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Osteoporosis Ask The Expert |
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| Q: I went through early menopause at 29 and have been on HRT for 25 years. I decided to go off of it, had a bone scan and was diagnosed with osteopenia. My gyn. wants me to consider going back on the hormones, but I've been handling the menopause II side effects with soy supplements and have no desire to start having periods and PMS again. What does my diagnosis say about the efficacy of HRT...when I've taken it for so long? Would taking Fosamax be a help? Thank you very much. |
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| A: You may or may not have had osteopenia at age 29 and without a comparison, prognostic ability is not possible as to what you were then and what effect HRT may have had. It is possible that the HRT stopped the osteopenia from getting worse. Depending upon the bone density T score (mild, moderate, severe osteopenia), Fosamax may be appropriate for severe osteopenia but in many, it may be premature to treat lesser forms of osteopenia. Adequate calcium and Vitamin D are also very important. |
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| Q: I am 38 years old. I have been a recreational runner for 20 years. In February I suffered stress fractures in my proximal femurs on both legs. A bone density (dexa) determined that I have osteoporosis. T scores of -2.2 and -2.3 in the hips and spine. I have reluctantly started fosamax. I would rather try calcium and natural bone building supplements and diet changes. I have tried to research the side effects and dangers of taking this at a young age but have found little. What are the long term effects of this drug? Should a younger pre-menopausal woman take this as well as a low dose pill (lo-estrin which has taken away my period)? I am walking 45 to 60 minutes a day but I am not taking calcium supplements because the fosamax is hard enough on the digestive/bowel systems. Thanks so much for your reply. I am concerned about the lack of information about long term side effects versus the actual benefits from taking this medicine. |
| A: Your DEXA scores are consistent with severe osteopenia. Osteoporosis is
defined as less than -2.5. Adequate Calcium and Vitamin D are important
for all women (and men). With such T scores at age 38, one must consider
possible malabsorptive abnormalities - problems absorbing such nutrients
as calcium and Vitamin D. One such problem would be non-tropical sprue.
If malabsorptive problems can be ruled out, other therapies are
available.
Other etiologies to be considered are long standing amenorrhea (lack of period) in the teenage years and early 20s, oral steroid use for over 3 months, thyroid abnormalities, parathyroid abnormalities and in some, a strong family history among other less likely choices. Fosamax has been used mainly in post-menopausal osteoporosis but is also approved for steroid induced osteoporosis. No large studies are available with use in women prior to menopause. With Fosamax being "out in the market" for about 7 years, longer term information is not available at this time. As you pointed out, estrogen therapy such as the pill, can be helpful in maintaining bone and in some may increase bone mass but should not be considered definitive therapy. When taking Fosamax, one must take Calcium and Vitamin D. Think of Fosamax as a bricklayer and Calcium and Vitamin D as the bricks. Without bricks, the best bricklayer is unable to do their work. Hope this helps. |
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| Q: I am 18 years old, have monthly periods although they vary in length from time to time. I am also 5'2" and Weigh 95 pounds. I am fairly muscular due to varsity volleyball and softball. However when I had my first pap test my physician recommended birth control pills to prevent osteoporosis because I was so small. I am not sexually active and do not plan to be in the near future. Are birth control pills for osteoporosis recommended at my age? |
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| A: Well, you're having monthly periods. That tells us that you are producing sufficient female hormones to get regular periods and that should indicate that your weight is sufficient to support that hormone production. With that in mind, you ARE at the lower end of the weight range for your height (99-121 pounds) which seems to be the concern of your physician. The literature at this time doesn't support the use of "the pill" solely to prevent osteoporosis in young women with regular periods. This, of course, presumes there are no other predisposing factors for osteoporosis. Hope this helps. |
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| Q: I had a check for a baseline of bone density. I was told my hips were fine but my spine was losing BDM at a SD of 2 below. I have been prescribed some nasal spray as a calcium supplement. The test also said because I am only 38 that reasons other than age are causing the bone loss. What could those reasons be and how can I find out? Is it medications I'm taking? Food I eat or don't eat or what? |
| A: The
most glaring point here is why a 38 year old with no mentioned risk
