Barry L. Gruber, MD

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The relationship between osteoporosis and high protein diets.

Question:
 	Could you discuss the relationship between high protein diets and osteoporosis, including how this link has been 	studied? What daily intake of protein is considered high enough to cause bone loss? Does it apply to men and women 	equally, and to all ages equally? I am interested because I've had great success with a low carbohydrate diet, 	which, by default, has high protein levels. I don't want to increase my risk of osteoporosis, however. Thanks for 	sharing your knowledge.

The exact reason that high protein diets might be associated with low bone mass is unknown, although researchers postulate alterations in pH and calcium urinary losses, among other considerations. The link has been an epidemiologic one by surveys. You can find out more by perusing any of these medical citations in a medical library, although I think that specific answers to all your questions may be elusive:

Lewis RD; Modlesky CM
 	Nutrition, physical activity, and bone health in women.
 	Department of Foods and Nutrition, The University of Georgia, Athens 30602, USA. Language: Eng
 	Source: Int J Sport Nutr 1998 Sep;8(3):250-84

Lau EM; Woo J
 	Nutrition and osteoporosis.
 	Department of Community & Family Medicine, Chinese University of Hong Kong, Shatin, N.T., Hong Kong. Language: 	Eng
 	Source: Curr Opin Rheumatol 1998 Jul;10(4):368-72

Bonjour JP; Schurch MA; Chevalley T; Ammann P; Rizzoli R
 	Protein intake, IGF-1 and osteoporosis.
 	Division of Bone Diseases, WHO Collaborating Center for Osteoporosis and Bone Diseases, University Hospital, Geneva, 	Switzerland.
     


 	Language: Eng
 	Source: Osteoporos Int 1997;7 Suppl 3:S36-42

Reid DM; New SA
 	Nutritional influences on bone mass.
 	Department of Medicine and Therapeutics, University of Aberdeen.
 	Language: Eng
 	Source: Proc Nutr Soc 1997 Nov;56(3):977-87

Feskanich D; Willett WC; Stampfer MJ; Colditz GA
 	Protein consumption and bone fractures in women.
 	Department of Nutrition, Harvard School of Public Health, Boston, Massachusetts, USA.
 	Language: Eng
 	Source: Am J Epidemiol 1996 Mar 1;143(5):472-9

 Antiphospholipid Antibody Syndrome, Heparin and osteoporosis.

Question:
 	Nine months ago I delivered my second child. My first pregnancy (age 24) went smoothly -- I had a normal pregnancy 	and delivery. After 3 first trimester miscarriages, I went to a specialist who diagnosed me with Antiphospholipid 	Antibody Syndrome. As soon I determined I was pregnant he started me on heparin shots and a low dose of aspirin 	to keep my blood from clotting. I continued this throughout my pregnancy until 48 hours before he induced me.

About 6 weeks before delivery I was having horrible back 	pain. He eventually prescribed mild muscle relaxers which did not begin to touch the pain. After crying from the 	pain in his office and nearly falling trying to get off of the examining table he admitted me and requested an 	orthopedic see me. The hospital refused to allow x-rays for obvious reasons - risk to the baby. The pain was unbearable 	-- I slept on the sofa - had to walk with a walker - my husband had to dress me, etc. After I delivered I saw my 	primary care doctor - an internist. He saw on the xray two places that looked like strained areas and vertebral 	compression and osteopenia (the radiologist's report said that the bone loss was extremely severe for a person 	of my age). He immediately stopped the heparin shots and told me that was a side effect of heparin.

I now take Fosamax, OsCal, Synthroid. The perinatologist 	that I saw told me that I should not take estrogen - due to the Antiphospholipid Antibody Syndrome. I'm at a loss 	as to birth control, hormones, aspirin, long term effects of bone loss, compression, etc. I lost 4 inches in height 	and suffer from back pain. (It's been 9 months since I delivered.) Will I always have back pain? Can bone loss 	be completely corrected? Do I need other hormones? Please give me some direction. Thanks!

Your case is quite complicated and it is probably in your best interest to seek the advice of a rheumatologist with particular interest in osteoporosis. It would not be of any service to you to try to give you specific medical advice by the internet.

Question:
 	I would like to know if the osteo sonogram is a good method for screening in osteoporosis because of it`s low cost 	and harmfulness and the correlation with the DEXA densitometry. I'll would like to know also where can I get some 	Bibliography about it.

Dr. Juan A. ALves
 	Gynaecology & Obstetrics
 	Montevideo
 	Uruguay
 	South America

The sonography of the heel is a good technique for screening purposes. The limitation of this technique at present is to utilize the data for comparison purposes should an individual go on therapy and require a follow-up measurement to monitor the response to therapy. The correlation with DEXA is adequate however for screening purposes (and more important for predicting future fractures). One citation which is often referred to:

Baran DT; Faulkner KG; Genant HK; Miller PD; Pacifici R
 	Diagnosis and management of osteoporosis: guidelines for the utilization of bone densitometry.
 	Department of Orthopedics, University of Massachusetts Medical Center, Worcester, Maine, USA.
 	Language: Eng
 	Source: Calcif Tissue Int 1997 Dec;61(6):433-40

Question:
 	I am a 53 year old going through menopause. I took Fosamax for 6 months but stopped taking it because it made me 	tired. I know that is not a listed side effect, but that is how it affected me especially if I would forget to 	take a calcium pill. I am now on Miacalcin Nasal Spray. But since I am not 5 years past menopause and I have been 	taking Prempro for 4 months is Miacalcin the right drug for me? Please reply. Thanks

Without Bone density results, it's difficult to comment on therapy, but it is accepted that Miacalcin shows it benefit most after 5 years of menopause and is more active in treating osteoporosis of the spine and has limited benefit on the hip in relation to other therapies. Estrogen (with or without progesterone) will help build bone in about 80% of women. About 18-20% of women are genetically incapable of building significant bone with estrogen and require alternative therapies. A urinary or serum NTx (discussed in many previous posts) would be helpful in patients who had one done prior to therapy (baseline) and again, three months after initiation of therapy (to evaluate reduction in breakdown products of bone and thereby determine if less bone is being "lost").

