Osteoporosis

Osteoporosis is a condition in which bone becomes brittle, weak, and more likely to fracture. Decreased bone mass is termed osteopenia and puts a patient at increased risk to develop osteoporosis. These conditions occur more frequently in women after menopause. But they can be seen in both men and women, even at much younger ages.

  • Approximately 23 million American women have osteopenia or osteoporosis.
  • This leads to about 1.2 million fractures in women each year.
  • Up to 50% of women over the age of 50 will break a bone due to osteoporosis during their lifetime. The bones at greatest risk for fracture include your hip, spine, and wrist.

Risks for Osteoporosis

Women more prone to osteoporosis include:

  • those with a family history of osteoporosis or fractures that may have been due to osteoporosis
  • Caucasian and Asian women
  • women who are thin or petite
  • those with decreased hormones during or after menopause or surgery to remove the ovaries
  • women who use medroxyprogesterone acetate (Depo-Provera®) injections for birth control.  Discuss this with your physician if you use or are contemplating using this method of birth control.
  • Women who consume 3000 mg or more per day of vitamin A (retinol, not beta- carotene) – this is information published in the Journal of the American Medical Association January 2, 2002

Other risk factors are:

  • lack of physical activity
  • cigarette smoking
  • excess alcohol intake
  • excess caffeine consumption
  • inadequate calcium (little or no dairy products or calcium supplements)
  • medications such as steroids or excessive thyroid hormone

 Do I Have Osteoporosis?

Signs of osteoporosis are frequently not seen until significant damage has occurred. These may include:

  • loss of height
  • certain types of back pain
  • a broken bone from minimal trauma in the hip, wrist, or spine
  • an upper back that is curved forward.
Certain clinical risk factors increase the chance of fracture in women with decreased bone density (those who have osteopenia – see below). These include a prior history of fracture, a bone density of –1.8 or less, fair or poor general health status, and poor mobility (women confined to a wheel chair and those who are bed ridden). Detection of osteoporosis is accomplished with a bone density test or Dexa scan. Some techniques evaluate the wrist or heel which gives incomplete information compared to dexa of the spine and hip. 
The best information is obtained by evaluating the spine and hip with a Dexa Scan. The dexa scan is a painless, very low dose x-ray that takes about 15 minutes to complete. It is recommended (by the National Osteoporosis Foundation) that all women over age 65 be tested and women under age 65 who have risk factors be tested. The test results will be reported as T-scores (or comparison to normal).
T-scores are interpreted as noted:

T-scores       greater than -1.0      Normal

T-scores       -1.0 to -2.49             Osteopenia

T-score         less than -2.5            Osteoporosis

 

The following shows a patient having a dexa scan. Click on image to see larger view.

DXA1

 

 

Prevention or Treatment of osteoporosis

Prevention or treatment of osteoporosis requires all of the following.

  • Estrogen or an estrogen substitute when appropriate
  • Adequate calcium absorption (vitamin D is need for calcium absorption)
  • Weight-bearing exercise.
  • Lifestyle change to address the above risk factors (smoking, excess alcohol, lack of physical activity, and excess caffeine intake)
Prior to the menopause, most women should have adequate estrogen. Exceptions to this include some women with eating disorders such as anorexia and bulimia, and some athletes including some gymnasts and dancers. When the total-body fat content falls below a certain level, deficient estrogen production may be a result. Estrogen therapy is indicated to prevent osteoporosis but not to treat it. Estrogen replacement is a complex decision that should be discussed with your physician. .
Alternatives to estrogen replacement include Fosamax®, Actonel®, Boniva®, Reclast®, Forteo®, Evista®, Miacalcin®, Atelvia®, and Prolia® Estrogen and the alternatives listed above work by decreasing absorption of bone. Teriparatide (Forteo®) is a medication approved by the FDA to stimulate new bone formation – it is taken by daily injection and may be used for up to 2 years. Finally, dietary soy consumption may reduce osteoporosis and cardiovascular disease.
In early 1996 alendronate or Fosamax® , a bisphosphonate, was first introduced.  Other medications added to this group of drugs include Actonel®,  Boniva®, Reclast®, and Atelvia® . These drugs work by inhibiting bone resorption and are used to treat and prevent osteoporosis. A recent study shows these can be used in combination with estrogen to increase bone density better than either drug by itself. Some patients experience stomach upset or heartburn with the drugs when taken by mouth. These drugs should not be taken by women who have significant kidney disease.
The medications may be taken daily, weekly, monthly, quarterly, or yearly (depending on the medication chosen). In order to minimize stomach upset and maximize absorption, the pill should be taken with a full glass of water when you first get up in the morning. You should stay upright and not eat or drink anything else for thirty to sixty minutes. The bisphosphonates do not have any other estrogen-like effect, either good or bad. Oral bisphosphonates are contraindicated in patients who have significant reflux disease (heartburn). Prolia® helps stop the development of bone-removing cells. These drugs can potentially have serious side effects.
A drug called tamoxifen was introduced in the late 1970’s, specifically for treatment of breast cancer. Tamoxifen is actually a member of a group of drugs called selective estrogen receptor modulators (SERMs). More recently, a SERM called raloxifene (Evista®) was introduced as another alternative to estrogen for prevention and treatment of osteoporosis. Raloxifene mimics some of the effects of estrogen in the bone and cardiovascular system but seems to show anti-estrogen action in the uterus and breast. What does this mean to the patient? Like the biphosphonates, raloxifene inhibits bone resorption and is used to treat and prevent osteoporosis. It has also been shown to have positive effects on serum lipids (cholesterol) and has recently been shown to decrease the risk of stroke, TIA (transient ischemic attack), and heart disease in women at high risk for cardiovascular disease. 
Raloxifene does not increase the risk of developing uterine cancer, and a medical study shows that raloxifene reduces the overall risk of breast cancer by 55%. It is not known if the SERMs will have a positive effect, no effect at all, or a negative one on brain function (i.e. Alzheimer’s and senile dementia). The current SERMs cannot be used to treat hot flashes, dryness of the vagina and skin, or symptoms of pelvic prolapse – in fact SERMs may make these conditions worse. This group of drugs cannot be taken at the same time as estrogen since they both compete for the same sites of action in the body. Finally, the SERMs are contraindicated in women with a history of thrombophlebitis (blood clots), significant liver disease, or pulmonary embolus, and should not be taken if a woman is bedridden. 

