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This month we review information related to osteoporosis and what options women have.


Osteoporosis vs. Osteopenia
Osteoporosis is a disease in which the bones become extremely porous (at least 70% bone loss in order to be detected on routine chest films or spinal X-rays), and are subject to fracture. These bones heal slowly and it occurs especially in women following menopause and often leads to curvature of the spine from vertebral collapse. Osteopenia is a clinical condition whereby the generation of new bone material is insufficient to compensate for normal bone loss. Osteopenia can be reversed more easily and responds well to weight bearing exercise and calcium/vit D supplementation (if there are no metabolic causes).
Diagnostic procedures used to determine bone loss include DEXA (Dual Energy X-Ray Absorptiometry) more commonly known as a bone scan test or densinometric CT scan.





Health Tips
Research has identified risk factors that commonly effect post menopausal women. These include:

-Cigarette smoking
-Alcohol abuse
-Physical inactivity
-Thin habitus
-Diet low in calcium
-Little exposure to sunlight
-Glucocorticoids (7.5 mg/day or more of prednisone for more than 6 mo)









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OSTEOPOROSIS

There has been quite a bit of discussion in the medical literature and the popular health media about a common bone condition that primarily affects post menopausal women but can in fact be a problem for a larger segment of the population. Recent literature has suggested that even men aged 31 to 87 years can benefit from pharmacologic intervention to combat osteoporosis.(1) But is it necessary? To help put things into perspective, we have reviewed articles published in respected, peer-reviewed, health and medical journals.

BACKGROUND

In order to gain an understanding of the current concepts in osteoporosis there are a few terms that need to be described.

Common drugs used to treat osteoporosis include:
Alendronate Sodium, more commonly known as "FOSAMAX" exists as 10 mg oral. It has been associated with esophagitis and upper GI upset with an increase in acid reflux symptoms.
Etidronate Disodium, more commonly known as "DIDRONEL" exists as 400 mg oral. More commonly used in the treatment of moderate to severe symptomatic Paget’s disease of bone. Symptoms include diarrhea, loose stools, nausea, GI upset, abdominal discomfort, vomiting and occult blood in stools.
Taken from the American Hospital Formulary Service Drug Information.


MISCONCEPTIONS OF OSTEOPOROSIS THERAPY.

Most drugs used to treat osteoporosis are termed antiresorptive drugs. This term misleads as bisphosphonates (DIDRONEL AND FOSAMAX), actually promote both resorption and bone formation because the two processes are actually tied together. When the antiresorptive drugs are given, the rate of bone resorption decreases within weeks but the rate of bone formation also decreases months later. This difference in timing is considered the remodeling space. This is why most bisphosphonate drugs must be combined with Vit D, calcium and calcitonin to be maximally effective. Some drugs act by increasing bone formation which include fluoride and intermittent parathyroid hormone, but they can also increase symptoms of bone pain and induce hypophosphatemia. The bone that is formed fills in cavities in the bone that have been left behind by previous resorption.


ESTROGEN REPLACEMENT THERAPY

Hormone replacement therapy (HRT), has often been combined with other forms of treatment for osteoporosis. Estrogen has been linked to maintaining bone density in women.(2) Although estrogen circulating in postmenopausal women is lower because of decreased secretion from the ovaries (if they haven't been removed), it does not mean that there can nothing done to prevent bone loss. Although there has been concern that increasing a woman's exposure to estrogen beyond menopause may increase the risk in breast cancer, a study by Nguyen et al. has found that the use of estrogen in osteoporosis treatment should not elevate the risk of breast cancer to the level experienced by other non-osteoporotic postmenopausal women.(3) Before older women begin receiving hormone-replacement therapy, clinicians should inform them of the increased risk of blood clots, gallbladder disease, urinary incontinence, and fatal stroke.


THE BOTTOM LINE

Consult your primary care physician about the options you have based on DEXA or CT scans of your bones combined with your medical/physical history. If you feel that your options may not be to your liking, consider weight bearing exercise (it's free), Vit D taken with a good calcium supplement. And if you smoke, perhaps this would also be a good time to quit!


(1) Eric Orwoll, Mark Ettinger, Stuart Weiss, Paul Miller, David Kendler, John Graham, Silvano Adami, Kurt Weber, Roman Lorenc, Peter Pietschmann, Kristel Vandormael, and Antonio Lombardi.
Alendronate for the Treatment of Osteoporosis in Men. NEJM 2000 Aug 31;343:604-610

(2) Garnero P, Sornay-Rendu E, Claustrat B, Delmas PD. Biochemical markers of bone turnover, endogenous hormones and the risk of fractures in postmenopausal women: the OFELY study. J Bone Miner Res 2000 Aug;15(8):1526-36


(3) Nguyen TV, Center JR, Eisman JA. Association between breast cancer and bone mineral density: the Dubbo Osteoporosis Epidemiology Study. Maturitas 2000 Jul 31;36(1):27-34

Additional References

Hulley S, Grady D, Bush T, et al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA 1998;280:605-613

Byers RJ, Hoyland JA, Braidman IP. Osteoporosis in men: a cellular endocrine perspective of an increasingly common clinical problem. J Endocrinol 2001 Mar;168(3):353-62

Hulka BS, Moorman PG. Breast cancer: hormones and other risk factors. Maturitas 2001 Feb 28;38(1):103-13; discussion 113-6

Eastell R. Treatment of postmenopausal Osteoporosis. NEJM 1998 Jun 12;338(11):736-46
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