Simon Kipersztok, MD

his month I will discuss a clinical question that is often asked when I lecture about osteoporosis and bone densitometry. The question is 

when should a clinician obtain a bone densitometry study? 

To answer the question I will present 2 cases.

Mrs. P.B. is a 54 years old Caucasian woman who recently developed amenorrhea associated with severe hot flashes and vaginal dryness. She is a sexually active woman with no medical problems who does not smoke or drink excessively and exercises regularly. Over the years she has had yearly examinations which have been normal except for an occasional vaginal infection. There is no family history of osteoporosis or breast cancer and her physical examination is within normal limits. She wishes to have hormone replacement therapy (HRT).

A common situation that many practitioners encounter is that of the menopausal woman who presents to her physician complaining of recent amenorrhea. Some of the patients may have already made a decision to proceed with estrogen replacement therapy (ERT) while others may have chosen to avoid it. A third group of women may present undecided, confused or misinformed about the issue. They hope that their physician will assist them in making a sound decision that, on one hand, is individually appropriate given their health history and, on the other hand, they will feel comfortable with.

Usually, those who choose to be replaced with estrogen will have experienced disturbing vasomotor symptoms or, if that is not the case, are intent in taking the hormone because of the potential benefits that have been associated with its use in many organs. The organ systems that can benefit from postmenopausal estrogen replacement are the cardiovascular, the skeletal, the central nervous, the integumentary, the genitourinary, the gastrointestinal, the dental and the ocular.

In the group of patients committed to the use of hormones, the performance of a bone densitometry study would mostly benefit the limited number of individuals (estimated to be 3%-10%) who are destined to continue to lose bone mass at an accelerated rate despite the hormone replacement. It is difficult to identify this group of "non-responders" from the larger group of women for whom HRT will help retard the accelerated bone loss observed when estrogen levels are low. Nonetheless, patients who have demonstrated to be poorly compliant, smokers, heavy drinkers and those nutritionally deficient are likely to be the ones who could benefit the most from initial evaluation and follow up of their bone mineral density status. Another strategy in those patients would be to obtain a baseline measurement of a bone marker and repeat it six to eight weeks later in order to assess response to therapy. Some bone marker measurements can be obtained from urine samples making it clinically convenient.

Mrs. P.B. was started on a cyclical HRT regimen without obtaining a bone density evaluation. She was seen again eight weeks after the initiation of her therapy to reassess any potential concerns that she may have and that might affect compliance. The HRT had relieved her hypoestrogenic symptoms and her vaginal bleeding was regular and timed appropriately in relation to the ingestion of the hormones. She was reassured and encouraged to call if any new concerns presented.

Mrs. E. A. is a 63 years old Caucasian female who underwent a total abdominal hysterectomy and bilateral salpingo-oophorectomy at age 37 because of severe endometriosis. She was never placed on HRT and except for the first couple of years after the surgery she has no hot flashes. She presents for a consultation after having heard on a television program that women such as her are at high risk for osteoporosis. Her history is significant for gastroesophageal reflux treated with antacids. Her mother died of breast cancer. Her father died from coronary heart disease. She is still active and involved in many social activities. Does not smoke and drinks socially. Adamantly opposes the use of ERT because of concerns about increased risk of breast cancer. The physical examination was significant for some kyphosis. Her fasting lipid profile shows an adverse risk for cardiovascular disease. The mammogram was normal.

Many of the women who choose to avoid estrogen replacement may have decided against it because of the side effects associated with the hormone replacement therapy (HRT). These commonly, but not exclusively, include: bleeding, the concern for a potential increased risk of breast cancer and the side effects caused by the addition of a progestin to the estrogen regimen. The progestin is almost uniquely added to the ERT of postmenopausal women who have a uterus in order to greatly minimize the risk of endometrial neoplasia observed in such women when they receive unopposed estrogen.

For women opposed to HRT the performance of a bone densitometry study can be beneficial since, if osteopenia or osteoporosis is documented, these patients are likely to adopt some changes in their lifestyle that will promote bone health. Some may change their mind about HRT while others will quit smoking, increase their intake of calcium and vitamin D, or engage in a new exercise routine. For these patients as well as for those who hope to make a decision about their menopausal care with the assistance of their physician, the professional encounter should be a unique opportunity. The physician should educate and evaluate the health issues that are going to bear on the patient’s longevity and quality of life.

In the United States there are several pharmacological agents, which like ERT, work to retard the bone resorption after menopause. Bisphosphonates and nasal calcitonin are available for the prevention and treatment of osteoporosis. Among the bisphosphonates, the Food and Drug Administration (FDA) have approved only alendronate for this purpose. Calcitonin is only effective in the spine and has a unique analgesic advantage for pain associated with vertebral fractures. Recently raloxifene, a selective estrogen receptor modulator, was approved for the prevention of osteoporosis. In addition to its benefits in bone health it has some protective benefits in the cardiovascular system. This agent has also not demonstrated adverse effects on the breast and the endometrium. In contrast to ERT, it has no effect on the central nervous system and in fact may cause an exacerbation of severe hot flashes when compared to placebo. In addition, the drug circular warns about a potential increased risk of venous thromboembolism that is more common during the first month of intake. The drug should also be discontinued for 72 hours before prolonged inactivity is anticipated such as in the immediate postoperative period.

Mrs. E. A. had a dual X-ray absorptiometry (DEXA) study performed. Her T-score in the spine was 2.7 standard deviations below the mean and in the left hip it was 2.3 standard deviations below the mean thus confirming the diagnosis of osteoporosis. She was counseled at length about the potential benefits of ERT, in particular to her cardiovascular and skeletal systems. She was informed that these benefits far outweigh the potential risk for breast cancer and that many patients with a family history of breast cancer die from cardiovascular disease, which ERT can prevent. She was also counseled about the appropriate amounts of calcium and vitamin D that she requires, and warned about possible accidents that can increase her risk of fracture. Nevertheless, she refused to take ERT and was placed on daily raloxifene. She was also advised to have her DEXA scan repeated in a year.

