosphonate to improve bone mineral density.
 
Q:  I am 55 years old, and have been told that I am in the bottom 25% on my bone density scan.  My doctor has suggested Fosomax.  I had a reaction to that, so I am going to try Actonel.  Is it possible to build up my bones with soy products, exercise and added calcium to my diet, without the use of medication?
A:  Calcium, exercise and good nutrition are very important for the maintenance of healthy bones. However, when treatment is necessary to correct a disease associated with low bone mass medications such as alendronate (Fosamax) or risedronate (Actonel) are needed. Several studies have established that both medications are efficacious and safe for the purpose of increasing bone mass. Calcium, exercise and the ingestion of soy products when used alone have not been shown to increase bone mass or decrease the risk of fracture.
 
Q:  I was recently given BMD values only in two areas that being Femoral Neck And Mean L2-L4.  Is this enough information to diagnosis Osteopenia?
A:  Yes.
 
Q: I am 50 years old and was diagnosed with severe osteoporosis several years ago. I probably had it even earlier than the diagnosis. I see a GYN and a family doctor. Is there another kind of specialist that I should see? I am currently on Evista (1 1/2 yrs.) and Foximax (last 3 mo.). I am also trying to walk and do weight bearing exercises. Are there any books or web sites that specify exercises? I do take calcium, 1200-1800mg. a day, but so many things in them I am allergic to. I have severe allergies (sulfates, sulfides, soy). Is there a good calcium pill that is easy to swallow and that will absorb? How do I take these to best absorb into the important parts of my body? I have been told that I have a difficult time absorbing nutrients.
A:  It appears that your present physicians are treating your severe osteoporosis with effective therapies. Other specialists that manage osteoporosis are Reproductive Endocrinologists http://www.socrei.org/, medical Endocrinologists http://www.aace.com/, and Rheumatologists. I suggest that you check the website for the National Osteoporosis Foundation www.nof.org for more information about calcium and exercise.

Please be sure to check-out the OBGYN.net Osteoporosis Bookstore for more information about your question.
 
Q:  My mother is 85 years old and her physician is now recommending she take Actenol because she had a bone density test and had a T score between -1 and -2.   Although quite active, she tends to be forgetful about her blood pressure medication and the instructions for taking Actenol are quite specific.  She lives alone and relatives are almost 3 hours away.  We are fairly certain that she will both forget to take her daily dosage and forget how it has to be taken.  Also, when she tends to feel anxious, she has difficulty swallowing and we are concerned about the Actenol's effect on her esophagus.  So far, my brother and I have advised her physician against prescribing the Actenol for the reasons mentioned.  She has never broken any bones, has a well-balanced diet, and has had no female relatives who ever had any problem with fractures and they lived well into their 90s.  My question is whether you feel we are being overly cautious?
A:  The concerns you have about your mother are valid. Alendronate (Fosamax) is a drug similar to risedronate (Actonel) that is also highly effective in reducing fractures and it needs to be taken once a week instead of on a daily regimen. Perhaps you could arrange a neighbor or a visiting nurse that can help your mother take her osteoporosis medication once every week.
 
Q: I'm studying physical and occupational therapy and I have just learned that salt and smoking are to be avoided with an osteoporotic patient. I was wondering if you could explain the actual pattern of action of salt and tobacco?  Is it that it decreases the binding of calcium and if so, how is it doing so? Thank you for your help.
A:  Individuals who ingest foods high in sodium have increased urinary excretion of calcium. This could be a mechanism by which table salt may deplete another element important in bone metabolism.

Tobacco acts more like a poison. Tobacco smoke, for example, contains many substances that can promote cancer and damage organs directly, including bone. Another effect of smoking is that it decreases the clearance of estrogen in the body and accelerates the age of menopause to an early age. Early menopause and low levels of circulating estrogens in smoking women can lead to low bone mass and osteoporosis.
 
Q:  I am a 48 year old DES daughter. I have been experiencing menopausal symptoms on and off over the past 3 years but with increasing severity over the past year. I had a hysterectomy (ovaries remain) at the age of 29 years following cancer of the cervix (ca in situ). A recent Dexa bone density test indicates that I have osteopenia. I am extermely fit; weight train and walk on a daily basis. I want to know if HRT is an option for me, and if so, is Premarin a safer medication since it has been used for a longer time period? Does HRT actually promote bone growth or does it just protect from further bone loss? Also, would it be advisable to take Actenol instead of HRT? I am suspicious of "new" medications but I believe that I need to do something. Thanks for your assistance.
A:  HRT is helpful to alleviate menopausal symptoms and prevent osteoporosis. Bisphosphonates, such as risedronate (Actonel) and alendronate (Fosamax) are highly effective and safe drugs used to prevent and treat fractures but will not alleviate menopausal symptoms. Given the more global nature of your health concerns you could benefit from HRT and monitor your bone mineral density. If needed a bisphosphonate could be added to your HRT regimen.

