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| Question from Russell: Male Osteoporosis |
| I am 74 years old and had a CATscan 3 weeks ago. The xray doctor said that I had a 70% loss is my spine. My medical Doctor put me on Evista, I have been taking extra calcium along with the Evista. I had been taking Lipitor for high cholesterol but the Dr. took me off of that because my blood platelets had gone down to 121,000. Do you have any suggestions? |
| Answer from Dr. Marchbein: |
| We are primarily an OBGYN (women's) internet site but why not! I would wonder why
the osteoporosis in that it is much less common in males. It is not stated why the CT scan was done (and I'm presuming
you had a QCT to evaluate for osteoporosis and not a CT scan for other reasons). Many consider the DEXA scan a
better test overall. Whether the osteoporosis was or was not steroid induced, Fosamax would be an excellent choice
for therapy. I have no personal experience treating men but have some considerable experience with Evista for osteopenia
and treatment of women with a family history of breast cancer. Evista, at this moment, is not approved for the
treatment of osteoporosis but rather the prevention of osteoporosis by "treating" osteopenia. It has
both estrogenic and anti-estrogenic activity on different organ systems, although the estrogenic activity is not
at the level of estrogen replacement therapy. Unanswered questions brought up at a recent conference I attended
about Evista includes the following: if estrogen acts as an antioxidant for many of its benefits and Evista has
many anti-estrogenic effects, does it act as an anti-antioxidant or an "oxidant" or oxidizing agent?
If this is so, will it increase the problems that estrogen has reduced (according to much of the literature), i.e.
will it cause increased heart disease (long term) despite lowering cholesterol slightly by increasing oxidizing
agents in the cardiac vasculature; will Alzheimer's disease increase in Evista users due to increased oxidation
in the area of the cerebral vasculature; will it cause increased numbers of colon cancer patients (ERT reduces
this number); will there be increases in macular degeneration (ERT reduces this), etc. I don't know the answer
but I have some concerns. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Randy: Livial (Tibolone) |
| My Sister lives in Europe and has been taking Livial (Tibolone) for the last three years. I understand Livial has not been approved by FDA yet but chances are it will be soon. Have you read any papers on this medicine and what are your thoughts? Thank you. |
| Answer from Dr. Marchbein: |
| The little bit we've seen looks very interesting but until it's approved, we'll have
to wait for more literature. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Serafima: Do I need to take anything else to stop the process or at least slow down the osteoporosis? |
| I am a 58 year old woman. Three years ago I started going through menopause. Two
years ago I started to take Prempro. Last year I switched to Evista, but could not handle the flashes and after
two months returned back to Prempro. At this time I only take Prempro, which help me to avoid flashes and as doctor
told me it will prevent osteoporosis. Do I need to take anything else to stop the process or at least slow down
the osteoporosis? I have a problem with my digestive system and use very little calcium in my diet. Should I take
vitamin E? I am doing daily exercises, almost 10 hours a week. Sometimes I have pain in my lower back and it's
goes all the way to the left leg. I also have some pain on the left side in the neck area. I only consulted with
my physician, because at this time I do not have a gynecologist. Can you suggest to me what I should do to stop
the osteoporosis and can you recommend a specialist in the area where I live. Serafima |
| Answer from Dr. Marchbein: |
| Prempro is a good choice for HRT and in most patients, will indeed reduce the incidence
of osteoporosis. A DEXA bone densitometry would be helpful to know your status now. Calcium is very important to
build bone and Vitamin D is also important as a facilitator in bone growth. Exercises are very helpful but may
only build muscle tone which will reduce falls but not necessarily build bone. The pain in your leg sounds like
sciatica. The neck pain may be arthritis but there is insufficient information for such a diagnosis. The DEXA and
adequate calcium intake are the first two steps. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Marlene: Infiltrative Ductal CA |
| Hello, my name is Marlene. In 1993 I was diagnosed with infiltrative ductal CA, it
was polyploidy and the estrogen receptors were positive. I underwent modified left and was told I could never take
ERT again. What about Evista, is it safe for someone with my past hx. I had a TAH/BSO in 1986 for endometriosis,
adhesions and benign fibroid tumors. Would appreciate input from you as a second opinion. God Bless You and Keep You, Marlene |
| Answer from Dr. Marchbein: |
| Raloxiphene (Evista) has not been FDA approved for treatment after diagnosis and
treatment of breast cancer. Some physicians are doing "offlabel" prescribing of raloxiphene in such patients
but there is no large body of confirmatory studies proving the safety of such an approach. This may be forthcoming
however. There is information on Tamoxifen, a "cousin" of raloxiphene. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Anonymous: Should I continue with the HRT and what would the benefits be? |