Most authorities feel that ERT is the preferred approach for the prevention and treatment of deficient bone mass because of its more global benefits. Yet compliance with this therapy is poor because of side effects. Given the many different available therapeutic options for the management of patients at high risk of fracture, bone densitometry should be obtained at any time when there is uncertainty about the bone mass status of any patient. Even in the older woman who has been postmenopausal for many years the use of bone densitometry can be helpful in identifying those patients whose bone loss is accelerated because of reasons other than age. The bone density study would indicate that their bone mineral density is significantly lower when compared to that of other individuals similar in age (the % aged matched or Z score). Proper diagnosis and treatment of the underlying condition causing the accelerated bone loss can improve the patient’s quality of life.

As of July 1998, in the United States, Medicare will cover the expenses related to assessment of bone mass in all its subscribers. Similarly, some states such as Florida have passed legislation that mandates such coverage by entities that market and provide health care services in the state. At our center we charge $170.00 for a scan that includes assessment of the spine and the non-dominant hip. The price also includes the interpretation of the study.

Articles

This month I will discuss a clinical question that is often asked when I lecture about osteoporosis and bone densitometry. The question is when should a clinician obtain a bone densitometry study? To answer the question I will present 2 cases.

Osteoporosis Case Of The Month

I am a 35 year old mother of 2 and have had back pain for over six       months.  My doctor sent me for a bone density and it showed moderate       bone loss. Am I a candidate for medication?  I am on 1800 mg of       calcium a day. Thanks.

I       do not know if you are a candidate for medication since I do not have full       information about your bone density study. Nonetheless, your doctor should       be able to determine the following based on the study and on a complete       medical evaluation: 1. If you are at increased risk of fracture because of       osteopenia and osteoporosis. 2. If your bone density is low, then why, and       3. Offer you treatments or recommendations that could help reduce any       possible increase in your risk of fracture. The daily use of calcium as       you are ingesting is more than adequate.                                                             

              My new test results from DEXA is -2.69 and -2.66.  Three years ago       they were -2.49 and -1.95. Although I took Fosomax 5mg each day and ran       and       lifted weights I did not have a supplement Calcium.  So now I       currently take Fosomax once a week 70 mg and added 1500 mg supplement with       Vitamin D and magnesium and changed my diet.  Will I be able to hold       the line? My mother had severe osteo and my sister has Paget's disease. My       gyn wants to also put me on HRT.  Will that help?  I want to try       diet and exercise first.  What do you think?                                                       

              The new test results you referred to show that you       suffer from osteoporosis. Therefore, the Fosamax that you are taking, in       addition to the calcium, vitamin D and weight bearing exercises should       help you to raise your bone       mineral density and decrease your risk of fracture. Please be aware that       lifting heavy weights could apply excessive pressure to your spine and       cause a compression fracture. So I suggest you discuss your exercise       regimen with       your physician or a physical therapist.
       
       The addition of HRT could be beneficial if you are having symptoms related       to low estrogen levels. These symptoms include hot flashes, dryness in the       vagina and urinary discomfort. It may also help improve your lipid       fraction       in a favorable way and maybe decrease your risk of cardiovascular disease       although many debates are ongoing with regards to this particular issue.       Estrogen replacement could also help in decreasing the incidence of colon       cancer, blindness and possibly Alzheimer's disease. As far as your bones       are concerned, Fosamax can produce a larger degree of bone mineral density       gain than estrogen.                                                  

There       was a recent article about a new drug, Forteo.  It was described as "A natural bone-building       hormone."  Last year, I had four spontaneous fractures (three       pubic and one sacral) due to use of Prednisone for three years for Lupus.        I am unable to tolerate Fosamax or       Actenol.  Could you please give me more information about Forteo?        The article stated that the manufacturer hoped to have the prescription       drug available by the end of this year.

Forteo       is the trade name of recombinant parathyroid hormone (rPTH). Parathyroid       hormone is normally produced by the parathyroid glands, four small glands       located underneath the thyroid gland in the neck. The glands produce       parathyroid hormone (PTH) which is involved in the metabolism of calcium       in the body. The term "recombinant" refers to the fact that the       hormone was not extracted from actual human glands but rather produced in       the laboratory through what is now considered to be acceptable and       standard genetic technology.
       
        All of the drugs thus far approved by the Food and       Drug Adninistration for the prevention and treatment of osteoporosis such       as estrogen (HRT/ERT - many brands), alendronate (Fosamax), risedronate (Actonel),       raloxifene (Evista) and calcitonin (Miacalcin) work by slowing the process of bone       resorption. Resorption is coupled to the process of bone deposition. Both       processes are necessary for bone remodeling a vital, ongoing process       necessary for bone maintenance. When the two processes are balanced bone       competency is maintained. After menopause, when estrogen production drops       to very low levels, resorption exceeds deposition and bone mass can be       lost leading to osteoporosis and to an increased risk of fracture. The FDA       approved drugs work by slowing down resorption and thus improve bone mass       to one degree or another.
       
       rPTH works mostly by promoting bone deposition       although it can also increase the rate of resorption. The initial trial of       the drug in patients with osteoporosis who had previous spine fractures       showed that Forteo can reduce the incidence of new fractures by 65-70%       with minimal side effects. Bone mineral density also increases with Forteo.       The new drug has to be administered daily by subcutaneous injection and is       not yet available in pharmacies.                                              