Articles

Question answered by Barry L. Gruber, M.D.

Osteoporosis Ask the Expert

       I have been reading up on Fosamax and one of the sites I've encountered       said this:
       
       "Fosamax is in the same chemical class (phosphonate) that is used in       the
       cleaners used to remove soap scum from your bath tub. This is a metabolic
        poison that actually kills the osteoclasts. These are the cells that       remove
       your bone so your osteoblasts can actually rebuild your bone.  It is       quite clear that if you kill these cells your bone will get denser.        What these studies do not show is that four years later the bone actually       becomes weaker even though it is more dense.  This is because bone is       a dynamic structure and requires the removal and REPLACEMENT of new bone       to stay strong. Fosamax does NOT build ANY new bone."
       
       Would you please comment on this and also tell me if you have any feelings
       about Fosamax versus Didronal?

 There       is no evidence that Fosamax acts as a poison to bone while it works to       inhibit osteoclast activity.  Stong medical evidence supports the use       of Fosamax to increase bone density and reduce fractures. Didronal does       the same thing but to a lesser extent than Fosamax.                                                            

       I'm 37 with 3 children and suffering from premenopausal osteosporosis.        On a recent bone density test, I was told that I only have 77% normal       density on my lower backbone and 81% on my left hip.  I am concerned       because my OBGYN wants to prescribe 2000mg calcium, Fosomax and birth       control pills.  How severe is the condition I'm describing above?        The % lost seems like a lot, but I am not educated in osteosporosis so I       don't know how to interpret these results.  Does the above treatment       sound reasonable?  Is Actonel better than Fosomax?  A book I       just bought references Ipriflavone.  What is this and is it as       effective and safe as the other treatments mentioned?  No other tests       have been performed at this time but I do have family history of this       condition.  Thanks!                                                        

Based on the bone density test report       you sent, it is difficult to tell the extent of your osteoporosis since we       read ours differently.  The treatment your physician has prescribed       sounds reasonable. The daily dose of calcium usually recommended is 1500       mg/day with 400-800units of Vitamin D.
       
        Both Actonel and Fosamax are effective in increasing bone density and       decreasing fractures.  There is some information available that       Ipriflavone may help prevent bone loss, but probably not to the extent of       bisphosphonates. There are no studies that have compared the 2 agents       directly.
       
       Since you developed osteoporosis at a young age, you should discuss with       your physician doing metabolic tests that could cause this condition. Most       often no underlying conditions are found for the early bone loss, but it       important to rule out other causes.                                                

What is the right thing to be doing if you are not in menopause       and have very mild osteopenia?

                       I think that your PCP was right. Before menopause,       if your bone mass is within normal range at spine and only -1,2 T-score at       the hip I think that for the moment you only need a correct diet (calcium       intake of 1200 mg daily), adequate vitamin D, and regular exercise (as you       do). I suppose that you don't have risk factors for osteoporosis (i.e.       malabsorption, hyperthyroidism, chronic use of steroids, abuse of alchool,       smoking). If so, you should re-evaluate your bone mass after menopause and       the decide if you need a therapy.
        
       Actonel, as all bisphosphonates, can interfere with the development of       fetal bones and therefore must not be used before menopause if there's a       chance of
       getting pregnant.                                                  

              I was 74 when diagnosed with osteopenia, my first bone density test.        Going off the HRT in July 2002, my doctor ordered the test.  I do not       want to go on medication and will be trying an exercise program.  I       will be 75 in March, excellent health, am on NO MEDICATIONS, thankfully.
        
       My new doctor states that my left hip has bone loss with a score of BMD/0.808;       T-SCORE/-1.1 AND Z SCORE 0.7.  Do you have a chart showing the normal       scores and is it ok if I postpone medications for several months?                                                  

You have mild osteopenia (or bone thinning)       which is normal for your age. In other words, the findings on your bone       density (your z-score) are showing
       only age related loss.
       
       At this time it would be reasonable to postpone treatment. I would       recommend regular exercise, 1200-1500mg/day of calcium with 400-800 units       of Vitamin D, and trying to avoid activities that could lead to falls. You       should discuss this with your doctor and plan to have a follow up bone       density in one year.                                                              

I       am a 50-year-old woman who has been paraplegic due to Landry-Guillain       Barre syndrome since age 14.  I use a wheelchair and cannot stand or       walk.  I know that I am especially susceptible to osteoporosis       because of the long years of paraplegia.  I am active, however, and       do weight training for upper body strength.  I do have curvature of       the spine, which I am monitoring with an orthopedic spine surgeon.  I       had a blood clot when I was 15, so I don't think I am a candidate for HRT       (plus my circulation is impaired) and am wondering how menopause will       affect my bone density.
       