factors would get a bone density. That being said, a spine BMD of -2 may
be related to never having gained rather than loss of bone. With that in
mind, weight bearing exercise along with adequate Calcium and Vitamin D
may help stabilize the bone density. As mentioned in many other responses
to this section of OBGYN.net, other possibilities are parathyroid
abnormalities, thyroid abnormalities, long term (greater than 3 months)
oral steroid use, strong family history, malabsorptive problems, other
bone disorders and list goes
on with less frequent causes. You ask if it's the medications you are taking but you failed to mention what those medications are. You should discuss this with your physician and see if that is a possibility. If your physician does not have the expertise needed for this, see an osteoporosis specialist, endocrinologist or rheumatologist. |
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Q: I am a 48 yr old post menopausal woman who is inactive due to a disc problem at L5-S1; as well as scoliosis, osteoarthritis of the spine. I have poor balance, have a back brace and walk with a cane for support. My DEXA reveals 2 standard deviation points of the spine and 1.75 of the hip; with a 4-6 times fracture risk. I am not on any therapy. What could be my osteoporosis prognosis? |
| A: Being at increased risk for fracture due to DEXA results in conjunction with your inactivity, scoliosis, osteoarthritis and issues with balance, back brace and cane for support makes one consider medication to prevent worsening of the present bone density. You would do well to discuss possible therapies with your doctor - bisphosphonates such as Fosamax or Actonel along with adequate calcium and Vitamin D. After a full evaluation by your doctor, possible prognosis or your moderate to severe osteopenia can be further discussed. |
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| Q: Does Actenol contain any estrogen? |
| A: Actonel belongs to the drug class of bisphosphonates. This is not an estrogen compound or hormone of any kind. In this class of drugs is also Fosamax and Didronel. |
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| Q: I was diagnosed with osteoporosis 2 years ago. I have been taking Fosamax, calcium and exercising since. I have just noticed a definite beginning dowagers hump. Is there anything that can be done to prevent it from worsening--any brace or exercise or anything else. Thank you so much. |
| A: This should be evaluated by your physician to confirm your suspicions. With the adequate therapy you noted, this may be from changes in the intervertebral discs, it may be a change in the vertebrae themselves (possibly from malabsorption of calcium or Vitamin D), it may be associated with posture or weight gain and it may be associated with a problem called Cushing's Syndrome. Once the origin of the problem is determined, appropriate therapy, if available, can be instituted. |
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| Q: Should fosomax be used with a calcium supplement such as caltrate? |
| A: Absolutely. When taking any anti-resorptive medication. Calcium must also be taken to help maintain and build bone density. |
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Q:
I'm a 60 year old female
who was recently hospitalized with clots in both lungs. This was
coming off a trip across country by car. The doctor immediately took
me off of my hormone Premarin that I had been taking for 20 years. Two
years ago when I had my bone density test, I had no bone loss. My doctor wants to put me on Evista. My research indicates
that Evista doesn't prevent bone loss. Is this accurate? Medical History asthma- controlled with Serevent Flovent allergies - weekly injections high blood pressure- controlled with Hyzaar irritable bowel overweight-(5"6" 200 pounds) pulmonary embolism- Coumadin |
| A: Evista may very well help maintain bone but the greater concern is why you had the pulmonary embolism to begin with, unless insufficient activity with the car ride led to a thromboembolic episode which broke off a clot and caused a pulmonary embolism. Evista is noted, as is HRT, to increase the very infrequent incidence of thrombophlebitis 2-3 fold. Based upon that, Evista might not be the best choice. It seems appropriate to treat bone loss when it occurs in a patient with your history. With no bone loss to date, medication to prevent bone loss is not recommended or indicated, especially since the bilateral PEs preclude the use of estrogen or SERMS (Evista, etc.) the recommendation is for bone densities every 2-3 years and treat as needed for measured loss. To minimize this, adequate calcium, Vitamin D and weight bearing exercise if able. |
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Q: I was given the results of my bone density test but unfortunately
the doctor did not give me a clear explanation of the meaning of
the figures on the test results. The numbers for SPINE were
Total BMD: 0.738 g/cm2. Peak ref. 70% - Tscore -2.8; Age
matched 91% - Zscore -0.7. For FOREARM R+U 1/3 [L] BMD: 0.508 g/cm2. Peak ref. 74% - Tscore
-3.0; Age mat. 91% - Zscore -0.8. For HIP Total [L] BMD: 0.768 g/cm2. Peak ref. 82% - Tscore - 1.4;
Age mat. 102% - Zscore 0.1 Specifically, for example - re SPINE - Peak reference is 70% and
Tscore is -2.8.