I have a 16yr. daughter who over the course of  the       past year and a half or so  has been overexercising and limiting       intake of particular foods.  She is working with a nutritionist on       her diet which has greatly improved.  The exercise is still just       about daily for a few hours(2-3).  Her physician had her get a bone       density test because her periods became irregular and then stopped       although she had not actually had it for very long. She considered       her to have subclinical anorexia since her weight was stable at 105lbs.        Her height is 5'1". The bone density test came back with 20% loss.        There was some question about the sample used to compare her test to. I       spoke with the radiologist who did the scan.  He was confident with       the results and said that she had 15 years to improve her bone health       through better diet.   Her physician started  her on Allese       (birth control) pills , added calcium and a multivitamin in addition to       her nutritional counseling. She is now getting her period. She was told to       repeat the scan in a year to see if her score was improved.  She will       be taken off the hormone for a month to see if she can get her period on       her own shortly.  Have we received good advice?                                                 

The       answer is yes. Some young women, usually as a result of excessive       exercise, an eating disorder or both, may develop menstrual irregularities       or have no periods altogether. Under those circumstances, their ovaries       stop       producing estrogen and they can have the same risks to their bones as       menopausal women. Unlike menopausal women, their condition is reversible       once the exercise level is reduced or the eating disorder treated.
        
       The Alesse your daughter received is a "low       dose" birth control pill. In your daughter's case it is being used as       a source of estrogen to protect her bones and regulate her periods. Some       authorities may suggest that at 16 a       pill formulation with a slightly higher dose of estrogen (35 micrograms       compared to 20 micrograms in Alesse) could not only offer better bone       protection but also improve or enhance your daughter's secondary sexual       characteristics such as breast development. The added calcium and a       multivitamin, which hopefully contains 400-800 international units of       vitamin D, will also help her bones.
         
       Eating disorders in young women can be life threatening. I read in your       message that your daughter is under professional supervision and I       encourage you to continue such care until her condition improves. The       advise of a       nutritionist can also be very helpful in monitoring her intake and weight       gain.                                                                             

I       am 51 years old, and just had my first bone density test.  My spine       is --2.4 and my hips are --2.0.  This is not quite but almost       osteoporosis.  In addition, I have been taking HRT daily for the last       two years.  I know this has not stopped my bone loss because I am       shorter in height now than I was a year ago.  Also I have what I call       "hip pain" that never goes away but is especially apparent when       I lie down.  I am close to menopause, with an occasional period every       four or five months for the last year or so. My mother, who was only 69       when she died, had severe osteoporosis, a huge dowager's hump, and had       lost height from 5'2" to 4'10".  I used to be 5'2" and       am now 5'1".  I am also extremely fair skinned, light eyed, the       whole "at risk" bit.  I literally had to fight with my HMO       to get them to even schedule a bone density test for me because of my age,       and it took nearly a year to be scheduled.  I want to present my       OB-GYN with as much information as possible in order to be active in the       treatment process.  What would your experts suggest as far as       treatment goes?  (The HRT dosage I currently take is .6 of Premarin       and I don't know what proportion of the Progestin is.)  Please help.        I don't want to end up like my poor mother!

              Assuming that the bone density scores you report are       the "T" - scores you indeed have osteopenia. The  T score       compares your bone density to that of individuals similar to you who are       at peak bone mass and accurately predicts       an increase in the risk of fracture.
       
       HRT is helpful to bones after the menopause.       However, some women may continue to loose bone even though they take       estrogen. One common reason for it is that they do not take their       medication. Another reason could be that       they may have a medical condition that causes bone loss in addition to       being menopausal. Smoking and alcohol abuse can also cause bone losses       despite HRT use. Low weight is also a risk factor for low bone mass. It       is, therefore,       important that your physician evaluate you fully to rule out the many       causes for osteoporosis other than menopause.
       
       If all causes for osteoporosis, other than       menopause, have been ruled out one way of telling if the HRT is working to       your bone's benefit is by performing a urine test called N-telopeptide.       Menopause thins bones by causing an acceleration of a natural process       called resorption. N-telopeptide levels can reflect the degree of       resorption taking place in your bones. If HRT is working then the N-telopeptide       level should be in the normal range. If it is increased despite the HRT       then you may need the addition of another drug that can slow down the       accelerated bone resorption.                                                        

I am a breast cancer survivor with estrogen positive       receptors, no node involvement.  After taking tamoxifen for about       four years, I was diagnosed with osteopenia, and placed on Fosamax for       about five years. My family has a history of osteoporosis.  Recently       I received a letter from my drug plan provider stating that Fosamax would       no longer be on the Preferred Medication List, and that I       should have my new prescriptions written for Evista or Actonel. I have       tolerated Foxamax well.  I am due for a DEXA scan next month.  Is       there a great difference in the results of the two drugs, Evista and       Actonel, and given my history which one would be best suited to me?                                                                

It       would be ideal if there was a drug that offered you protection from breast       cancer recurrence while giving you protection from the risk of fracture       particularly to the bones in the spine and the hip. Such drug,       unfortunately, does not exist.
       
        Raloxifene (Evista) has been shown to prevent the       occurrence of breast cancer in osteoporotic women although, unlike       tamoxifen, it has not yet been shown to prevent the recurrence of breast       cancers. It can also decrease the incidence of fractures in the spine but       not in the hip.
       
       Conversely, risedronate (Actonel) can decrease fractures in the spine and       hip but has no beneficial effect on the breast. Both risedronate (Actonel)       and alendronate (Fosamax) are compounds that belong to the same family (bisphosphonates).       One of the main differences between the two is that alendronate can be       taken once a week while risedronate has to be ingested as a daily pill.
       
