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Osteoporosis Ask The Expert |
| Question from Johanna: hormone replacement therapy |
| My mother is 69. She had a total hysterectomy in her early 40's. She had to stop
hormone treatment due to blood clots. She has not been on any HRT since. She now has bad Osteoarthritis, joint
pains, muscle pains, etc. She had Lyme disease a few years ago also in severe stages (10 years ago.) She still
feels better when ever they put her on any antibiotics for sore throats for instance. She had a bone density test
done recently and her doctor prescribed Miacalcin. Mom has been on 1000 milligrams of Calcium with a combination
pill of vitamin D and boron for years. She is becoming more and more bowlegged and has increasingly difficulty
walking (it is painful) She does ride her bike since it is not a weight bearing activity. By the afternoon she
is very tired. Is it too late for her to have hormone replacement therapy, what kind of doctor should she be seeing,
med.'s etc.? Is there a way to reverse this process? Mom has allergies with sinus drainage and gets frequent bronchitis
because of it during the winter months. She takes Allegra. Will this interfere with the Miacalcin? Any information
you could possibly give me would be appreciated. Thank you very much, Johanna |
| Answer from Dr. Marchbein: |
| "Is it too late for her to have hormone replacement therapy?" If a patient has had blood clots associated with HRT, restarting HRT would be contraindicated. "Is there a way to reverse this process?" Bone can be strengthened but new bone is not be formed after mid to late 20s and 30 at the latest. We are constantly breaking down bone and replacing it with newer bone on the same lattice work throughout life but new lattice work within the bone is done by age 30. Miacalcin does not seem to work as well as Fosamax and Fosamax doesn't work quite as well as ERT/HRT (with some exceptions). Incidentally, Fosamax and HRT work better than either one alone. The doctor should be queried about the pros and cons of Fosamax for your mother. "Mom has allergies with sinus drainage and gets frequent bronchitis because of it during the winter months. She takes Allegra. Will this interfere with the Miacalcin?" Miacalcin occasionally causes nasal stuffiness but Allegra will not interfere and, in fact, by controlling allergic symptoms, allow the usage of Miacalcin if that is the best choice. "what kind of doctor should she be seeing?" The type of physician is not as important as having one that is well versed in osteoporosis and its varied therapies, usually a gynecologist, an interested Internist, Endocrinologist or Rheumatologist. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question About Body Mass Index |
| Is there any relation between body mass index (BMI) and osteoporosis |
| Answer from Dr. Marchbein: |
| Two well known risk factors for osteoporosis are being thin and losing weight over
age 50. Extrapolating that to BMI, being on the very low end of the BMI scale would seem to be a potential risk
factor. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question About Multiple Sclerosis and HRT |
| Can you provide me with any information or known contraindications for a lady with multiple sclerosis prescribed hormone replacement therapy? |
| Answer from Dr. Marchbein: |
| None that I'm aware of. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Trish: About Fosamax |
| Hi, My name is Trish, I am 48 years old, very small frame, white and I smoke....I
had what I guess is early menopause which started I would say at the age of 44 or before (was diagnosed at 44).
I have now been told that I have osteo in my left hip (the only one that was checked with the bone density test)
and osteopenia in my spine. I have been started on Fosamax and have only taken 2 doses. I have never had a fracture
of any kind, my gyn just wanted me checked due to my size etc. I have lost only 1/2 inch in height but do not know
in what time frame this occurred. I am 4 foot 11 inches and 100 lbs. I also take Prempro and have for the last
4 years. I am also taking Viactiv as my calcium supplement. I have many questions and hope that I do not overburden
the person who gets this message. Oh and I was told that I had lost 33% of my bone mass.
1) How much risk am I at for breakage with a 33% loss of bone mass?
2) Would drinking more than 8 oz of water with
the pill each morning decrease the risk of possible side affects. 3) Can I take aspirin with Fosamax. I take it for head aches and not very often.
4) If I am getting calcium with the foods I eat
and the milk I drink should I continue to take the supplement? Will it help.