Any estrogen formulation appears to be helpful to bones. Conjugated equine estrogens (Premarin) has been in use for more than 50 years and numerous studies have confirmed its effectiveness in alleviating menopausal symptoms and preventing osteoporosis. Like many other medications some patients may not tolerated or may prefer a one of the many other formulations available in the market. Many of these formulations are similar in their effectiveness, safety profile and possible side effects.
 
Q:  I was just diagnosed with Osteoporosis.  I am a 36 year old premenopausal female.  My physician has recommended taking Fosamax.  I have read that it is not recommended if you plan on having children.  Would it be safe to take Fosamax and then discontinue for a few months prior to trying to get pregnant?
A:  Most of the studies done with alendronate (Fosamax) and other bisphosphonates have been in postmenopausal women and men. Some studies have included reproductive age women who have steroid induced osteoporosis. Women on steroids usually have suppressed ovarian function. Anecdoatal reportsindicate that some young women who have used alendronate have conceived without ill effects to them or their infants. So the experience available in women likely to conceive is very limited.

We know that alendronate remains in the maternal bones for a long period of time and the drug is a category C as far as pregnancy is concerned according to the FDA. Category C means that there are no human studies to clearly show fetal harm however the drug has the potential of causing such harm so its benefits should be weighted against its possible risks.
 
Q:  I was diagnosed with osteopenia recently.  I am 22 years old.  My hip is in the 5th percentile and my spine the 12th.  I do not remember the percentages.  I am currently seeing a gastroenterologist to look for Chron's disease as their is a family history of this.  I am aware that according to the National Osteoporosis Foundation I am a candidate for intervention with anti-resorptive drug therapy.  This I read in the recommendations from the doctor who analyzed my bone density results.  My gastroenterologist is taking great care of me and doing her best to find the source of the bone loss.  Should I go ahead and ask about the anti-resorptive drugs?  or am I taking this too seriously?  I am very scared because everyone has told me how strange it is for me to have bone loss at my age.  I cannot find much information about what to do at my age. Does my age rule out many treatments for bone loss,  or again do I just need to exercise and increase my calcium intake and not worry beyond that?
A:  You are young and seem to have low bone mass and possibly Crohn's disease. You are at a stage in your life where you should be accruing the bone mass that will take you to your full life expectancy. I give you much credit for being concerned about this issue and making a big effort to become educated about it. What you need to know and understand in detail is if you are at risk of increased fracture and if yes why, and what can you do about it. Good Luck!
 
Q:  About 4 years ago, I was having lots of back pain. My Dr. ordered  a couple of epidurals, where they inject something directly into the spine. Would  that have been Cortisone? If so, would that have been the cause of my severe Osteoporosis? Also would like to let you know that instead of taking the expensive medications for Ostesporosis, I have my own  natural  way of dealing with it because I am intolerant to everything my Dr. recommended. I have a bone mineral test done every year, and I keep improving with each one so something is working. I take 1200 mg of Calcium and 400 units of vitamin D, Plus it contains some soy and isoflavones, a triple Boron Complex,6mg. I also use the Progestrone cream every day and just recently started taking Ipriflavone, which I just happened to find in my vitamin catalog. It helps support bone density. No Dr. has ever mentioned it to me before. I wonder why? I had a hysterectomy at 31 years old but kept my ovaries. Because I couldn't tolerate HRT, I was never told that I would suffer bone loss later in life. I have lived with pain every day for four years, probably due to spinal compression fractures. Have never broken a bone, but have hip and back pain constantly. Also have Fibromyalgia, so that could be some of the pain. Can't do much exercise because of having that. Thank you for letting me share my story with you.
A:  If the injections were steroids, the osteoporosis you may have should not have been related. Most experts feel a minimum of 3 months on daily steroids are needed to even start the process of bone loss in that regard.

Very often, claims in vitamin catalogs and the like are advertising statements rather than proven information from medical studies. Randomized controlled trials, double blind, are required to prove a medical point. Unfortunately, people spend billions of dollars a year in the U.S. on vitamins and herbs with no proven benefit. Isoflavones, however, HAVE recently been shown to be of potential
help with bone formation and preservation.

The disease, prior to fractures, is painless in contrast to osteoarthritis. Any pain without fractures in NOT osteoporosis related. Spinal compression fractures are indeed, broken bones of a sort. Hope this helps.
 