       I suggest you discuss this matter with your       physician who should be able to advise you which aspect of your health       requires greater attention, your breasts, your bones or both organs. If       breast protection is a priority then perhaps raloxifene (Evista) should be       better suited than risedronate (Actonel). If bone protection is the priority then risedronate       (Actonel)       should be chosen. If both organs are equal priorities both drugs can be       considered. There are reports indicating that raloxifene (Evista) was used       effectively with a bisphosphonate to improve bone mineral density.                                                              

I am 55 years old, and have been told that I am in the       bottom 25% on my bone density scan.  My doctor has suggested Fosomax.        I had a reaction to that, so I am going to try Actonel.  Is it       possible to build up my bones with soy products, exercise and added       calcium to my diet, without the use of medication?                                                               

Calcium, exercise and good       nutrition are very important for the maintenance of healthy bones.       However, when treatment is necessary to correct a disease associated with       low bone mass medications such as alendronate (Fosamax) or risedronate (Actonel)       are needed. Several studies have established that both medications are       efficacious and safe for the purpose of increasing bone mass. Calcium,       exercise and the ingestion of soy products when used alone have not been       shown to increase bone mass or decrease the risk of fracture.                                                             

       I was recently given BMD values only in two areas that being Femoral Neck       And Mean L2-L4.  Is this enough information to diagnosis Osteopenia?                                                        

Yes.                                                              

 I am 50 years old and was diagnosed with severe       osteoporosis several years ago. I probably had it even earlier than the       diagnosis. I see a GYN and a family doctor. Is there another kind of       specialist that I should see? I am currently on Evista (1 1/2 yrs.) and       Foximax (last 3 mo.). I am also trying to walk and do weight bearing       exercises. Are there any books or web sites that specify exercises? I do       take calcium, 1200-1800mg. a day, but so many things in them I am allergic       to. I have severe allergies (sulfates, sulfides, soy). Is there a good       calcium pill that is easy to swallow and that will absorb? How do I take       these to best absorb into the important parts of my body? I have been told       that I have a difficult time absorbing nutrients.                                                         

It       appears that your present physicians are treating your severe osteoporosis       with effective therapies. Other specialists that manage osteoporosis are       Reproductive Endocrinologists 

, and Rheumatologists. I suggest that you check the website for the National       Osteoporosis Foundation 

 for more       information about calcium and exercise.

 for more information about your question.

My       mother is 85 years old and her physician is now recommending she take       Actenol because she had a bone density test and had a T score between -1       and -2.   Although quite active, she tends to be forgetful about       her blood pressure medication and the instructions for taking Actenol are       quite specific.  She lives alone and relatives are almost 3 hours       away.  We are fairly certain that she will both forget to take her       daily dosage and forget how it has to be taken.  Also, when she tends       to feel anxious, she has       difficulty swallowing and we are concerned about the Actenol's effect on       her esophagus.  So far, my brother and I have advised her physician       against prescribing the Actenol for the reasons mentioned.  She has       never broken any bones, has a well-balanced diet, and has had no female       relatives who ever had any problem with fractures and they lived well into       their 90s.  My question is whether you feel we are being overly       cautious?                                                        

The concerns you have       about your mother are valid. Alendronate (Fosamax) is a drug similar to       risedronate (Actonel) that is also highly effective in reducing fractures       and it needs to be taken once a week instead of on a daily regimen.       Perhaps you could arrange a neighbor or a visiting nurse that can help       your mother take her osteoporosis medication once every week.                                                      

I'm studying physical and occupational therapy and I have just       learned that salt and smoking are to be avoided with an osteoporotic       patient. I was wondering if you could explain the actual pattern of action       of salt and tobacco?  Is it that it decreases the binding of calcium       and if so, how is it doing so? Thank you for your help.                                                        

Individuals who ingest foods       high in sodium have increased urinary excretion of calcium. This could be       a mechanism by which table salt may deplete another element important in       bone metabolism.
       
       Tobacco acts more like a poison. Tobacco smoke, for example, contains many       substances that can promote cancer and damage organs directly, including       bone. Another effect of smoking is that it decreases the clearance of       estrogen in the body and accelerates the age of menopause to an early age.       Early menopause and low levels of circulating estrogens in smoking women       can lead to low bone mass and osteoporosis.                                                      

I am a 48 year old DES daughter. I have been experiencing       menopausal symptoms on and off over the past 3 years but with increasing       severity over the past year. I had a hysterectomy (ovaries remain) at the       age of 29 years following cancer of the cervix (ca in situ). A recent Dexa       bone density test indicates that I have osteopenia. I am extermely fit;       weight train and walk on a daily basis. I want to know if HRT is an option       for me, and if so, is Premarin a safer medication since it has been used       for a longer time period? Does HRT actually promote bone growth or does it       just protect from further bone loss? Also, would it be advisable to take       Actenol instead of HRT? I am suspicious of "new" medications but       I believe that I need to do something. Thanks for your assistance.                                                         

HRT is helpful to       alleviate menopausal symptoms and prevent osteoporosis. Bisphosphonates,       such as risedronate (Actonel) and alendronate (Fosamax) are       highly effective and safe drugs used to prevent and treat fractures but       will not alleviate menopausal symptoms. Given the more global nature of       your health concerns you could benefit from HRT and monitor your bone       mineral density. If needed a bisphosphonate could be added to your HRT       regimen.
       
       Any estrogen formulation appears to be helpful to bones. Conjugated equine       estrogens (Premarin) has been in use for more than 50 years and numerous       studies have confirmed its effectiveness in alleviating menopausal       symptoms and preventing osteoporosis. Like many other medications some       patients may not tolerated or may prefer a one of the many other       formulations available in the market. Many of these formulations are       similar in their effectiveness, safety profile and possible side effects.                                                             

I       was just diagnosed with Osteoporosis.  I am a 36 year old       premenopausal female.  My physician has recommended taking Fosamax.        I have read that it is not recommended if you plan on having children.        Would it be safe to take Fosamax and then discontinue for a few months       prior to trying to get pregnant?                                                         

Most of the studies done       with alendronate (Fosamax) and other bisphosphonates have been in       postmenopausal women and men. Some studies have included reproductive age       women who have steroid induced osteoporosis. Women on steroids usually       have suppressed ovarian function. Anecdoatal reportsindicate that some       young women who have used alendronate have conceived       without ill effects to them or their infants. So the experience available       in women likely to conceive is very limited.
       