5) Does extra calcium really increase the risk of kidney stones? I have never had any of
them nor has anyone in my family. 6)
How much of my bone mass will come back with the Fosamax? My doctor says she wants me on it for 2 to 3 years with
another bone scan done in 2 years. I am sure I have asked too many questions but this is all new to me.. Thank you for your time... Trish |
| Answer from Dr. Marchbein: |
| Fosamax is excellent for osteoporosis. HRT may even be better except for the 10-15%
of women whose bones don't respond to HRT. How much risk am I at for breakage with a 33% loss of bone mass? 1) That's part of the report your doctor has and is determined by a computerized table. Ask your doctor specifically about you. Would drinking more than 8 oz of water with the pill each morning decrease the risk of possible side affects. 2) The company recommends 8-16 ounces of water and they feel (according to my local rep) that more water is better (12-16 ounces rather than 8). Can I take aspirin with Fosamax. I take it for head aches and not very often. 3) Aspirin is OK with Fosamax. If I am getting calcium with the foods I eat and the milk I drink should I continue to take the supplement? Will it help? 4) While on Fosamax, Calcium 1000 mg per day is required. In that you do not absorb more than 500-600 mg at one time, split dosing (as you are doing with Viactiv) is fine. More Calcium per day won't hurt but may not help. Does extra calcium really increase the risk of kidney stones? I have never had any of them nor has anyone in my family. 5) In an article in the New England Journal of Medicine 1993, calcium intake does not lead to kidney stones. How much of my bone mass will come back with the Fosamax? 6) It depends. For this you'll just have to wait and see but results are usually quite good. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Anonymous: About Raloxifen |
| Do you have information on Raloxifen? What are the pro's and con's? |
| Answer from Dr. Marchbein: |
| The complete answer would take days of lectures. Essentially, raloxifen or Evista
is a selective estrogen receptor modulator or SERM. It can help the heart (reduce cardiovascular disease) but not
as much as hormone replacement therapy. It can help the bones (prevent osteoporosis) but not as much as hormone
replacement therapy (approved to treat osteoporosis). It has no adverse effect on the breast and may even reduce
breast cancer. 25% of patients get hot flushes and many get vaginal dryness. We have no idea how it will affect
Alzheimer's, colon cancer incidence, macular degeneration and a host of other problems that hormone replacement
therapy may help. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Tracey: About Osteopenia |
| Hello, I am a 34 year old woman who has just been diagnosed with osteopenia. I am 5 ft 1 and weight 7 stone 10 lbs. Both my mother and grandmother have osteoporosis. I have been taking the contraceptive injection Depo-Provera for 2 years now and for 3 years I have not eaten any dairy products (except yogurt) due to sinusitis. My consultant has told me that I need to produce more estrogen and so I have 3 options. The first is to go back on the pill. The second is to take estrogen with another form of contraceptive. The third is to keep taking Depo-Provera and have a non-bleed HRT. I do not want to stop taking Depo-Provera as I enjoy not having any periods. However I do not want to take HRT due to my young age and the risk of cancer.I would be grateful if you could advise me on the best path to take. Do you think if I just increased my calcium intake and did weight bearing exercise this would be enough? Thanks for your help Tracey |
| Answer from Dr. Marchbein: |
| Osteopenia can be mild, moderate and severe. It is unusual that one so young would
have had a bone density and the exact levels would have been helpful. A bone turnover result (NTx) would be helpful
to determine if this is recent or long standing and possibly normal for you. Although you state reasons for eliminating dairy products, calcium is found in many foods, including broccoli, okra, salmon in the can with bones, sardines, soy milk and the list continues. In addition, calcium supplementation is available. At a younger age, higher estrogen levels would be more helpful, i.e. the pill should be more successful than HRT. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Find more information on adding calcium rich foods to your diet here |
| Question About Improving The Density Of The Spine |
| I am a white female 61 years young. I went through menopause at 42 and did not go
on HRT for 2 years. I later had a partial hysterectomy. and I am still taking Premarin. I am slender, take anticonvulsants
drugs (Phen & Dilatin) for 50 years. I have read that Dilatin interferes with the absorption of vita D needed
to absorb calcium. I went for a bone density test and it came back that I have osteoporosis in my spine. I have
an appointment to see a certain specialist as they said they specialize in osteoporosis and diabetes. My question
is can I improve the density of my spine through exercise, a calcium supplement and also doing weight bearing exercises?