       What steps can I take at this point to decrease the occurence of problems       associated with osteoporosis?  I am particularly concerned about my       lower back, where I have significant curvature (35 degrees at this point)?

         In order to assess your current bone density it is       recommended that you have a baseline bone density. It may be difficult to       assess the spine due to your curvature, but the hip could be checked. A       bone density would tell you whether or not you have any significant bone       loss.
        
       Preventative measures include weight bearing exercise/strength training,       regular calcium intake of 1200mg/day (1500mg/day if you are       post-menopausal and not on hormones) with 400-800 units of Vitamin D,       avoid excess alcohol intake, and tobacco use. If you did develop       osteoporosis or significant bone loss requiring treatment, there are other       agents available besides hormones, such as bisphosphonates.                                                               

I am a 41 year old women.  I have been having approximately       four periods a year for about 3 or 4 years now, before that in my mid       thirties they became very light and further apart.  About three years       ago I went to my doctors as I thought I may be starting menopause they       assured me I was not, my bloods came back within normal range.  They       did not offer to do further bloods at a later date.  A year ago I       returned to the doctor as I was still feeling very unwell, aching muscles,       exhaustion etc.  This time the results came back post meno.        Oestrogen 65 FSH 95.  At that time I was 40.
        
       My doctor has said that as I am still getting occasional periods that my       bones are not a risk.  She has diagnosed peri menopause.  I have       since found out that with POF you still get periods even though you are in       the post menopause range and that this is not the case with older women.        The point I am making is as I have  low oestrogen (it has been tested       again, no significant change) and in older women this would cause my       periods to stop, is it correct that my bones are not a risk.  What       level of oestrogen should we have to protect our bones.  One doctor       said she could not understand why I was still getting periods as in her       view I shouldn't be.  My doctor has advised me to wait a year without       a period, from what I have read about POF this could go on for years.        Also is it the case that we loose bone in the years leading up to       menopause?                                                              

Premature ovarian       failure may have a several year course of waxing and waning ovarian       function before the ovaries completely stop making estrogen. Estrogen       levels over at least  50pg/ml all the time would be considered       adequate to preserve bone. Levels of estrogen can vary throughout the       month even in normal cycling women and may be over 100pg/ml.
       
       In order to assess your bones at this time, you should discuss with your       doctor getting a baseline bone mineral scan by a dexa scan that evaluates       the hip and spine bone density.
       
       To maintain bone health you should get 1200-1500mg/day of calcium with       400-800units of Vitamin D along with regular weight bearing exercise and       avoidance of tobacco use and excessive alcohol intake. You should also       discuss with your doctor whether you require any hormone replacement       therapy.

If your doctor thinks you are having periods when she thinks you       shouldn't be, then you should discuss with her an evaluation for abnormal       uterine bleeding.

I       am 39 and my DEXA T scores indicate moderate osteopenia in the Hip       (neck) -1.5 and lower spine -1.7 and mild osteopenia in the upper       spine.  I suffered a premature menopause at 31, am petite and small       boned and have been taking anticonvulsants for over 20       years.  I am on HRT, calcium and take plenty of exercise. Given       my history, please could you advise whether you think these T scores merit       going on to a biphosphonate now?                                                                              

        It sounds like you are getting appropriate treatment       at this time.  In order to decide whether you need additional therapy       or just close follow-up with repeat bone densities, it would be helpful to       know your Z-score. The Z-score compares your bone density to age matched       controls. If the value is less than -1.0, then consideration would be       given to checking a marker of bone resorption (such as urinary N-telopeptides)       and if it is elevated possibly adding another agent for treatment.        You should discuss this further with your doctor.                                                             

Literally by accident (as a result of x-rays for a car       accident, no fractures) I found out I have what I believe to be a rather       severe case of Osteoporosis,  I am 43 years old with a 6 month old       daughter I am nursing.
       I am very concerned about the diagnosis because I want to be able to do       the
       things that other moms do with their daughters for many years to come.        My
        z-scores were -3.6 for the AP Spine L2-L4, -2.7 for the right femur and       2.2
       for the left.  I have gone to doctors and have not been satisfied       with their
       experience with osteoporosis for someone in my situation. I have not been
       satisfied that we understand the cause,  I had a milk allergy as a       child and
       did not have a lot of calcium intake, I have asthma and I am taking an
       inhaled Steroid but only for 3 years, I am very small framed, and as I       said
        I am currently nursing.  My thyroid test and Calcium test were both       normal.
       One doctor proscribed Actonel to begin taking after I finish nursing.        My
       questions are:
       
       What type of specialist should I be seeing?  Is it possible that I       will have some bone mass gain after I finish nursing? Actonel seems to be       for post menopausal woman.  In your opinion, should I be taking       that?  I am hoping you will take the time to provide a response, I am       very desperate at this point for information.  I want to be able to       take care of my daughter.                                                         

       You have valid concerns. You should be fine to       continue taking care of your baby and future child. I would recommend you       consult either a medical endocrinologist, internal medicine, or       reproductive endocrinologist for treatment and further follow-up.
       
       You will regain some bone density usually about 6 months or more after you       stop breastfeeding. You should have another bone density 6-12 months after       completion of breast feeding. At present make sure you are getting       1200-1500mg/day of calcium with vitamin D 400-800 units.
        