Calcitonin (Miacalcin®) is used as a daily nasal spray, alternating nostrils. Calcitonin may be used by patients with kidney disease, liver disease, a history of thrombophlebitis, and in patients that are bedridden. It can also be used along with estrogen and does not cause gastrointestinal upset but can cause nasal irritation.

Soy products contain phytoestrogens (plant estrogens) which have weak estrogen activity. Soy products contain isoflavones that are structurally similar to estrogen. Soy products are being studied to see if they will prevent osteoporotic fractures and reduce cardiovascular disease. Most medical studies do not show significant benefits. Some patients report that soy helps relieve estrogen deficiency symptoms such as hot flashes. Soy products do not seem to increase the risk of blood clotting like estrogen does. The standard amount of soy protein recommended is 40 grams per day (contains 118 mg of isoflavones).

Calcium

The best source of calcium is from your diet (mainly dairy products).  If you are relying on a calcium supplement, it is very important that it be taken in a slow release form. A medical study in the journal Heart (2012) showed an increased risk of heart attack in patients taking calcium pills when compared to patients getting calcium in their diets. An author of the study commented that a patient should only take a slow release form of calcium to prevent the level in the blood from rising too quickly.
The only form of slow-release calcium I am familiar with is  Citracal®+D Slow Release which you take 2 tablets in the morning. The recommended daily consumption of calcium is 1200 mg, or for women with decreased bone density and/or over 65 years of age 1500 mg.  Along with calcium, you need vitamin D 600-800 IU daily to improve absorption of the calcium.

Other nutrients that may help reduce osteoporosis include vitamin B6 (1.5mg/day), vitamin B12 (2.4 micrograms/day), folic acid (.4 mg/day), and moderate alcohol (one drink – 14 grams alcohol).

Exercise

Weight-bearing exercise is another important component to prevent and treat osteoporosis. The best forms of exercise are walking and jogging. Ideally this is going to be done for 30 minutes a day, seven days a week. Although swimming is an excellent exercise to reduce cardiovascular risk, it does not qualify as a weight-bearing exercise. Weight lifting is also an excellent exercise to help prevent and treat osteoporosis.
It also provides increased strength, range-of-motion, and balance. If you have never lifted weights before, it is advisable to have a certified trainer help you get started to minimize risk and maximize benefit. Lifestyle change should address the risk factors of smoking, excess alcohol, lack of physical activity, and excess caffeine intake (may reduce absorption of calcium).

The information provided by Advanced Healthcare for Women and E. Daniel Biggerstaff, III, M.D. is for informational purposes only. As each woman is unique, do not rely on this information for diagnosis and treatment. We cannot guarantee the accuracy of the content and advise that you see a qualified Health Care Professional for individual needs and care.

 Advanced Healthcare for Women
5354 Reynolds Street, Suite 518
Candler Professional Building
Savannah, Georgia 31405
 
Telephone 912-355-7717
Fax 912-355-0979
gyndoc@bellsouth.net