Also will it help my body to better absorb calcium if I take my calcium supplement with boron and Premarin and
then about 1 hour later take my Dilatin? I really appreciate any help you can give me. Thank you. |
| Answer from Dr. Marchbein: |
| Depending upon the level of osteoporosis, it might pay to get a bone turnover level
such as a urinary NTx to determine if this is ongoing or if this is long standing. Malabsorption of Vitamin D is a critical problem in that it is the "key" to allow calcium into the bone. Calcium and weight bearing exercises are helpful but may not build new bone, or rather, make the remaining bone more dense. Lack of calcium and vitamin D may be the origin of the problem in that estrogen therapy prevents upwards of 85-90% of osteoporosis. Boron has not been shown to aid in calcium absorption as vitamin D has. The specifics of medication timing would be best discussed with the endocrinologist. Other treatment options include Fosamax and Miacalcin. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Joyce : About Water Aerobics |
| I am in a water aerobics class for senior citizens. We do a lot of "jogging"
and "jumping and twisting" exercises in the pool, some weight lifting using bottles filled with 2 to
4 pounds of water, lifting above head, arm curls, butterflies, etc. Also use Styrofoam dumbbells pushing &
pulling under the water with our arms. We do leg lift exercises, figure 8 with legs, kicking water, etc. It's a
real good workout for "range of motion" and really makes us all feel much better and more energetic.
In addition, I am swimming laps 3 to 4 mornings per week, about 1/2 hour each time - good hard swimming. Are these
exercises of any value in retaining or building bone? Joyce |
| Answer from Dr. Marchbein: |
| Recent data seem to indicate that weight bearing exercises of any sort do more to
build muscle mass and muscle coordination (which, together, reduce falls and fractures) than they do to build bone
mass. It may, however, enable people to maintain bone mass in conjunction with adequate calcium intake, adequate
Vitamin D intake and avoidance of risk factors. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Rita: Pre-menopausal osteoporosis |
| After completing 40 years of age, my gynecologist asked me to undertake a routine
bone density measurement. The results indicated severe osteopenia and osteoporosis in the proximal femur regions
neck BMD = 0.682 / T = -2.48 / Z = -1.94 wards BMD = 0.546 / T = -2.80 / Z = -2.14 trunk BMD = 0.538 / T = -2.29
/ Z = -1.88 Measurement for the lumbar region was diagnosed as normal (L2-L4 BMD = 1.098). The measurements were
performed using a Lunar System owned by one of the best Brazilian Clinical Labs (internationally certified). Personal data: Age: 40 years Height: 156 centimeters Weight: 51.0 kg Ethnic group: White Caucasian (Spanish, Italian and Portuguese ancestors) Health: Very good, no major illness. Three normal pregnancies and deliveries. No bone fracture. Hormone levels: Normal (I never used hormonal birth control methods). Menstrual cycle: Normal. Eating habits: well balanced diet. Physical activities: 1) moderate to intense - 3 times per week - 1 to 1.5 hours per session * aerobic exercises (steps, ergo metric bicycle) * weight lifting * "body-pump" 2) horse back riding: endurance rides (35 miles ride) on National Championship level. Family history: Mother 65 years old: no osteoporosis 2 aunts with osteoporosis: 1 from my mother's lineage (63 years) and 1 from my father's lineage (73 years) I was shocked and worried with the result and decided to retake the bone density measurement in another top Brazilian lab (also internationally certified). The measurements were made only 30 days after the first exam, also using a Lunar equipment. The results were similar: neck BMD = 0.701 / T = -2.3 / Z = -1.8 wards BMD = 0.582 / T = -2.5 / Z = -1.9 trunk BMD = 0.546 / T = -2.2 / Z = -1.8 I also performed a total body densitometry (using the same Lunar equipment). The results were: TOTAL BODY BMD (g/cm2) = 1.105 +/- 0.01 TOTAL BODY % young adult = 98 +/- 3 TOTAL BODY % age matched = 103 +/- 3 I have consulted three doctors : a Gynecologist, an Endocrinologist and a Rheumatologist, all of them very competent clinical professionals and linked to top Brazilian medical schools. They all have treated patients with "classical" peri and post-menopausal osteoporosis but never had patients with a pre-menopausal case. They found no explanation for my case and the although I have been submitted to comprehensive tests to search possible causes. Since osteoporosis is a degenerative disease, I would like to know what may be causing the early onset of the disease and what is the appropriate treatment for my case. If necessary, I can also send (by mail, e-mail or fax) the results of my clinical tests. I thank you very much for your attention. Sincerely yours, Rita |
| Answer from Dr. Marchbein: |
| With such an interesting case history, this was presented to the entire Osteoporosis
Board. The responses were all similar but put most succinctly by Dr. Barry Gruber- "I would be interested in her bone turnover markers and most likely (unless these showed marked increased turnover values) sit and repeat the DEXA in 12 months to see if these values are stable. If so, then I would suggest waiting until perimenopausal age and then treat with an antiresorptive agent. Did the work-up rule out hypercalciuria, Vitamin D malabsorption, etc. (without these details it is difficult to fully advise)..." Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Linda: About Fosamax |
| Hello, My mother in law is 81 years old and has had osteoporosis for years. She has had one broken wrist, and has fractured a few vertebra. At the urging of my husband and I, she finally asked her physician for a medication to help her. She has been placed on Miacalcin. My question is whether Fosamax should be used instead? I seem to find it the drug of choice. She did have breast cancer about 15 years ago. Thank you very much for your time. Linda |
| Answer from Dr. Marchbein: |
| Fosamax seems to be superior to Miacalcin in most studies for increasing bone density
patients with osteoporosis. Neither of these medications will adversely affect her past history of breast cancer.
