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

 

Print this page
OBGYN.net Advertisement
OBGYN.net Publications Osteoporosis Ask The Expert December, 2000

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

R. Wayne Whitted, MD., MPH, OBGYN.net Editorial Advisor 

Q:  Is there any evidence linking Fosamax and weight gain?

A:  None that I am aware of or can find literature for.
This question answered by Harvey Marchbein, MD, OBGYN.net Chairman Osteoporosis Editorial Advisor

Q: I am 36 years old, and was diagnosed with Transient osteoporosis associated with my pregnancy which started in my third trimester. I am 3 weeks post c-section with a healthy baby girl, and have been on Fosamax daily for two weeks now and 1800 milligrams of calcium daily. The pain I had in my hip and knee has gone away but still have severe pain in one of my feet. X-rays have been done and there is no fracture, an MRI revealed the diagnosis of osteoporosis. How much is known about pregnancy related osteoporosis? I am finding it hard to find information on it. How soon should I expect relief or recovery? Can you suggest any other ideas of treatment I might mention to my doctor?
A: You have what appears to be a complex situation. You need to have a dexa scan in order to help follow treatment. It is important to see an endocrinologist to have secondary causes of osteoporosis evaluated. Once this evaluation is done than appropriate treatment options can be decided. Generally speaking, osteoporosis is a non-painful disease unless there is fracture.
Q: I am 46 years old and have endometriosis. I had a complete hysterectomy 10 years ago, but cannot take RET because of the endometriosis. I have been diagnosed with osteoporosis, and also have a history of intestinal difficulties (caused by scarring from the endometriosis): irritable bowel, chronic constipation, ulcers. What would you recommend as the best drug treatment option? I exercise and take calcium supplements.

A:  Evista and Fosamax or Actonel can be used for the prevention and treatment of osteoporosis.  I'm not sure why you can't take ert unless you had a recurrence of endometriosis while on it.  I would ask my doctor about the above options.
Q: I am a 52 year old woman with osteoporosis of the low back and osteopenia of the hip.  My scores were something in the area of -3.5 - that's the low back and I understand that's pretty bad.  I found out I had this after searching for an answer to back pain over the last 3 years. At the time I was diagnosed, I was still having menstrual periods, but am now in menopause.  I have been on Fosamax for about a year.  After seeing my ob-gyn Dr. for a yearly pap, he has suggested I switch to Evista.  I have 2 sisters that have had breast cancer, so ERT is not an option for me.  My question is:  Is Fosamax or Evista the best medicine for me to be on?  I have researched this a lot, and it sounds like the Fosamax is better for bone building, but the Evista sounds like a good thing for me too - because of the breast cancer risk.  Can I take both medicines?
A: Bone stability is very complex and more involved than bone density readings.  what we know to date is that Fosamax and Evista near equally prevent fracture from available fracture data, especially in the spine.  This is despite differences in improvement of bone density.  Unfortunately there are no studies looking at the synergistic effect of the two medications.  Given your strong family history of breast cancer the protective effects of evista may be important. This too is being studied now. You may consider trying both medications for one year with a f/u BDS.  It is very important to prevent the first fracture if possible.

Q: I am a 47 year old women with regular periods.  I have been diagnosed with osteoporosis. I am small frame, fair, history of osteoporosis in my family.  I have led an active life style, do not drink or smoke, but did not have enough calcium growing up.  My doctor has prescribed Evista with increased calcium intake.  It is specifically only prescribed for women in menopause. Is it unsafe to take Evista while my body is still producing natural estrogen?