| I am 51 yrs old and have been taking HRT for two yrs. I am not sure if I want to continue due to side affects of breast cancer/or uterine cancer. I had a bone density test done and was told that I have Osteopenia. My Tscore was 1.7. Heart disease and osteoporosis runs in my family. I was taking Prempro but stopped 3 mos ago. I just did not like the way my body felt while taking these meds. My breasts went up two sizes, and I gained 20 lbs., and it has been very difficult to loose any weight. My question is: Should I continue with the HRT and what would the benefits be? My other question is: Would I benefit from taking the transdermal patch and what brand and what would be the lowest dosage a person can take in order to get the benefits for osteoporosis and heart disease. |
| Answer from Dr. Marchbein: |
| Weight gain is a very interesting problem in that studies have shown weight increase
in menopausal women with AND without HRT as well as men of a similar age. You already know that HRT is associated
with the following: reduction in heart disease, reduction in osteoporosis, reduction in Alzheimer's, reduction
in colon cancer, reduction in macular degeneration (the leading cause of blindness in the elderly) and the list
is continuing to grow. Only you can decide if HRT is right for you. The information about the Combipatch is noted
above. There are estrogen only patches, but they require progesterone of some sort (meaning if you don't use the
Combipatch, you'll need an oral source of progesterone). The dosages are different in various studies but Premarin
or Estratab at 0.625 mg is the accepted dose (with some articles indicating 0.3 mg as effective but this is not
universally accepted). Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from SLP: Weight Training |
| I have just been diagnosed with osteoporosis. I am 47 and otherwise in good health.
My doctor has prescribed HRT and Fosamax, but I would like to do more to reverse the condition. I have been told
that low weight use with many repetitions will help, but this seems vague. How low a weight? And how many repetitions?
Also, is bone actually built or does it just increase in density? SLP |
| Answer from Dr. Marchbein: |
| Many points can be discussed here. It has recently been shown that the combination
of HRT and Fosamax is superior to either therapy alone. Weight bearing exercise does little to build new bone.
It mainly builds muscle which helps posture and balance which reduces fractures from falls. In that osteoporosis
can occur in different areas of the skeleton, exercises can be tailored to these areas. Weight bearing exercises
should start with lower weights and higher reps (depending upon the area being worked, 35 pounds and 1520 reps
and 3 sets might be adequate). As strength increases, weights can be increased to build muscle rather than low
weights, high reps for toning. For specifics in any one person, a physical therapist may need to be consulted.
Once the "bridges" of bone have been lost, they cannot be rebuilt. They can be strengthened and "thickened"
but not rebuilt. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Anonymous: Getting Pregnant with Osteoporosis |
| At age 30 I was diagnosed with osteoporosis. A bone density test revealed I had the
bones of a 65-70 year old woman, the result of corticosteroid use for 6 years prior. I would like to get pregnant,
but am concerned about my situation. Will I be able to carry easily? Will delivery be a problem? I just don't know.
I know pregnancy will be a big calcium strain. Should I not even consider getting pregnant? Please help. Thank you. |
| Answer from Dr. Marchbein: |
| Although osteoporosis with corticosteroid usage is not uncommon, no long term studies
have been carried out on women of reproductive age. With no literature to assist in answering the questions, it
would depend upon whether or not the osteoporosis were in the hip or spine (or both) and the level of severity
(proportional to the risk of fracture). Osteoporosis is asymptomatic unless there is a fracture, therefore, unless
you sustain a fracture, there should be no problem. There will be weight increases on the average of 2530 pounds.
You should discuss with your physician about adequate calcium supplementation, weight bearing exercise and whether
or not Alendronate would be appropriate for you in treating the steroid induce osteoporosis. If potentially reversible,
waiting to get pregnant might be a judicious choice. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from waiting: Osteoporosis and Diabetes |
| 51 year old lady who went through menopause 5 years ago, who is also diabetic (type
II) since ten years ago presently she is on diet control. At present has complains of backache not relieved by
NSAID's. Recently diagnosed osteoporosis as of BMD (DEXA) report which is spine: low bone mass (mild osteopenia)
neck femur: significant low bone mass (osteoporosis) distal radius :normal bone mass. Her LAB Reports are in normal
range except Blood sugar level are fasting 150 mg/dl random 190, Triglycerides slightly above normal. Can she take
all these medicines without risking her diabetes especially Tibolone (livial). thanxs, waiting for your reply |
| Answer from Dr. Marchbein: |
| Neither ONE ALPHA nor tibilone are available in the US. From the literature, no studies
are available treating with tibilone and fosomax together as of yet. One must question why the fosomax was prescribed
since 80-90% of women will build bone with hormone replacement therapy (tibilone qualifies). The only thought is
that the patient developed osteoporosis despite tibilone therapy. Neither of these should impact on the diabetes.