       Actonel is usually used for post-menopausal osteoporosis, but has been       used
       in reproductive age women with osteoporosis. You should discuss this       further
       with your physician.                                                               

       When I was 48 years old, I was diagnosed with Metastasis Breast Cancer. I       am now 53 years of age. I have been receiving chemotherapy since 1998. The       drug is Taxotere, and is administered to me every 21 days. So far I have       had 83 treatments, and am doing quite well.  I recently have a bone       scan and was diagnosed with mild osteopenia. My doctor wants to start a       drug called Zometa.  Zometa is administered every 4 weeks by I.V.       injections. It is a bisphophonates drug.It is used to treat Hypercalcemia       of Malignancy-HCM high calcium levels.  My blood calcium levels       are in the normal range.  My doctor told me that Zometa and       Fosomax are the same type of drug. I'm not that convinced they are.        I was wondering if I could take Fosomax 70 mg. once weekly for my       Osteopenia? Would the Zometa be better for me?  Could I take both       drugs?

If someone is taking chemotherapy drugs can they take Fosomax?  I       was wondering if I could take Fosomax 70 mg. once weekly instead of the       Zometa?  Or perhaps I could take both drugs?

   It       sounds like you are in good hands with your doctor.  The Zometa would       likely be beneficial for you to improve your bone density as well as being       indicated due to your history of bone metastasis. Fosamax and Zometa       should not be used together. Also, Fosamax will improve bone density but       has no indication for treatment of women with bone metastasis.  It       would be fine to use Zometa with other chemotherapy agents. You could       discuss it further with your doctor.                                                               

        I have a 27 degree curve in my spine from scoliosis.  At 41 I now am       developing a "hump" around the top of my spine where       my neck connects and I know that is directly related.  Does this       mean I also have osteoporosis and how should this be treated?                                                                    

         The "hump" in your spine may reflect       changes from your scoliosis rather
       than osteoporosis with vertebral compressions.  Perhaps the best way       to
       determine whether low bone mass or osteoporosis is the cause is to obtain
       both x-rays and bone density measurements and review these with your
       primary care physician or orthopedist.                                                               

I am 57 yeas old female and have been on didrocal for the       past year for osteoperosis.  I have noticed that since I have been on       this drug I have
       gained an unusual amount of weight while keeping on the same diet that I
       have always followed.  I have also lost quite a bit of hair and have       been
       told that I have alepecia.  I have now read that this could be due to       the
       medication which I am taking.  If I discontinue the medication is       there any
       chance of my hair regrowing.  I really feel I am a little young to       have such
        hair loss and am now concerned that it will get worse and it is definitely
       now becoming visible to everyone.  Previous to my taking this       medication
       there was absolutely no hair loss visible as I visit the hairdresser once       a
       month and she started to notice it about six months ago.  I had been       on this
       medication for about six months at that point but did not realize that       this
       was a possible side effect of the drug.  Is there anything else I can       take
        for the osteo that does not have this side effect?  Other than       fosamax which
       does not agree with my stomach. Your advice would be appreciated.                                                               

        You provide few details as to the severity of your       condition.  The relationship of your hair loss to your medication,       which is a combination of etidronate and calcium, remains puzzling.        Although post-marketing experiences have been reported by individuals       which include alopecia, double-blind clinical trials and years of       experience have not substantiated that this adverse event is more common       than the placebo arm.  Nonetheless, since you are experiencing this       perhaps an alternative should be contemplated.  You do not mention       that anyone tried Actonel which would be a consideration and most recently       Forteo, an injectable anabolic agent, has been approved by the FDA.        These might be products to consider as well as a selective estrogen       modulator such as Evista.  You might be best served to discuss these       options with a specialist.                                                               

I       took a bone density screening test since it was free.  I am a 45 year       old premenopausal woman. I have had 4 children, the last a set of twins,       four years ago. I nursed all my children for at least 2 years. I have       always depended on diet to serve my calcium needs. Before having children       I had irregular periods and required clomid to become pregnant. My mother       who is now 88 suffers from osteoperosis and has had many fracutures due to       this condition. My screening test resulted in a -1.5 T score. My doctor       has perscribed actenol and 1500 mg of calcium along with Vitamin D and       exercise. I will also have an upcoming DEXA scan. In answers to other       questions you mention that osteoperosis in premenstraul women has an       underlying cause. With my history does this mean that I have a disease       underlying my problem and that it is not a result of my family history and       other factors? Do I have osteoperosis or am I jsut on my way?                                                               

The DEXA results indicate       low bone mass, or osteopenia, rather than osteoporosis.  Nonetheless       , the causes may range from your genetically programmed peak bone mass       which you may have acquired by age 25 (and not lost much since then) or an       underlying disorder that obviously is not causing other symptoms (such as       thyroid disease or parathyroid disease).  A
        simple medical work-up with certain blood and urine tests could be done to       exclude these possibilities.  Consult with your physician.                                                                                                

       I am 48 1/2 years old and have been on long term prednisone for 3 years       straight.  Should I have other harmones tested?  Am I going       through menopause or having altered harmones from prednisone and shut down       adrenal gland?  If I'm low in DHEA would taking supplements help       estrogen and possibly regulate periods? I don't want to go through       menopause any earlier than I have to because of bone loss!                                                        