       We know that alendronate remains in the maternal bones for a long period       of time and the drug is a category C as far as pregnancy is concerned       according to the FDA. Category C means that there are no human studies to       clearly show fetal harm however the drug has the potential of causing such       harm so its benefits should be weighted against its possible risks.                                                       

I       was diagnosed with osteopenia recently.  I am 22 years old.  My       hip is in the 5th percentile and my spine the 12th.  I do not       remember the percentages.  I am currently seeing a gastroenterologist       to look for Chron's disease as their is a family history of this.  I       am aware that according to the National Osteoporosis Foundation I am a       candidate for intervention with anti-resorptive drug therapy.  This I       read in the recommendations from the doctor who analyzed my bone density       results.  My gastroenterologist is taking great care of me and doing       her best to find the source of the bone loss.  Should I go ahead and       ask about the anti-resorptive drugs?  or am I taking this too       seriously?  I am very scared because everyone has told me how strange       it is for me to have bone loss at my age.  I cannot find much       information about what to do at my age. Does my age rule out many       treatments for bone loss,  or again do I just need to exercise and       increase my calcium intake and not worry beyond that? 

              You are young and seem to have low bone mass and       possibly Crohn's disease. You are at a stage in your life where you should       be accruing the bone mass that will take you to your full life expectancy.       I give you much credit for       being concerned about this issue and making a big effort to become       educated about it. What you need to know and understand in detail is if       you are at risk of increased fracture and if yes why, and what can you do       about it. Good Luck!                                            

About       4 years ago, I was having lots of back pain. My Dr. ordered  a couple       of epidurals, where they inject something directly into the spine. Would        that have been Cortisone? If so, would that have been the cause of my       severe Osteoporosis? Also would like to let you know that instead of       taking the expensive medications for Ostesporosis, I have my own        natural  way of dealing with it because I am intolerant to everything       my Dr. recommended. I have a bone mineral test done every year, and I keep       improving with each one so something is working. I take 1200 mg of Calcium       and 400 units of vitamin D, Plus it contains some soy and isoflavones, a       triple Boron Complex,6mg. I also use the Progestrone cream every day and       just recently started taking Ipriflavone, which I just happened to find in my vitamin catalog. It helps       support bone density. No Dr. has ever mentioned it to me before. I wonder       why? I had a hysterectomy at 31 years old but kept my ovaries. Because I       couldn't tolerate HRT, I was never told that I would suffer bone loss       later in life. I have lived with pain every day       for four years, probably due to spinal compression fractures. Have never       broken a bone, but have hip and back pain constantly. Also have       Fibromyalgia, so that could be some of the pain. Can't do much exercise       because of having that. Thank you for letting me share my story with you.                                                        

              If the injections were steroids, the osteoporosis       you may have should not have been related. Most experts feel a minimum of       3 months on daily steroids are needed to even start the process of bone       loss in that regard.

Very often, claims in vitamin catalogs and the       like are advertising statements rather than proven information from       medical studies. Randomized controlled trials, double blind, are required       to prove a medical point. Unfortunately, people spend billions of dollars       a year in the U.S. on vitamins and herbs with no proven benefit.       Isoflavones, however, HAVE recently been shown to be of potential
       help with bone formation and preservation.

The disease, prior to fractures, is painless in       contrast to osteoarthritis. Any pain without fractures in NOT osteoporosis related.       Spinal compression fractures are indeed, broken bones of a sort. Hope this       helps.

I       am 55 years old, and have had a bone density test done.  I am in the       low 25 percentile.  I tried Fosomax and got a terrible headache from       it.  I don't know whether to use Evista or Actenol.  My       internist suggested Actenol       and my gynecologist suggested Evista.  Upon researching on the       internet, there seems to be a connection between Evista and Ovarian       Cancer.  That frightens me, should I try Actenol?  What is your       feeling comparing to the two medications?  Thank you for your       information.                                                        

              Several points to consider here. If you used the       Fosamax at the daily dose of 10mg, you may do better with the once a week       70mg dose. Both Actenol and Evista may have benefits on the bone but a       variety of studies question whether the improvement is the same as Fosamax.       Not all studies agree and there are data to suggest that bisphosphonates       such as Actonel and Fosamax are superior  to other agents for       osteoporosis. Evista may reduce the risk of breast cancer but may not be       as beneficial for the bone as bisphosphonates. The question of       increased risk of ovarian cancer is a new concept and most physicians feel       this has not been proven yet.                                            

Hi       there...this is response to a reply to a young lady who wrote in and said       she is 44, regularly menstruating, with advanced osteoporisis which was       diagnosed 10 years ago.  Your reply was that a 44 regularly       menstruating       woman do not get osteoporosis and that something very unusual may be going       on.
        
       Well, I would like your thoughts on what you consider "something very       unusual going on".  I am only 41 years old, have no children,       and was diagnosed with osteoporosis last September.  I couldn't       believe it either.  I have exercised most of my life, try to eat the       right foods and thought that I was doing everything right as well.  I       could not get any real answers or reasons from my doctor on how or why I       have osteoporosis, considering I had been on birth control for almost 20       years and was told there should have been enough estrogen in my body.
       