A: Evista, although a good medicine for the prevention and treatment of osteoporosis, is not indicated until a women is postmenopausal (no menses for 12 months). 
Q: Please give me some information on Alendronate (Fosamax). I already take HRT and calcium forte tablets. In 1 year my bone density has increased by 4%. I am very reluctant to take this and would welcome comments.
A:  HRT and calcium with vitamin D  along with exercise and minimizing environmental risk factors to bone loss is the first and second line therapies to keep the bones strong.  Fosamax, Actonel, calcitonin nasal spray is used more frequently when bone loss is significant making the person at risk for further fractures.  These medications are osteoclastic inhibitors which allow some bone buildup.  They also have been shown to reduce fracture risk.  The main side effects of Fosamax and Actonel are stomach complaints.  The nasal spray can cause rhinitis.
Q: My 65 year old aunt has been a health nut for years.  She takes many herbal and vitamin remedies for all her ailments, but rarely eats meat or dairy products.  Lately, she has been having a lot of stomach problems and her doctor has detected that two of her vertebrae have severely deteriorated due to osteoporosis.  She does not want to undergo any large medical procedures
or take much prescribed medicine. I have heard that calcium and osteoporosis related medicines may be harmful to the stomach and esophagus. Are there any ways to halt the osteoporosis from continuing without damaging more of her stomach lining? Are there any home remedies?
A:  Your aunt sounds like she has complex medical issues to consider.  Calcium is a benign medication but some people get terrible stomach cramps with it.  Generally Tums (calcium carbonate) is well tolerated by even people with "stomach problems".  Your aunt may consider diets high in soy, although no good science to date shows that soy protein can inhibit bone loss.  She needs to be regularly exercising, taking 1500mg calcium daily and 400IU of Vitamin D.  I would have her discuss her options with her primary care physician and someone who understands the patient that likes alternative therapies.
Q: I have osteoporosis and am taking evista and calcium ever day but I have been on steroids for 26 years and I have real concerns.  I'd like to know what to expect down the road.  I'm afraid someday I will be in a wheel chair. My Doctors are great-but of course tthey won't predict. I have Scleroderma and Bulbous Phemigus and that is why I'm still on steroids. I take 10mg. ever other day. I can't go lower-we've tried but I get weak and very tired.  Any suggestions would be helpful.
A: You are in a difficult situation.  Unfortunately, few studies have been done to determine the efficacy of medications against steroid induced osteoporosis.  to date only risedronate (Actonel) has been studied and has been shown to increase bone density.  Unfortunately the studied did not have significant numbers of events and people to determine whether fractures were actually significantly impacted.  You may consider the synergistic effect of both evista and a biphosphonate such as Actonel.  Again no studies have really looked at this issue but it makes sense.
Q: I am 43 years old, peri-menopausal (never missed a period yet)  with bone density readings in the -2.5 to -3.3 range. I have been on Evista for over a year, recently the hot flashes have become worse and more uncomfortable. I began taking soy (55 mg isoflavones) in hopes of reducing the hot flashes. After nearly three months of a daily tablet I have suddenly developed very sore breasts, bloating and other "PMS-like" symptoms during the early part of the cycle and see no relief as the days pass. Could the combination of still having my own estrogen, taking the Evista and high concentrates of phyto-estrogens be causing my very sore breasts and other symptoms?
A:  Firstly, evista is not indicated in the perimenopause or in women having menses.  It is indicated in a woman who has stopped menstruating for 12 months and is menopausal.  Your bone density is alarming and suggest secondary reasons for the cause of your bone loss. These need to be investigated.  Your pms symptoms suggest that you are still ovulating and at best are perimenopausal.  Although I am a proponent of phytoestrogens, they have not been shown to significantly impact bone loss or fracture and therefore I would proceed with caution at this time.
Q:  I am a 38 year old female with a history of systemic lupus.  I recently completed one of the most intensive chemotherapy treatments for diffuse proliferative glomerulonephritis using plasmapheresis, Cytoxan (22 grams in 6 months) and steroids(150mg tapered to 0mg).  I am currently off the cytoxan and prednisone.  I am now taking Plaquenil, 200mg per day.  Due to the cytoxan therapy I am now in menopause.  I am taking calcium supplements 600mg twice daily along with eating/drinking foods with calcium.  My last dexa scan (Jan 2000) was slightly decreased from the previous year yet in the normal range for my age. My questions are: Is Fosamax safe for someone like myself who has a history of Class IV kidney disease?  I understand that a change in its administration has been recommended from 5mg/day to 40 mg /week for preventative and 10mg/day to 70 mg/ week for treatment of osteoporosis.  Do you have an opinion on this recent change?  My kidneys are currently functioning at 85% with protein of 450mg and serum creatinine of 0.9.  My fear is that the Fosamax might flare the lupus in my kidneys as for me this has been the primary attack of my lupus.  I also have an inherited blood disorder, APC resistance, where my blood tends to clot more easily.  I have had a history of blood clot after my son was born.  I also have tested positive on some occasions for anti-cardiolipin antibody.  Because of this I am not a candidate for estrogen. Estrogen has also been considered a possible trigger for lupus patients.  Is progesterone known to be beneficial?  Would Actonel be beneficial in my case? I am a very small framed and light weight person....5'4'' (shrunk one inch) weighing 110 pounds with a history of steroid use, now menopausal, so I know I am the prime candidate for osteoporosis.  I appreciate any comments and recommendations you all may have.