Asked to address the       interaction with prednisone as far as osteoporosis, there is no question       that steroids for longer than 3 months can lead to bone loss. If the need       is temporary, so much the better. If the need is recurrent or long term,       adequate anti-resorptive therapy such as Actonel or Fosamax is needed AS       WELL AS adequate Calcium and Vitamin D. The fact that osteoporosis is not       present yet is good. Keeping up with the above noted therapies will help       stave off further bone loss. If not, Forteo, a new medication may be of       some use. You may need to discuss this with your doctor if deemed       appropriate.                                                       

I       just completed a health screening at my place of employment. I had my       blood pressure, cholesterol, glucose and bone density screened. All the       results were great except for my bone density which I scored -1.3. Which       would indicated I have osteopenia. The bone density test was performed on       my right foot. I inserted my right foot into a device and received a       reading of -1.3. I am in very good health. I do cardio 5 -6 times a week       for 40-60 minutes a day. I also do weightlifting exercise 3 times a week       which includes all my major muscles groups.  How can I have such a       low bone density score if I am in such great shape?  Can you make any       recommendations for someone with my score?  Is it too late to rebuild       the bone mass I have lost?
       Thank you.                                                                

  The world health       organization has defined osteoporosis as a t-score less
       than minus 2.5.  It is important to remember that bmd is distributed       along a
       bell curve.  This means that on any given bone density 50% of the       population
        is above the mean and 50% is below the mean.  A t-score at minus 1.3       is not
       a "bad" bone density.   The best thing you can do is       healthy living, vit d,
       exercise, calcium intake.  I would follow the National Osteoporosis
       Foundations guidelines for having a bone mineral density especially a
       follow-up one.  This area is very controversial at this time.                                                            

When I was 25 I was diagnosed as osteopenic.  My mum has       osteoporosis, I am a small built woman, an asthmatic, I have been on       prednisone intermittently for the past 15 years, and inhaled steroids for       about 13-14 years.  I went off the preventer medication so as not to       damage my bones further.  I have been on the combined contraceptive       pill for the past 11-12 years.                  When I was first diagnosed, I took up yoga to remain flexible, I have         since also begun Tai Chi.  I walk up and down the stairs a lot at         work, and my job involves some lifting.  I eat a lot of dairy         foods, and take calcium supplements.  I was on Caltrate 600 + Vit.         D for about a year and now I take Super Calcium Complete, with calc         citrate 1190mg, magnesium oxide, manganese, zinc, Vits K4 and D3 and         hydroxyapatite.                 Would you please tell me of any treatment options that may be open to me         as a pre-menopausal woma?.                Any help you can give will be greatly appreciated.  Thank you.                                                                        

              You have a very complex situation.  Their is a       lot of controversy in performing bone mineral densities on women       premenopausally.  I would recommend seeing a reputable       endocrinologist who specializes in bone who can clarify these issues for       you.                                                                  

         I am 49 and was diagnosed with osteoporosis of the left hip three years
        ago and osteopenia of the spine and elbow as well.  My doctor
       immediately put me on Fosomax (30 mg/day) and told me to increase my
       calcium intake up to 1200-1500 mg per day.  My first follow-up bone
       density test after two years showed improvement in my hip, spine and my
       elbow is now out of range of osteopenia.   I have been in peri-menopause
       for about 2 years with hot flashes, lots of tears(!), lack of energy,
        etc.  My periods are much heavier and last much longer, but once in a
       while they are extremely light or just a few days.  I have had two
       months where I had it twice. 
       
       My best friend was recently diagnosed with osteoporosis and osteopenia
       and mentioned that her doctor refused to put her on Fosomax (or anything
        for that matter) because it is now contraindicated before menopause.
        That scared me, so I asked my doctor about it.  She stated that       it was
       a similar concern like the prem-pro issue.  But because I am in PERI       and
       not pre-menopause, I was safe. And with the marked improvement in my
       scores, I should stay on Fosomax. 
       
        What IS the new concern about Fosomax before menopause?  I am not in
       danger of becoming pregnant because I had my tubes tied 15 years ago
       after my last pregnancy.  Do I have reason to be concerned?                                                                    

       The bisphosphonates such as fosamax are FDA approved       for the prevention and treatment of osteoporosis in the postmenopausal       patient. There is much controversy with the utilization of these       medications in the years prior to the menopause.  It is always wise       to adjust lifestyle and make sure a secondary evaluation for osteoporosis       is done as this is unusual in a women who is not menopausal.        Certainly hormonal treatment for the management of menopause symptoms is a       consideration with the added benefit of bone density protection.                                                           

I have been on Depo-Provera for ten years, with no unpleasant side       effects.  However, recently I had a screening for bone density, a       heel scan, and it indicated I am in early osteopenia.  I'm 44 years       old, take calcium supplements, do weight and aerobic exercise, eat foods       with calcium, no family history of osteoporosis, occasional drinker.        In other words, I do everything I'm supposed to with no risk factors       except my Depo shot.  I need reliable birth control.  What are       my options?                                                                             

                     You can continue taking depoprovera and living very       healthy.  Other forms of birth control include the IUD (10 years),       birth control pills, the patch, and now the vaginal ring.  All are       reliable with low failure rates.                                                        

              I have been diagnosed with Osteopenia and very close to osteoperosis.        First I must tell you that I have reflux which is barely being controlled       by Nexim. I have tried Evista with side effects like breast soreness,       tingling headache and I woke up each night at the same time twice a night       and just became too tired. This went on for4-5 weeks. So, I am now trying       Micalcin. After3 weeks I have developed diarrhea, bloating , gas and I       generally feel lousy. I stopped it and after 2 days couldn't believe how       much better I feel. Now my question is: Can I try it every other day and       expect to get some benefit from the medication? I was told by a drug rep.       that only 1% of the drug gets into the bones, which makes me wonder if       every other day is worth a try. 