       Is there some type of specialist or medical findings that can give me some       answers? If there is something else going on then what type of tests       should I be taking or looking for?                                                        

               When someone of your age and hormonal status       develops osteoporosis, one must consider etiologies out of the norm. With       adequate calcium intake and exercise as well as adequate estrogenization,       the possibility of lack of Vitamin D or lack of absorption of calcium       and/or Vitamin D comes to mind. This can be from a variety of       gastrointestinal problems, among them sprue and some inflammatory       disorders. Another reason may, in others, be steroid use for extended       periods of time. The appropriate specialist in your area may be an       osteoporosis specialist, Sometimes they are rheumatologists, sometimes       endocrinologists. A gastroenterologist may need to become       involved.                                            

My       mother-in-law has osteoporosis and was recently diagnosed with compressed       vertebrae and herniated discs. I recently came accross an innovative       procedure called vertebroplasty to relieve pain caused by this condition.       Unfortunately, she lives in Mexico and this procedure is not yet known in       this country.  The physicians there want to operate by fusing a       donated bone from a bone bank. Have you heard of any such procedure and       risks?                                                         

              Not being an orthopedist, I am not completely       familiar with orthopedic procedures. The kyphoplasty or vertebroplasty is       relatively new but has good data standing behind it. The fusing of donated       bone may work but you need to speak to the surgeons about the long term       mobility and success rates as well as the risks of the procedure and the       anesthesia.                                            

A       short while ago I was taking Estratab and I felt good about taking it       cause I was told it was from Yams and soy. The druggist says it was taken       off the market. The obgyn put me on it for bone loss and menopause. Is       there something similar to it for the same condition or a more natural       substance to take? Thanks.                                                        

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

Osteoporosis Ask The Expert

       I am 37 and have been taking Fosamax for a         couple of months.  I took the osteo test because it was free.          I was shocked to find I already have osteoporosis.  My dexa scan         showed mainly -3s with the worst being -3.97.  My blood work was         normal.  I've never smoked or drank.  I have always been thin.          Would having four pregnancies and breastfeeding within the last eight         years be a reason for my condition?  I've read that breastfeeding         weakens bones,but in normal women their bones come back stronger helping         to prevent osteo.  Will my bones get stronger when I stop nursing         or am I out of luck since I already have the disease?  I also asked         my Dr. at what T-score number does a bone just break without a         fall?  She didn't know.  She said my numbers were the worst         she'd seen.  Has anyone had -4s, -5s. . .?  She wants me to have         1800 mg calcium daily and lift weights in addition to the Fosamax.          Lastly, will I dissolve after         menopause?  I assume I will be put on HRT then.

 Women       who breastfeed will experience decreases in bone mineral density. Changes       in bone mineral density during breastfeeding are reversible to the       pre-pregnancy bone density. If the bone mineral density remains low 6       months after breastfeeding is discontinued, it warrants consideration for       therapy.                                                             

       I have osteoporosis in my hips and osteopenia in my spine.  I am an aircraft electric mechanic, which means I have to crawl inside the hole of       the plane and I am climbing stands ect.  I am wondering if i am at       risk of fracturing myself.  I fall alot, my hips go out from under me       and I just fall.  so I am worried if I should change my job?  This       is a deep concern of mine.                                                         

Both osteoporosis and osteopenia increase the risk of       fractures. Avoiding activities that could lead to falls lessens the risk of a fracture.                                                

Have I been prudent to stop HRT after 11 years when I found out I had T-4 level osteoporosis?  Since estrogen clearly did not prevent       bone density loss, is the drug of choice alendronate? And if it is, what       are the chances an HMO would be forced legally to permit its use at their       expense? I am 71 years old, white, do not drink or smoke and am not       overweight. I am still working.

       When hormone replacement therapy is discontinued or no longer useful to       prevent bone loss, the initiation of a  bisphosphonate such as       alendronate is both appropriate and useful.                                                         

I was diagnosed with MS       in 1994. Due to 6 past treatments with solumedrol and prednisone my neuro       ordered a recent bone scan "just for a baseline," and to my       shock it came back positive for osteoporosis. Now, I am on Fosamax 70mg.       weekly. Was there anything I could have done to prevent this from       happening, and shouldn't prescribers of high dose steroids inform patients       of this risk and ways to prevent it? I am 43 with no family history.                                                  

Based on your history you have 2 risk factors for       osteoporosis-immobilization and prolonged steroid use. Fortunately,       bisphosphonates such as Fosamax are capable of markedly protecting bones.                                                              

I       am 68 years old. my bone mineral densiity test reads as follows:
       DEXA study of A P spine and proximal femurs on a Norland 798 bone       densitometer.  Bone mineral density in the lumbar region is 1.74       consistent with osteopenia. Bone density in ;the area of the right femoral       neck is 3.95 consistent with osteoporosis. Area of the left femoral neck is 3.77       consistent with osteoporosis. Conclusion:  Findings of osteopenia in       the lumbar region and osteoporosis of both femoral necks.

       What does all this mean ?  Will I get a hump in my back as I have       seen on some older women?  I am unable to take fosamax.  What       are other treatments?  Thank you for your time. 