ONE ALPHA is unknown to me in the US. A pharmacist should be consulted for this last question. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Alendronate is a bisphosphonate that should have no effect on the diabetic patient.
Tibolone is a synthetic hormone like product that at different tissues can work either as an estrogen, a progesterone
like hormone or as an androgen (male hormone). The compound is not marketed in the U.S.A. and I have read nothing
to indicate that it can adversely affect glucose control in diabetic patients. Alendronate should have no effect
in lipids. Tibolone, on the other hand can cause a decrease in triglycerides, total cholesterol and HDL (the "good
cholesterol") but LDL (the "bad" cholesterol) is unaffected. Simon Kipersztok, M.D. OBGYN.net editorial advisor. |
| Question from Jolena: Is -1.0 bad for a 30 year old woman? |
| Hi I am a 30 year old woman and I was diagnosed with osteoporosis through a bone scan of my index finger the reading said I was -1.0, what I would like to know is how reliable is a test done at a fair by a chiropractor? Were these people just trying to get me into their office? Is a -1.0 really a bad sign for someone my age? |
| Answer from Dr. Kipersztok |
| There are a number of techniques to assess bone mineral density (BMD) and many of
them can predict the risk of fracture. These techniques include radiographic absorptiometry, single photon and
dual photon absorptiometry, quantitative computer tomography and dual energy Xray absorptiometry. Many consider
the latter as the state of the art technology since it has a high precision and accuracy, low amount of radiation
and a reasonable cost. Usually the measurement on a given anatomical site is more accurate for that particular
site (the index finger is more accurate in the prediction of risk of fracture at the finger than at the spine)
but measurements at any site could predict the risk of fracture at a distant site (BMD measurement at the heel
can predict fracture at the hip). According to the World Health Organization a BMD measurement of -1.0 when compared
to the mean measurement of a population of individuals at peak bone mass (this is called the T score) indicated
low bone mass or osteopenia and could be an indication for using drugs to prevent a future fracture. If you feel
that the measurement you had could be incorrect or done with an unreliable technology you should discuss this with
your physician. Thank you for your interest in OBGYN.net. Simon Kipersztok, M.D. OBGYN.net editorial advisor. |
| Question from Anonymous: Growing new bones. |
| I am a 57 year old woman who has been diagnosed with osteoporosis. I had been taking Estrace and Provera for 14 years (had an early menopause) but my bone density continued to decrease. I'm afraid to take Fosamax because I understand it can grow bone over old, weak bone and that fracture risk may not be decreased. I stopped the HRT last year and went with only Progest (transdermal natural progesterone) because I'm concerned that lifetime use of hormones that don't fit the human hormone receptors can be dangerous. My bone density worsened over the past year since I stopped the estrogen and I have decided to get back on estrogen but using a natural one that does fit the human receptors. I heard that Tri-est could be good because it has a small percentage of estradiol which may be the most harmful component of estrogen. Do you have any recommendations for taking Tri-est? What other factors could play a part? Just saying it's genetics doesn't solve anything, I've been very active physically over the years. I'm an avid back- packer, back country skier, hiker, jogger, bicycler and yet my hip bmd is worse than the spine. I also meditate, eat well and take calcium citrate supplements. I would appreciate any comments. |
| Answer from Dr. Kipersztok |
| You raise several important issues regarding osteoporosis that merit comments. The
first one addresses the quality of bone preserved after the use of alendronate (Fosamax). The second issue relates
to the use of alternative compounds such as transdermal progesterone cream and "Tri-est" (a combination
of estradiol, estrone and estriol - 3 estrogenic compounds with different affinities for the estrogen receptor).