            This medication needs to be taken daily to receive     benefit.  Generally speaking the side effects of Evista resolve over     time.  Most women do not experience breast tenderness from this     medication as it is an estrogen antagonist in the breast tissue.  The     good news is their are other options being studied.  Hopefully a bone     agent that is easily tolerable will come out of the new research.                                                 

 I     am 48 1/2 years old and have been on long term prednisone for 3 years     straight, for an autoimmune lung disease (2 years at average of 25mg/day and     1 year at average 15mg/day). I have been told my adrenal gland is completely     suppressed and will probably stay that way until/unless I can get below     7.5mg/day for a long time.  I have also been low in thyroid since I was     in my 20's and have controlled this easily with tests and taking synthroid.      I have experienced many side affects from the steroids.  I have read     that when the adrenal gland is shut down, that it may affect DHEA harmone     which controls estrogen? Should I have other harmones tested?  Am I     going through menopause or having altered harmones from prednisone and shut     down adrenal gland?  If I'm low in DHEA would taking supplements help     estrogen and possibly regulate periods?                                                 

                   Prednisone, unfortunately, has many side effects with     long term use.  These include muscle weakness, osteoporosis, diabetes, adrenal     insufficiency, etc.                                            

Questions this month have been answered by:Barry L. Gruber, MD, OBGYN.net Osteoporosis Editorial Advisor Alice Rhoton-Vlasak, MD, OBGYN.net Osteoporosis Editorial AdvisoR. Wayne Whitted, MD, MPh, OBGYN.net Osteoporosis Editorial Advisor	Harvey S.Marchbein, MD, USA, OBGYN.net Osteoporosis Chairman and Editorial Advisor

Osteoporosis Ask The Expert

55 yr. old female...routine DEXA scan showed  5.0 for lumbar       spine, 3.9 for hips. Can't find any info on elevated readings. Any cause       for concern?

High       T-scores from DXA may be due to either artifacts, drifts in calibration of       the DXA apparatus, large sized bones (or people), or underlying bone       "sclerosis".  It is prudent to start with a radiograph of       these regions to r/o artifacts such a s degenerative changes leading to       false elevations of bone density and also to search for evidence of       underlying bone disease. Underlying bone sclerosis can be caused by a       variety of diseases, but one that should be kept in mind is hepatitis C       which may otherwise be without any symptoms.  In summary, high       T-scores do require some concern and appropriate further evaluation.                                                             

              I have just turned 50 and have been on Actonel for about         5-6 months now.  I am 5'7" and my weight has remained the same         for the past 15 years.  Now that I am on Acetenol, my weight         has changed by 8-10+ pounds without changing my eating habits.  My         stomach swells and I am "thick" and it's disturbing.  Is         this one of the side-effects?  I had a hysterectomy 5 1/2 years ago         but still have my ovaries; hormone level is normal so I am not on         hormones.  Actenol and calcium, Vitamin C, Vitamin E are the only         other medications.  Thank you!                                                       

There       is no evidence from clinical trials or general experience that a drug such       as Actonel would be the cause of your swelling.  Suggest that you       discuss this with your physician and look for other reasons.                                                   

I do not fit in the standard categories for osteoporosis, although       there is some family history of the disease.  I am not small, thin,       do not smoke, never took steroids, etc.  However, my periods began a       bit late (14) and were irregular.  I never took anything to make the       periods more regular.  I was diagnosed as post-menopausal last year       at age 46 (after the standard blood test).  I had a bone density test       and scored -2.3 on the hip.  Is       this because of the irregular periods, and were the irregular periods due       to lack of adequate estrogen?  I now take Femhrt hormone replacement       therapy, but am wondering if I am a candidate for Fosomax, as well.        Thank you for your comments.

       Unfortunately, "risk factors" for developing osteoporosis are       only a part of the entire story.  There is much we do not understand       that leads to an individual having low bone mass and a high risk for       future fractures and the postural effects of weaker bones.  It is       difficult to know whether your irregular periods played an important role       in this regard; especially without information as to the levels of your       circulating estrogens during those times.  It is conceivable, but       more likely is your "positive" family history.  You might       be a candidate for Fosamax or alternatively wait for follow-up bone       densities to monitor the effect of the FemHRT- this is something you need       to discuss with       your physician.  Hope this is helpful.                                              

My mother has been asked to take Osteofos (same as Fosamax)       10 mg. per day. Her concern is that since she has Sjogren's which causes       dryness etc. Perhaps she may be more prone to the side effects of Osteofos.       She is worried about the pill getting stuck somewhere in her system. I       have asked her to check with her physician about the once a week dose.       Would appreciate any suggestions you may have. She is also taking calcium       supplements - 500 mg. per day - I have asked her to increase this to 1000       mg. per day.                                                  

I       see no reason to suspect that alendronate (Fosamax) should be a problem       merely because of xerostomia (Sjogren's Syndrome).  The dry mouth       from lacrimal gland dysfunction should not effect the esophogus and place       her at higher risk for side-effects or problems.  Once a week dosing       sounds like an excellent choice, as compared to daily dosing.                                                                            

I       would like to stop HRT & alternatively use soy products &  flaxseed       and a more whole foods eating style.  I am 50 yrs old and have had a       Hysterectomy with BSO.  Is this an appropriate alternative and is it       possible to provide similar protection to HRT?  Also, what is your       view on calcium orotate vs other calcium supplements? Is it better       utilized by the body?