Unfortunately, no one can       predict whether you will develop a "hump" or not, but based on       your bone density you are at increased risk for a fracture. There are a       variety of treatment options available. The first choice would be to try another bisphophonate called risendronate (Actonel) once weekly       which may be better tolerated. Other potential options to discuss with       your       physician include estrogens, raloxifene, or nasal calcitonin. Neither       raloxifene or calcitonin seem to offer protection in the hip. Another       option       that will be available at some time in the near future is recombinant       parathyroid hormone.                                                               

As a radiologist we do many self-referred DEXA scans. What should       we recommend for therapy if any for premenopausal women with -1. to -2 t       scores?                                                              

Our office does many       self-referred DEXA scans and we interpret results       without offering therapeutic recommendations. The treatment is deferred to       the clinicians who treat osteopenia and osteoporosis.  Our clinical       practice also includes treating pre-menopausal women on whom we perform       DEXA scans and diagnose osteopenia. Current treatment options include       estrogen replacement (depending on the clinical situation) or       bisphosphonates such as Fosamax 35mg weekly or Actonel 35mg weekly.                                                               

       I am taking Fosomax in response to osteopenia. Should I be taking       calcium + vitamin D along with it?                                                                             

         You should be consuming adequate Calcium and Vitamin D to ensure optimal       bone health. Daily requirement for Vitamin D is 400-800IUs. The amount of       calcium depends on your age but would be 1000-1200mg  daily. These       amounts include dietary intake and supplements if needed. A good source to       get these guidelines is 

.                                                             

I am a 46 year old female with sever osteoporosis. I have       been on fossamax for 8 months and I have been taking my 1500 mg. of       calcium a day. My question is I am getting the hump  on my neck and       its getting worse. And there is quite abit of back pain. Is there a way to       correct or stop the compression of my vertebrae. I have been doctoring       with just my family doctor? He has only sent me to a pain management       clinic for shots. I am getting shorter and my legs and arms are getting       thinner. I am very worried about what is to come. Thank you for any help       you can give me.                                                         

       You should continue your Fosamax and calcium as well as avoiding any       activities that could lead to falls which would increase your fracture       risk. You should consider consultation with either a neurosurgeon or       orthopedic       spine surgeon to further evaluate your spine.                                                                

       I was diagnosed in February with osteoporosis (minus 4.2), and I am taking       Fosamax.  What is your opinion of ipriflavone (in addition to Fosamax)?                                                                       

 Ipriflavone is       an over the counter  nutritional supplement that has not been       shown to be  beneficial  for bone health. Fosamax (alendronate)       and other       bisphosphonates are effective in treating osteoporosis.                                                               

        Is there evidence to support what I recently heard that anti-seziure       drugs such as gabapentin and clonazepam can cause or exacerbate       osteoporosis?  These days anti-seizure drugs are prescribed more and       more as psychotropic aids as well as for seizure control.  Would you       recommend that a 60 ish woman with mild osteoporosis who is on       substantial doses of Neurontin 600-1200mgs per diem) and clonazepam       (6mgs per diem) for anxiety be switched over to Valium or other sedative       type medications? Your input will be greatly appreciated.                                                                     

        To my knowledge neither of the anti-seizure drugs mentioned affect bone       density. Your osteoporosis should be treated independently of any of you       psychiatric conditions.                                                               

I have been on FemHrt recently, and in total about 5 years       of hormone
       replacement. Prior to that I took Fosomax for about a year. I saw both my       primary physician and my gyn. today, and they have differing opinions on       medication changes in light of the new studies. One wants me to take       Fosomax- 70- one time weekly The other suggests Fosomax 35 and evista.       I am 54 years old, through menopause, and do have osteoporosis. Which       would you suggest, and why? Thank you, as I am very confused                                                               

       It is difficult to deliver an intelligent opinion       based on the limited information given. Clear indications for hormone       replacement now include vasomotor symptoms, treating uro-genital atrophy,       and preventing /reducing fractures in women at high risk. Hormone       replacement  reduces the risk of fractures in the spine and hip, but       not to the same extent as bisphosphonates. If you are using HRT for the       above reasons and your bone density is worsening then a bisphosphonate (alendronate       or risedronate) should be added. Raloxifene (Evista) is not recommended       with osteoporosis in the hip as it has only proven useful in the spine.                                                              

I       am a postmenopausal woman 48 yrs old, have been told I have osteoporosis       in my hip and spine. I don't remember the T scores but I have just below       the line between osteopenia and osteoporosis. I weigh 140 lbs and am 5 ft       7 in tall. My problem is my primary care physcian told me to take Fosamax,       Oscal 1000 mg a day and work out with weights, my orthopedic Dr told me it       is not bad to do all the things my primary care Dr said to do, told me I       can lift any weights I want, snow ski, etc just be active and do anything       I want to. I went to a endrocronologist and she told me it was real bad,       not to lift over 10 lbs, not to do crunches, not to wear high heels, etc.       She has me scared to death whereas the other two Drs have told me to not       change anything I do. I wear the Vivelle Dot patch for estrogen       replacement. Is the Vivelle Dot sufficient to help me to keep from losing       more bone and what do you think I can do as far as activity? Also! , I       have acid reflux and the Fosamax makes me sick, have tried Actonel also. I       can take the Fosamax and be sick that day and feel fine the rest of the       days. I just want to make sure the Fosamax is not going to cause me to       have bad problems in my stomach because of the acid reflux. Please advise.       I am so confused and know no other person that has this.                                                               

It is difficult for me to       give an accurate answer without more information and without knowing your       medical history in more detail. I suggest you check some websites, of       reputable organization, with a lot of information about your problem. In       the web sites you should be able to learn what advice most experts in the       field of osteoporosis give to their patients. The web sites are:               

           this is the site of the National Osteoporosis Foundation                       

           the site for the North American Menopause Society                      

            the site for the                       American                      College                      of Obstetricians and Gynecologists                       

           the site of the                       American                       Academy                      of Family Practice                      

I       am 47years old and have osteoporosis.I was diagnosed last year,and now       taking fossamax with my premarin and calcium. I have been loosing weight,       it started in my ankles and now seem to be loosing size every where. I am       in a lot of pain all of my bones are so sore and throb And i am getting       that hump..And my stomach is always upset. My doctor gave me prilosec for       that. I just dont know where to try next. Any information or direction       would be greatly appreciated.                                                       