Knowing nothing else about your mother's medical problems, there may be another reason why her physician recommended
Miacalcin.... possibly the timing required to take it....on an empty stomach with 1-2 full glasses of water and
waiting 30-45 minutes before eating anything else or lying down. This should be discussed with her physician. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question from Coryl : About enjoying Life With Osteoporosis |
| I work for a women in her early 70's who has osteoporosis. She has broken several
bones, walks with a walker and is in a lot of pain. The doctors tell her there is nothing else they can do to help
her. She was a very active women until this all started and it drives her crazy to not be able to do the things
she used to do. Is there really nothing that can be done so that she might be able to enjoy life a little? Coryl |
| Answer from Dr. Marchbein: |
| Unfortunately, once multiple bones are broken, the betterment of quality of life
is in the field of physical therapy and occupational therapy. She should see a physician about medication to strengthen
the bone that remains. This will not rebuild bone that is gone but rather thicken the microscopic bone-bridges
which still exist Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question From Concerned: About Osteoporosis After A Hysterectomy |
| I am 39 years old and recently had hysterectomy because of endometriosis. I am apprehensive
about taking HRT because of remaining adhesions on my colon. Are there any alternatives that I can do to prevent
osteoporosis? Should I be getting a bone scan periodically? Thank You! |
| Answer from Dr. Marchbein: |
| Most patients with complete extirpation of endometriosis can go on HRT. This must
be discussed with the operating physician for any particular case. In that you have been put into surgical menopause,
menopause recommendations apply. Bone density readings would not be inappropriate. Unless there were predisposing
factors, it would usually not be necessary now. Prevention of osteoporosis involves adequate calcium intake from
a very early age through the teens and early-mid twenties for maximum bone density. For maintenance of bone, adequate
calcium intake, adequate Vitamin D, weight bearing exercise and ERT or HRT would give maximum benefit. Many physicians
recommend HRT (as opposed to ERT) in cases of endometriosis even when the uterus has been removed in order to continue
endometriosis "suppression". This is not a universally accepted concept but bears discussion with your
physician. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question From Marilyn: About |
| I am a 61 year old woman who has been taking Fosamax for three years because a bone
density scan showed significant bone loss. Oddly enough, I had been taking hormone replacement therapy for a year
prior to having the DEXA-scan. Last year, which was after taking Fosamax for two years, a DEXA-scan showed great
improvement. This year, however, the DEXA-scan showed improvement in my hip but a loss of almost 3% in my spine.
I have also lost over 1/2 inch in height over the past year. I had stopped taking the hormones at the time I started
taking the Fosamax three years ago because of a blood clot in a superficial vein in my leg. I take calcium and
Vitamin D and get exercise regularly. Can you explain the bone loss over the past year even though I am taking
Fosamax? I would appreciate your help. Thank you very much. Sincerely, Marilyn |
| Answer from Dr. Marchbein: |
| DEXA scans should probably be done at 2-3 year minimums. Yearly DEXA's will frequently
confuse the picture as it appears to have done here. A 3% change in either direction after 1 or 2 years in within
the normal standard deviation of the test (essentially no change). In other words, this "loss" is not
confirmation of a true loss. A more helpful test in the short term is a comparison of the NTx (a urinary (and now
blood) test for the chemical products of bone turnover) before and three months after new therapies have been initiated.