Exactly how do they get 70% Peak and Tscore -2.8? On Age matched it shows 91% and Zscore of -0.7. How do they get 91% and from that Zscore of -0.7.? I know a lot of us don't understand the results and the doctors don't seem to want to explain. Thank you. |
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A: I
always recommend that when patients don't understand their doctor, they
schedule time, as I do with my patients, specifically to explain bone
density results and when therapy is indicated. I have all patients with
abnormal DEXA scores come in for a talk and explanation. You have T scores of -2.8 for the spine, -3.0 for the forearm and -1.4 for the hip. The other numbers relate to specific bone density measured in grams per square centimeter (g/cm2) or the actual bone density. Peak reference refers to peak bone mass normally achieved at age 25-30. This is considered maximum bone density, to which other bone density measurements are compared for the T score. T score is a measure of statistical standard deviation above or below the mean or in this case, peak bone mass. The percentage of 70% or 91% refers to the percent of peak bone mass that a particular measurement represents. 91% means that this is 9% below peak bone mass. The Z score is used to compare a measurement to that of people the age of the patient examined. If you are similar to those your age, the standard deviation should be between 0 and +/-1. If the statistical portion of this is confusing, that's beyond the scope of this forum. Please consult your doctor. Hope this helps. |
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| Q: I am 49 years old and have not had a period in 2 years. I am not experiencing menopausal discomfort and do not want to take hormone supplements. In the last 6 months I have experienced a loss of flexibility. Can this be a symptom of osteoporosis? What are the general symptoms of osteoporosis? |
| A: Osteoporosis has little to no relation to flexibility as you describe it. Osteoporosis, in fact, has no symptoms until a fracture occurs. That's why this disease is so dangerous and insidious. Loss of flexibility may relate to other problems with your bones, joints, ligaments and the like. An orthopedic consultation may be helpful. |
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| Q: I have moderate to severe osteoporosis and have been taking fosamax for 10months and 1,000 mg of calcium daily. My stomach is so bloated and I have constant flatulence. I have gained 15 lbs in the last yr. I tried all kinds of calcium and also began using charcoal tablets. I am taking ginger, fennel and cardoman to help with the gas. What can I do? |
| A: The complaints are possibly related to calcium and not the Fosamax. Calcium can certainly give gastrointestinal complaints such as you note. Taking smaller doses more frequently helps many patients and I find that calcium citrate is much easier on the system than calcium carbonate. The weight gain, alas, is probably unrelated to all of this. You may wish to speak to your pharmacist to try other calcium preparations and again, take it in smaller doses with meals. |
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| Q: I have been taking Fosomax for approximately 1 year. I have been troubled with sore joints every since I started taking it. Right now my ankles are always sore. Almost like I have shin splint. Could this be Fosamax? |
| A: Of late, I have heard more of this specific complaint from my patients with respect to Fosamax. Joint pain (arthralgias) are indeed listed as a common side effect of the drug. |
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| Q: I'm 65 years old and started taking Synthroid dosage of 50 MCG for low thyroid hormone level for the past 4 months. In June 2000 I had a full BMD taken and there was no sign of osteoporosis/penia. Today I had taken the BMD via the foot and my T-score -1.8. Could the Synthroid have any effect on bone loss? |
| A: There are two important points here. First, one must question the result of a foot score in comparison to a full DEXA BMD. The full DEXAs are going to be more accurate. The foot T score is a guide to follow up with a full DEXA. With a thyroid abnormality and a "change" in a foot T score from what you expected, a repeat DEXA may be in order. Remember that Medicare (if you are in the US) may not pay for a repeat this soon, especially if the foot measurement was also a DEXA measurement. |
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| Q: One doctor suggests starting Actonel for my 19 year old daughter, who was recently diagnosed with osteoporosis. He states that she should remain taking her already prescribed Premarin and Prometrium. Another doctor states to start Actonel but stop taking Premarin and Prometrium. Prednisone use has caused her bone loss. She suffers from a seizure disorder and diagnosis acquired brain injury, post viral encephalitis at age 7. Medications cause her weight to fluctuate. She has gained and lost in the past. She does menstruate, but a late start of age 16. She does not have an eating disorder, but medications tend to increase and decrease appetite. I am questioning increased seizure activity with use of any of the three drugs? How progesterone comes into play? Any suggestions whether to combine or not? |
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A:
Bisphosphonates, such as Actonel and Fosamax, get deposited in bone and
can last for many, many years. It is important to note when discussing
the use of such medications on a young patient, that women who may in
the future be childbearing, may need to avoid such medications because
of insufficient data on pregnancy. That being said, estrogen can (though
the mechanism is unknown) increase some of the potential adverse effects
of prednisone.
We have literature to indicate that Fosamax and HRT (estrogen and progesterone) have additive effect on bone. Some have noted betterment of the bone density but others have noted something called "frozen bone" where this increase in producing bone of a potentially "lesser quality" than if Actonel were used. There is disagreement amongst experts on this point. Regardless, the mainstay of therapy with steroid induced osteoporosis is a bisphosphonate. It is not likely that seizure activity would be altered by the medications mentioned. When you ask about progesterone, it is part of hormone replacement therapy necessary to prevent overgrowth of the lining of the uterus. Some recommend the medications you mentioned, others use birth control pills if medically acceptable, to help maintain and / or build bone. |
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| Q: I am 43, non-smoker, have regular periods, take synthroid (3 years). I broke 2 toes and just broke my left ankle (12 screws & a plate) in less than a year. I asked new Dr. to run bone density test. Results - mild to moderate osteoporosis (-2.38). Dr. says age is reason. Are there any other medical reasons why I have developed this? Mother (68) has osteo, as well. He prescribed calcitonin. All info on this drug reads for postmenopausal women. Is this the right drug for me? And again, could there be a medical reason for the development of osteo.? |
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A:
T score of -2.38 is severe osteopenia. Family
history can contribute to the disease but so can inadequate calcium and/
or vitamin D. The thyroid disease can also be a risk factor. In some,
being underweight as a teen and missing your period during the formative
years can be another problem. Long term steroids similarly, can also be a
problem. Malabsorptive problems are also a risk factor. Since you have no
earlier bone density, we don't know if your density is lower than 20 years
ago or no change. A serum NTx can be helpful to evaluate
present bone turnover. As far as the calcitonin, most studies find nasal calcitonin fairly ineffective. You should be evaluated for other metabolic causes and if these can be ruled out, calcium and vitamin D with weight bearing exercises may be the mainstay of therapy. If this proves unsuccessful, bisphosphonates such as Fosamax and Actonel may be more effective. |
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| Q: I have been through an early menopause at the age of 28 (I'm 32 now). I now find that I have osteoporosis but am still unwilling to go on HRT because apart from the bone problem I feel OK. Are there natural alternatives to help me build new bone - natural progesterone cream, estriol? What would you recommend? (I do not want to take Fosamax or biophosphonates). |
| A: At this point, there are no proven "natural" therapies" for osteoporosis. When we say proven, we refer to chemicals, mixtures and the like which have gone through rigorous testing. The best testing upon which to make decisions is a double blind, randomized controlled trial. This type of testing has not been done on osteoporosis therapies other than the bisphosphonates and Evista, a selective estrogen receptor modulator (SERM). |
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| Q: My dr. just prescribed Fosamax for me. But I have read it causes eye problems. Are there any other bad side effects? I'm not sure I want to take this drug. He said my spine was kind of week, when I had a bone density test. Is there anything else equal to this, without the side effects? Thanks. |
| A: With the limited information provided, it is difficult to give a specific recommendation for medical therapy. Many medications may have numerous side effects listed in the PDR and information printouts you may be able to obtain from the druggist. Eye problems are not a side effect I have noted in my patients. |
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| Q: I have been taking Fosamax for 1 1/2 years. In January 2001 at my annual physical I had an elevated liver enzyme. I have since had multiple tests for liver problems and a liver sonogram -- all normal. However, my liver enzyme still remains elevated. Could this be related to the Fosamax? |
| A: No. Although Fosamax is mainly incorporated into bone, a small amount of excretion is handled by the kidneys, not the liver.I have seen no such problem associated with Fosamax and neither did a literature search turn up evidence to make the association. |
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Q: I
am a 62 year old white male who was first diagnosed with osteoporosis two
years ago via a dual beam bone density scan. For years, I had been
an active jogger (2-3 times per week) and aerobic exerciser (stationary
bicycle 2-3 times per week). I have stopped jogging and increased
the stationary bike work.