The third deals with the effects of modifiable lifestyles, such as diet and exercise, on the promotion of bone
health. The fourth issue comments on the genetics of osteoporosis which is important even though you prompt me
to ignore it. Last, but not least, you also openly express your concerns about the possible harmful effects associated
with estrogen excess. With regards to the first issue, alendronate (Fosamax) works like estrogen as an anti-resorptive
agent and does not promote bone deposition. In animal studies the type of bone formed after the administration
of alendronate did not differ in any way from other bone not exposed to alendronate. Some bisphosphonates (class
of compounds to which alendronate belongs) can increase bone demineralization if given daily. Etidronate (Didronel)
is such an example. Etidronate is administered for 2 weeks every 3 months for that reason. The subject of use of
alternative compounds in the menopausal years is very much in vogue. The main concern that physicians have with
regards to these compounds have to do with the quality and quantity of information (data!) available with regards
to safety and efficacy of alternative compounds. When you take Estrace or Fosamax or any other drug that has been
approved by the Food and Drug Administration (FDA) for use in defined medical conditions, there are a minimum amount
of data that must have been collected on the drug's safety and efficacy before approval is granted. The data collected
is not always perfect and at times drugs must be withdrawn from the market because of unexpected side effects,
sometimes serious enough to cause fatalities. However, at the very least a regulatory agency keeps an eye on the
marketed drug. With alternative compounds, such process does not exist. For example, I would like to know how much
of the transdermal progesterone cream you are using gets absorbed into your system. I also would like to know if
the Tri-est formulation you refer to can decrease the rate of fractures and to what extent. I am not aware if such
data have been collected and if so in a scientifically sound way. This is turning out to be a long discussion and
I may loose some of the readers so I will try to address the remaining issues briefly. Diet and exercise - very
important! Calcium has some protective qualities perhaps mostly in the years before peak bone mass is reached (30-40
years) but alone is not enough. Vitamin D is also important even in sunny places such as Florida. Weight bearing
exercise also protects the bone from excessive losses but should be done in a way that minimizes possible trauma
that can lead to a fracture. Genetics: White or Asian ethnic background, female gender and a thin figure are all
non-modifiable risk factors for osteoporosis. Luckily, many other risk factors can be modified. These include:
low estrogen levels, sedentary lifestyle, smoking and excessive alcohol drinking. Estrogen excess can be harmful
particularly to the uterus and the breast. Women on estrogen who have a uterus in place can eliminate any risk
of uterine cancer by taking a progestin (progesterone like compound) with their estrogen. By the way, I do not
know if the transdermal progesterone cream you refer to offers any uterine protection to women taking estrogen.
The potential risk to the breast is increased at worse by 30-35%. Remember: most, if not all, activities in life
pose a risk of some sort. Compared to women who do not go to college, it has been observed that the women who do
have a 30-35% increase in the risk of breast cancer. This may just be an association and not a cause but nevertheless
the magnitude is identical to that seen with estrogen. Thank you for your interest in the Osteoporosis section of the OBGYN.net.The opinions presented above are informal and are a free service of the OBGYN.net to its readers. My opinions, or that of other physicians, may differ if a complete medical history is obtained, a thorough physical exam is performed and pertinent laboratory studies are evaluated. I advise you to consult with your health care provider before you make any changes in matters related to your health. Sincerely, Simon Kipersztok, M.D. OBGYN.net editorial advisor. |
| Question from Rosemary: Osteoporosis and pre-menopause |
| I am a 46 year old premenopausal woman. I'm still getting regular periods. I have a uterine fibroid tumor which leads my doctor to think I'm still producing estrogen. My 82 year mother has osteoporosis and has lost 4.5 inches in height. I am a very small boned slender woman with a fair complexion. My doctor sent me for a bone density scan to get a baseline. The scan showed a value of -0.29 for the spine but -2.49 for the hip. My doctor prescribed Fosomax and calcium supplements. I keep reading about osteoporosis in postmenopausal women but what about premenopausal women ? |
| Answer from Dr. Kipersztok |
| Dear Rosemary: There are many reasons why a person can be affected by osteoporosis. The most common reason, in developed countries, is loss of production of sex hormones particularly in women after the menopause. However, premenopausal women, and men of any age, can also be affected. Some examples of diseases that can lead to osteoporosis include: excess thyroid hormone (hyperthyroidism), excess production of parathyroid hormone (hyperparathyroidism), renal disease, malnutrition, use of systemic steroid hormones (commonly used for asthma or arthritis) and a long list of other less frequent conditions. I feel your physician was smart to obtain a bone densitometry study to assess your risk of fracture even though you are premenopausal. Bone densitometry has been consistently shown to be extremely accurate at predicting the risk of fracture. Indeed the study done on your bones indicates that you are at increased risk for fracture and the therapy advised by your doctor is very appropriate.In good studies, alendronate (Fosamax) has been shown to increase bone mineral density and to reduce the incidence of fractures in the spine and the hip. Thank you for your interest in the Osteoporosis section of the OBGYN.net.The opinions presented above are informal and are a free service of the OBGYN.net to its readers. My opinions, or that of other physicians, may differ if a complete medical history is obtained, a thorough physical exam is performed and pertinent laboratory studies are evaluated. I advise you to consult with your health care provider before you make any changes in matters related to your health. Sincerely, Simon Kipersztok, M.D. OBGYN.net 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. Click here to see Previous Ask the Expert Questions and Answers |