               The first part of your question is too complex for a forum of this sort.         That being said, no "natural" alternative can do what HRT can         do as effectively as HRT in double blind, randomized controlled trials         with respect to menopausal symptoms. With respect to heart disease,         eating right, exercising and cholesterol lowering medication may even be         superior to HRT. The same goes for  Alzheimer's disease with         respect to eating and exercise in addition to keeping an active mind.         Both osteoporosis and colon cancer will benefit from the better         lifestyle changes and additional calcium (plus Vitamin D). HRT may still         be one of the better ways to reduce macular degeneration however.               In a literature search of calcium orotate, no articles came up         except for sales pitches. In contrast, there was one article from         Hungary about magnesium orotate reducing cardiovascular disease. Since I         found no "objective" literature about calcium orotate, I         cannot comment on it at this time but look forward to new studies.                                                               

I am 50 years old and still getting my period, although       irregular. I have some bone loss already and my dr. decided to put me on       footman once a week because I have very small bones.  He did       this so there would be less bone loss and perhaps growth of bone instead. I       would like to know the side effects of taking this drug if any?                                                                

Side       effects from alendronate (Fosamax), especially when administered in once       weekly dosing, are quite rare.  In clinical trials, when subjects       were unaware whether they were taking alendronate or a placebo pill, the       frequency of side-effects was equivalent to the placebo group.  No       one side-effect was seen more prominently with alendronate as compared to       placebo.  However, there have been cases of esophageal irritation (esophagitis)       subsequently noted after the trials were completed and this drug was       released into the market.  These cases were usually associated with       the patient either taking very little water with the pill or lying down       immediately thereafter.  This led to the warnings which stress the       importance of at least 8 oz. of water and remaining upright.        Fortunately these are rare instances, and for the most part, Fosamax is       well tolerated and has impressive salutary effects on the skeleton to       reduce chances of future fractures. Hope this puts everything in       perspective.                                                               

Hi. I am a 36 year old white female with a tof -3.2. I had       rhabdomyosarcoma as a child, diagnosed at age 7. I had one ovary and my       uterus removed at the time. I had 18 months of chemo and radiation       directed in my pelvic area. I was not given estrogen replacements. I found       out last June, I have gone through menopause, hence the bone density. I       tried Fosamax and had severe reactions to it. I currently take Klonopin       for post traumatic stress disorder and cannot take antidepressants due to       side effects. Any direction would be greatly appreciated.                                                               

It is difficult to assist       you in that the reaction to Fosamax was not elaborated.  It is       conceivable that dosing Fosamax weekly or every other week to start with       perhaps lower doses and even antacids (proton pump inhibitors) the evening       before the weekly dose might all be considered in strategies to treat your       low bone mass.  Alternatively, you might be a candidate for Actonel.       These are all suggestions to discuss with your physician or local bone       expert.  Good luck.                                                             

       I am 55 years old, and am in the low 25 percentile, on my bone density       scores. Spine -2.4 Hips -l.7. I have not been able to take Fosomax or       Actonel.  My doctor wants me to take Evista.  I have read that       Evista increases the risk of Ovarian Cancer.  My doctor said this is       not so.  Do you think there is an increase in Ovarian Cancer when       taking Evista?  Can I do weight bearing exercise, and proper diet,       and not take medication?  I       would really appreciate your response.                                                         

 I am unaware of any data       that suggest Evista increases the incidence of ovarian cancer, and based       on its ability to antagonize estrogen effects on reproductive organs (or       act neutral), it is unlikely to anticipate a rise in ovarian cancer from       Evista use. In terms of exercise and nutritional modifications, these are       important and should be helpful, but are unlikely to be sufficient to       avoid medication.  This may be best discussed with your physicians or       a local expert in osteoporosis. Hope this is helpful to you.                                                              

        I am a 52 year old female with osteopenia         as of 1998 discovered thru a bone density test. Prior         to that In 1995 had a major leg and foot injury due to a fall in         the living room of my house.  Leg broken in the joint and foot in 5         places. Immediately went on Fosamax and in 1999         bone density had increased to -2.1. In 2000 due to gastro problems         (reflux /GERD) came of Fosamax and went on Evista. Did not have a bone         density in 2000. New bone density test as of June 2001         indicates bone density much worse .. now at -2.4.   The Evista         is awful for night sweats and increased hot flashes. Very uncomfortable         but my ob/gyn says best  way to go due to reflux.  Would you         recommend HRT instead of the Evista? Also I understand their is a         new time release Fosamax out that you take only once a week. What would         be your opinion of taking it with having GERD/Reflux?  Another         question that I have is concerning  Actenol? Would this be         another alternative?  I currently take 1500 mg of Calcium and try         to take 800 iu of Vitamin D.  My exercise program is much harder         for me due to my past leg and foot injury. Would it be helpful to take a       combination of medications? I do not         want my next bone density to be full blown Osteo. Your help is         appreciated. 