Q:  I am 55 years old, and have had a bone density test done.  I am in the low 25 percentile.  I tried Fosomax and got a terrible headache from it.  I don't know whether to use Evista or Actenol.  My internist suggested Actenol and my gynecologist suggested Evista.  Upon researching on the internet, there seems to be a connection between Evista and Ovarian Cancer.  That frightens me, should I try Actenol?  What is your feeling comparing to the two medications?  Thank you for your information.
A:  Several points to consider here. If you used the Fosamax at the daily dose of 10mg, you may do better with the once a week 70mg dose. Both Actenol and Evista may have benefits on the bone but a variety of studies question whether the improvement is the same as Fosamax. Not all studies agree and there are data to suggest that bisphosphonates such as Actonel and Fosamax are superior  to other agents for osteoporosis. Evista may reduce the risk of breast cancer but may not be as beneficial for the bone as bisphosphonates. The question of increased risk of ovarian cancer is a new concept and most physicians feel this has not been proven yet.
 
Q:  Hi there...this is response to a reply to a young lady who wrote in and said she is 44, regularly menstruating, with advanced osteoporisis which was diagnosed 10 years ago.  Your reply was that a 44 regularly menstruating woman do not get osteoporosis and that something very unusual may be going on.

Well, I would like your thoughts on what you consider "something very unusual going on".  I am only 41 years old, have no children, and was diagnosed with osteoporosis last September.  I couldn't believe it either.  I have exercised most of my life, try to eat the right foods and thought that I was doing everything right as well.  I could not get any real answers or reasons from my doctor on how or why I have osteoporosis, considering I had been on birth control for almost 20 years and was told there should have been enough estrogen in my body.

Is there some type of specialist or medical findings that can give me some answers? If there is something else going on then what type of tests should I be taking or looking for?
A:  When someone of your age and hormonal status develops osteoporosis, one must consider etiologies out of the norm. With adequate calcium intake and exercise as well as adequate estrogenization, the possibility of lack of Vitamin D or lack of absorption of calcium and/or Vitamin D comes to mind. This can be from a variety of gastrointestinal problems, among them sprue and some inflammatory disorders. Another reason may, in others, be steroid use for extended periods of time. The appropriate specialist in your area may be an osteoporosis specialist, Sometimes they are rheumatologists, sometimes endocrinologists. A gastroenterologist may need to become involved.
 
Q:  My mother-in-law has osteoporosis and was recently diagnosed with compressed vertebrae and herniated discs. I recently came accross an innovative procedure called vertebroplasty to relieve pain caused by this condition. Unfortunately, she lives in Mexico and this procedure is not yet known in this country.  The physicians there want to operate by fusing a donated bone from a bone bank. Have you heard of any such procedure and risks?
A:  Not being an orthopedist, I am not completely familiar with orthopedic procedures. The kyphoplasty or vertebroplasty is relatively new but has good data standing behind it. The fusing of donated bone may work but you need to speak to the surgeons about the long term mobility and success rates as well as the risks of the procedure and the anesthesia.
 
Q:  A short while ago I was taking Estratab and I felt good about taking it cause I was told it was from Yams and soy. The druggist says it was taken off the market. The obgyn put me on it for bone loss and menopause. Is there something similar to it for the same condition or a more natural substance to take? Thanks.
A:  Menest appears to be comparable to Estratab.
 
Q:  My mother has osteoporosis problem. She did bone mineral density in spine, the report show she lost 32% compare to the health person. Is that a serious problem? Now she is very painful. Are there any good medicine to treat this disease? Now she is using Miacalcin Nasal spray with some Calcium. But the effect is not so good. Is the nasal sypray not good enough? Do you have any suggestions about this? We are desperate about this. Thanks a lot for your information!
A:  Your mother has osteoporosis, most likely severe osteoporosis from the report. Pain can be from fractures or arthritis but not from osteoporosis without fractures. The Miacalcin has limited appeal and limited benefit. She needs to speak to her doctor about a group of medications called bisphosphonates. In this group, Fosamax once a week and Actonel once a day should be discussed. Calcium and Vitamin D are still necessary even with adequate treatment.
 
Q:   I am a 54 year old female taking Avapro, Norvasc & Ortho-prefest.  Are these medications for the rest of my life, or how/when does one know it is safe to discontinue the use of these medications?  A bone density test 12 months ago indicated borderline osteoporosis.  My BP now is usually 120-130 over 80-90.
A:  Your first question about taking the three medications and how long are beyond the scope of this site. As far as HRT and borderline osteoporosis, if bone turnover is low while on HRT, that may help maintain bone. The test NTx, can give that information. HRT is not, at this time, approved for treatment of osteoporosis. Due to this, optimal treatment might be with a bisphosphonate such as Actonel or Fosamax. Evista may be the same or better with respect to bone preservation but discontinuation of the HRT would be part of starting this medication. These options and the first question you asked should be addressed to your physician.
 
 

**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