After two years on Fosamax, coupled with total calcium intake of roughly 2000 mg per day, my condition is virtually unchanged as determined via another bone scan of lower back and hip: "high risk" of spinal fractures, "moderate risk" of hip fracture. Given my active life style, I was surprised by my condition. It is not clear what the cause is/was and what more can be done to address the problem. (I am thankful that my condition did not worsen, mind you!) Does Actenol work by the same mechanism as Fosamax? Is it an option? I have heard about experimental treatments that involve injection of parathyroid hormone to stimulate the bone building cells (osteoblasts?) that might complement the suppression of the bone absorbing cells (osteoclasts?) that are addressed by Fosamax. What is the outlook for this therapy? I understand that some surgical work has been done to "re-fortify" vertebrae by treating them with a plastic (methylmethacrylate?) that hardens and strengthens the bone. Is/does this become an option at some point? |
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A:
Since the Osteoporosis Ask the Expert section is part of OBGYN.net, I
think this is the first male questioner I've seen, and I applaud you
finding out about your osteoporosis and following up on it.
I would wonder why a 60 year old male had a bone density in the first place. Although it did find a problem, doing a DEXA is not considered "standard of care" so was there a predisposing problem that caused the DEXA to be done? Was there steroid induced osteoporosis? Were there fractures without obvious causes? Two years on Fosamax (one might expect the same success rate with Actonel) and 2000 mg of calcium (most experts agree that 1000 mg with a bisphosphonate are enough as well as adequate Vitamin D (400-800 IU)), should have caused a betterment of the DEXA. We sometimes see no change but will statistically see a reduction in fractures, none the less. Without an obvious reason for osteoporosis in a male who exercises and presumably took adequate calcium and Vitamin D prior to the diagnosis, a malabsorptive problem or a parathyroid hormone level abnormality might be the cause. Lack of ability to absorb the calcium or the Vitamin D can be a cause of osteoporosis. There are several possibilities here and this should be looked into by an internist or gastroenterologist. PTH (parathyroid hormone) injections are expected to be more widely available soon and will be a wonderful therapy for selected patients but first the question of malabsorption needs to be settled. Your last question has to do with kyphoplasty. This procedure described in earlier responses in the last month or so is used AFTER vertebral fractures to expand the vertebral dimension after collapse and take pressure off the nerve roots as well as re-direct the axis of the spine in that area. A second answer from Dr. Paul Burstein: I guess I would not have expected those results. As a gynecologist, I can only give a limited response on male osteoporosis - although we should be aware of its existence. Fosamax is approved for male osteoporosis, Actonel is not. It appears that PTH does not have much success in males. I would refer you to a rheumatologist or endocrinologist. Other history would be useful: use of corticosteroids or drugs like Lupron. Lupron is often used in patients with prostate cancer, and as they are surviving longer and longer, osteoporosis will be a real concern. The new procedures such as vertebraplasty or kypheloplasty are used to treat painful vertebral compression fractures. Sorry to be of only limited help. |
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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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