The       underlying condition of GERD is not necessarily a contraindication to       using  Fosamax or Actonel.  Especially with our recent       understanding that Fosamax may be taken only once a week and still derive       similar effects as with daily use.  Many patients with GERD opt to       use a proton-pump inhibitor such as Prilosec or Prevacid the evening       before their once a week dose.  If you are losing bone mass while on       Evista, then either weekly Fosamax or alternatively Actonel would seem       like rational alternatives or additions.  Conventional hormone       replacement is
       also a viable option- all these choices must be discussed in detail with       your physician or local osteoporosis expert. Hope this is useful       information for you.                                                                

        I have been diagnosed with mild to moderate osteopenia.  My physician       started me on Actonel nearly a year ago in a 5mg daily dose.        Recently I was switched to a 30mg weekly dose.  I understand that,       like Fosamax, the manufacturers of Actonel are expected to get FDA       approval of a once-a-week Actonel later this year, probably a 35mg pill.        Am I now getting an adequate amount of the drug to protect me from further       bone loss until this new and slightly higher dosage becomes available?                                                        

The data concerning       weekly Actonel with a 35 mg dose is currently being submitted to the FDA       for analysis.  Whether this becomes available depends on the outcome       of that analysis and the data from this recently completed clinical trial.        The question of whether 30 mg is an adequate substitute cannot be truly       answered since this dose wasn't subject to study.  Therefore,       depending on a number of factors (e.g., the severity of your disease,       etc.) a judgement must be made by your health care       providers as to whether this is a sufficient dose. Hope this is useful       information.                                                       

How long prior to conceiving a child would I have to stop taking       Fasomax in order to ensure it does not get to the fetus?                                                         

The answer to this is not       completely known, but is probably in excess of 12 years.  On the       other hand, the amount that is released from that contained in the       skeleton and actually reaches the fetus is infinitely small and most       experts in the field believe that it is unlikely to be harmful. Hope this       is helpful.                                                      

I am a 38 year old female who         has been on long-term steroid (prednisone) therapy for asthma (December         1999 to present), doses ranging from 60-80mg per day.          There were also several hospital stays with higher intravenous         doses.  I am currently at 5mg per day.  As a result, a         bone density test has shown osteopenia.  I recently fractured         my left hip requiring surgery.  In April of 2000 I had a          Nissen-fudliplication for severe GERD.  Other surgeries in         2000 include a fistulectomy and sinus (twice.)   I have         also been treated with multiple antibiotics for all but a few weeks         during this period of time for pneumonia and chronic sinusitis.  I         have high blood pressure and total weight gain of 70 pounds.          I have been taking 600 mg of calcium with 200 I.U. of vitamin D         twice a day since March of 2000 as well as a multi-vitamin.          Other medications I take daily are Diovan, Tiazac, Prilosec, Zyrtec,         daily aspirin therapy, Flovent, Serevent discus, Flonase and Combivent.          Exercise is limited due to the fracture, however before the fracture I         was in aquatic therapy for 45 minutes twice a week and walking.  I want to be         educated in possible treatments of osteopenia before I meet with my         doctor in two weeks to discuss my personal treatment.                                                                 

You present some very       challenging issues to deal with in terms of the dependency on steroids to       control your asthmatic condition, which unfortunately weaken the structure       of your skeleton.  With the severe GERD, using oral bisphosphonates       such as Fosamax (even once weekly) is not without some risk.  You did       not provide information as to the severity of your osteopenia, which might       influence the decision as to whether you require additional therapies.        If parathyroid hormone injections are approved by the FDA later this year,       this might be an ideal consideration.  Alternatively, some bone       experts will give bisphosphonates by injection every month or few months       avoiding the risk of esophagitis.  These are just a few suggestions,       assuming that your hormonal status is normal and the osteopenia is severe       enough to warrant therapeutic intervention. Hope this is useful for you.                                                            

Is       Fosamax as effective as Estrogen in promoting bone mass growth? Are there       known side effects of Fosamax?                                                         

The gain in bone mass that       has been observed with Fosamax is about equivalent to that seen with       estrogen in individuals who have not been on either agent previously.        The longer term data available with Fosamax indicate about 11-12% increase       in bone mass over 7 years- such long term prospective data do not exist       with estrogen.  The side effect profile of Fosamax is fairly limited       to occasional esophageal irritation or esophagitis.                                                      

I       am 50 years old and have just been diagnosed with significant       osteoporosis. I am an RN in an ICU and I frequently have to move and lift       very heavy patients in and out of bed.  My lower back already feel       very weak. Am I at risk for vertebral or hip fracture?                                                         

              The question of risk from daily activities such as       lifting in       individuals with osteoporosis is not an easy one.  Certainly, lifting       with proper technique is important (bending from the knees, etc.)- as is       muscle strengthening from qualified physical therapists to reduce the risk       of vertebral compression fractures developing.  Your sense that your       back is weak is probably more subjective than anything else, as you cannot       perceive low bone mass (or "weakened bones") unless a fracture       were to occur.  Dr. Mary Bouxsein, a scientist at Harvard, has been       trying to study the relationship of everyday activities including lifting       and the stress to specific skeletal sites.  You can retrieve some of       her work on the internet. Hope this is useful for you.

 which includes a reference of publications.

**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.

Questions this month have been answered by:Barry Gruber, MD, OBGYN.net Osteoporosis Editorial AdvisorHarvey S. Marchbein, MD, USA, OBGYN.net Osteoporosis Chairman and Editorial Advisor

Author | Barry L. Gruber, MD

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