The maximum gain with Fosamax is noted in the first year or two and that is consistent with your history. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question From anonymous |
| Please explain the process in which the back "humps out". I need to know the hows and whys of the formation of the hump. We cannot get our sister (in-law) to get a density test. Her mother was severely humped at death at 83, an aunt died from hip fracture complications at 84 (with hump) and a sister already has hump at 67. |
| Answer from Dr. Marchbein: |
| The so-called "Dowager's hump" is a frequent sign of osteoporosis. Compression
fractures of the vertebrae in the upper back cause the vertebrae to become "compressed" in the front,
causing the spine to look curved like a hump. Patients like this require appropriate testing, follow-up and treatment to reduce the chance of future fractures. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question From Dennis: about Osteoporosis Secondary to Spinal Cord Injury |
| Hi I am looking for information on osteoporosis secondary to spinal cord injury and associated bed rest. Any information you could provide would be greatly appreciated. In particular I am looking for information related to how long it takes for Osteoporosis to develop from the time dis-use begins? I was diagnosed with Dis-Use Osteoporosis, when I was 46 years old. I had a spinal injury that rendered me completely immobile for a length of time. The Diagnosis is as follows: 1. Caudal Equina Syndrome. 2. L5 and S1 radiculopathy. 3. Dis-use osteoporosis. 4. Multiple Vertebral Compression Fractures. (11 in total ) 5. Complex regional Pain syndrome Type II, Causalgia. 6. Gibbious formation. The Doctors have agreed that a fair chronology for the evolution of my condition is as follows: The accident of May /95 caused, cauda equina syndrome with a sensory radiculopathy involving the L5 and S1 nerve roots, and at least one compression fracture, which in turn caused bed rest and associated immobility, which in turn caused dis-use osteoporosis, which in turn caused multiple vertebral compression fractures. I would very much appreciate a response to to the following questions.: 1. How long does it take for Dis-Use Osteoporosis to develop? 2. Is it possible for Dis-Use Osteoporosis to develop within 18 days from the initial trauma, with total bed rest for the entire 18 days. 3. Is it possible to accurately diagnose osteoporosis from plain radiographs, unless it has progressed to a level far more significant than a loss of 2.9 standard deviations compared to a young adult? Thank you for taking the time to review the above information. Your response to the above noted questions would be greatly appreciated. Thanking you in advance, Dennis |
| Answer from Dr. Marchbein: |
| #1 This has not been well studied until now. I can find no accurate information at
this time. (see Dr. Gruber's note below) #2 Presuming no osteoporosis prior to bed rest, 18 days is insufficient. The exact amount of time necessary has not yet been determined. (see Dr. Gruber's note below) #3 Plain X-rays may give the indication of osteoporosis by their appearance, but quantification like that of bone densities is not possible. Barry L. Gruber, M.D., Chief of at Stoney Brook University School of Medicine and one of many world renowned osteoporosis specialists on our editorial board, wrote: "I have recently reviewed the literature on disuse osteoporosis secondary to spinal injuries and designed a research project in this area. The literature is relatively scanty but suggests that bone loss is rapid and often severe in the first year and then slows down thereafter. I found nothing on treatment and hence this is the area that we designed a study." Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question About Hereditary Risk Factors |
| Can Osteoporosis be hereditary in women? |
| Answer from Dr. Marchbein: |
| A family history is considered a risk factor. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
| Question From Judi: |
| I am 49 years old and took HRT for two years. I quit two months ago because of hair
loss and elevated blood pressure. Both are improved (hair loss not for sure). This week I was diagnosed with osteoporosis
(I seldom drink milk or eat cheese,yogurt, etc.) - am vegetarian. My doctor put me on Fosamax. My question is,
"Will I be on this permanently or does it repair bone loss and then one goes off of it?" Because of severe
foot pain for the past two years - neuroma, plantar fasticitis, bunion, tendonitis, surgery- I have done very little
weight-bearing exercise. I have been ballroom dancing for the past 10 months but not frequently enough to qualify
as good exercise. What exercise can I do to improve my bone strength without stressing my feet? Thank you very much for your assistance. Judi |
| Answer from Dr. Marchbein: |
| First point for all readers is that it is unlikely that the HRT alone is responsible
for either of the problems you indicate in the beginning of your note. "Will I be on this (Fosamax) permanently or does it repair bone loss and then one goes off of it?" This depends upon the amount of loss and the speed with which the bone density increases. Fosamax does not rebuild bone that is lost. It thickens and strengthens bone that is remaining. Weight bearing exercises with the number of orthopedic impediments you have may be best left to a physical therapist or physiatrist. Harvey S. Marchbein, M.D. FACOG, FACS Chair, Osteoporosis Section, OBGYN.net |
|
**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. |