A: You have a very complex problem that needs the input of an endocrinologist.  You are not a candidate for estrogens or evista because of your clotting issues.  the bisphosphonates are metabolized by the kidney but will not flare your lupus.  The recommendations are to alter doses if creatinine clearance is less than 35ml/min. Always, you should evaluate your bones in relationship to the t-score which compares you to the healthy 30 year old women.   
Q: I am a 44 year old pre-menopausal women.  I had a bone density test in 1998 which showed a -1.6 in the neck of my femur and only slightly better readings in the rest of the hip area. This test was at my request as my mother has osteoporosis --  I'm white, small frame, have had a low calcium intake since a baby (do not like milk and stayed away from cheeses because of the fat content), and am somewhat sedentary due to a damaged joint in my left ankle that began in 1994.   I requested another test this year as I have been taking 1200 mg of calcium since the 1998 test results and have tried to increase my activity.   This year's test shows the neck of my femur is a -2.0.  Other hip readings are slightly better than 1998 results.  Spine tests show anywhere from a -1.0 to -1.5.  At my request, my gynecologist is referring me to a rheumatologist as she indicates they are the experts on bones and therefore osteoporosis.  Is this true?  What possible medications can a pre-menopausal woman take to build bone back so that they don't actually get full blown osteoporosis (-2.5).  Everything I have read indicates all medications are designed for post menopausal women.  It may be quite a few years yet before I become menopausal and need to do something now (not later) to build bone mass back. Thanks for taking my question.
A:  Actually, I would refer you to a endocrinologist who specializes in osteoporosis.  However, you can help yourself.  You need to consider you personal risk assessment and alter the problem areas.  There are other exercises you can do that can take into consideration the ankle issue.  Do not let this be a deterrent to healthy living.  Secondary reasons for osteoporosis need to be evaluated.  Medications are available to assist you in building bone back but to not take away your need to improve you daily living issues.
Q: Can you tell me if Actenol or Fosamax have any steroids or any estrogen replacements in them?
A:  Neither of these drugs have steroids or estrogens within.
Q: I am a 49 year old obese but physically active white female who, until age 35, drank huge quantities of milk.  All my life, I have had plenty of weight-bearing exercise including resistance training.  About 6 months ago, my dental hygienist commented that I had bone loss in my jaw out of proportion to my oral health and she did not understand that.  So, at my annual gyn appt., I mentioned that to my physician.  Since my periods had been regular up until 4 months ago and I was apparently still ovulating, I am not taking any hrt. It was decided to order bone scan.  I don't smoke, I do take Flonase (and have for past ten years, for perennial allergies) though it is not supposed to be systemically active. I take 1000 mg calcium and a multiple vitamin with 400mg Vit D. I also appear to have lost .75 inch in height.  My mother, at age 70, is fine.  I have always assumed, because of all the milk, exercise and heavy weight, that bone loss was one of my lesser concerns.  The bone scan showed mild osteopenia.  The only symptom of perimenopause is the last 4 months of irregular bleeding.  Are these tests ever wrong or misleading?  What's the best course of action?  And how much coffee is too much?  Also, about 13 years ago, it was thought I may be developing Rheumatoid Arthritis and I had x-rays of my hands and feet. Would these be helpful in assessing rate of loss?  Thank you for any thoughts you may have.
A:  One bone density scan gives a person an impression of the strength of bone at any given moment but it is comparing one scan with another that helps us understand the rate of bone loss in any given individual.  Mild osteopenia is likely nothing to be concerned about.  I would like to see the actual T-score values in order to interpret your bone density.  Remember anything less than -1SD is consider normal bone.  It takes 4 glasses of mild daily to provide adequate calcium and we know the average American takes in about 500mg/day. Also it takes a minimum of 30min daily weight bearing exercise to help promote bone stability.  This program is above and beyond normal activity in the day.
Q: I am a 49 year old premenopausal woman just diagnosed in Sept. with osteoporosis.  I don't have my numbers, but the dr. said that unless we can stop the bone loss, I'm at risk for spontaneous fractures by the time I'm 60.  I tried Fosamax but was unable to take it due to esophageal problems.  I am currently taking Miacalcin. I eat well, exercise, don't smoke, did not have a late menarche, but am a thin Caucasian with a family history of osteoporosis. I have just sustained a stress fracture in my hip. I am really curious as to any information on osteoporosis in premenopausal women - everything I read describes it as a postmenopausal problem. I also have a history of calcium kidney stones.  We have checked for parathyroid function, which seems to be normal.
A:  Without all of the information it is difficult to offer information.  I need to know the exact t score analysis.  Have you had a risk assessment analysis looking at all of the risks for osteoporosis.  Have you been evaluated for secondary causes of osteoporosis?  I would recommend considering finding a good endocrinologist to evaluate this problem.  Premenopausal osteoporosis is unusual and suggest another problem that needs to be investigated.