You have a number of complaints that are difficult       to address without a proper history and physical examination. I recommend       that you discuss your concerns with a primary care physician you feel       comfortable with. Also, some changes in our body are expected as we age.       Your physician hould be able to tell if he       changes you notice are acceptable as normal or are a sign of disease.                                                      

I       had a DEXA scan done yesterday and was told by the technician that I was       in the "yellow" and should be in the blue????  I was given       Fosomax (once/week).  I am a 43 year old premenopausal woman with       regular periods.  I have never smoked, fairly active(aerobics &       weights), smallboned(5'4" 118 lbs.).  I have two questions 1. I       nursed 3 children on       the average 8 months, but I have never been a milk drinker, would this       cause       this? 2. I have not been able to get a Doctor to believe that anytime I       take       calcium my blood pressure goes up and I do not feel well, I have tried       viactiv, tums(makes my chest feel tight) and caltrate & citracal, why       is       this? And have you heard of others that have a problem with blood pressure       when they take calcium?                                                                

1.  Possibly if your calcium intake from all       foods was low. Dairy products are an excellent source of dietary calcium       but other sources are adequate as well. These include green vegetables,       meat, poultry, fish, etc.

2.  I do not know and have not heard about       it either. In fact the study below shows that increasing amounts of       calcium ingested from dairy products causes a decrease in blood pressure.

Am       J Clin Nutr. 2001 Mar;73(3):659-60.

Calcium from dairy products, vitamin D intake, and blood pressure:         the Tromso Study.

          Department of Medicine, the University Hospital of Tromso, Tromso,         Norway. medrj@rito.no
         
         BACKGROUND: The present epidemiologic study was conducted in Tromso,         Northern Norway, in 1994-1995. OBJECTIVE: The objective was to evaluate         the relation between calcium intake from dairy products and the intake         of vitamin D on systolic and diastolic blood pressure. DESIGN: Subjects         who were taking drugs for hypertension or heart disease, those taking         calcium tablets, subjects reporting cardiovascular disease, and pregnant         women were excluded, leaving 7543 men and 8053 women aged 25-69 y for         analysis. Calcium and vitamin D intakes were calculated from a         food-frequency questionnaire. RESULTS: After correction for age, body         mass index, alcohol and coffee consumption, physical activity, cigarette         smoking, and vitamin D intake, there was a significant linear decrease         in systolic and diastolic blood pressure with increasing dairy calcium         intake in both sexes (P < 0.05). However, the difference in blood         pressure between subjects with the highest and those with the lowest         calcium intake was </=1-3 mm Hg. Similarly, with increasing blood         pressure there was a significant (P < 0.001) linear decrease in         age-adjusted calcium intake from dairy sources; the difference between         the highest and the lowest blood pressure groups was 3-10%. Vitamin D         intake had no significant effect on blood pressure. CONCLUSIONS: There         is a negative association between calcium intake from dairy products and         blood pressure. However, although the effect of calcium on blood         pressure appears to be small, calcium could have a significant effect on         primary prevention of cardiovascular diseases.

        I am a 60 year old and I have tried taken Fosamax and it       tears by stomach up.  I am trying the once a week Actenol.  In 3       weeks time I have noticed a burning stomach, neck ache and headache for 2       to 4 days after I take the medication.  I do take a considerable       amount of calcium and have for the past 30 years.  I was taking the       actenol due to the fact that my Mom is 91 and is totally disabilitated       with osteoporosis and has had it since she was 27.  My bone dentistry       test showed very small amount of osteoporosis.  My question is, do I       have to take Actenol if I am taking calcium and other supplements?  I       don't want to tear up my stomach and keep having these pains.  I       would appreciate an answer when possible.                                                                

               The medical term that is used for the upset stomach       is dyspepsia.  The       neck ache and headache are very unusual side effects for this medication       class and may be related to something else.  The dyspepsia has been       well       described however and may be symptomatically improved by using an       anti-acid medication such as Prilosec or Prevacid the evening before       your weekly dose.  You would be best advised to discuss this with       your       physician.  Occasionally we note that the calcium supplement itself       is       causing the gastrointestinal problems.  Good luck and hope this has       been useful.                                                                  

Questions this month have been answered by:Simon Kipersztok, MD, OBGYN.net Osteoporosis Editorial Advisor 	Alice Rhoton-Vlasak, MD, OBGYN.net Osteoporosis Editorial AdvisoBarry L. Gruber, MD, OBGYN.net Osteoporosis Editorial Advisor 	Harvey S.Marchbein, MD, USA, OBGYN.net Osteoporosis Chairman and Editorial Advisor

       I am currently taking Fosamax to help prevent bone loss due to taking
       prednizone.  How soon do I need to discontinue taking Fosamax before       it is
       safe to become pregnant.  I am currently tapering off on the       prednizone and
        have been told that that would not interfere with a pregnancy, but I am
       concerned by the information I have found on Fosamax during pregnancy.

 Unfortunately       there are no data available that to my knowledge can help me answer your       question. Fosamax may remain in your bones for years and it is unknown if       it could have an adverse effect on a pregnancy after the drug is
        discontinued.


       I encourage you to discuss with your physician all the drugs available to
       prevent bone loss. You both can then make a good evaluation of the risks       and
       possible benefits of each formulation.

       I am a 23 year old woman that has been diagnosed with osteopenia. I have 2       transverse process fractures, L2&L3 with a Grade I spondylolisthesis
       to L5.  It has been ten months since the accident and my back still       hasn't healed, what can I do?  My Doctor has me on Fosamax to build       the bone and Vicodin/Hydrocodone for the pain.  I can't sleep at       night because of the pain. Their is no comfortable position.  Is       their a chance my case may be untreatable?  None of the doctors I       have seen have been able to help.  Please, what can I do?                                                         

It       is unlikely the osteopenia is related to the other spine problems. There       may or may not be a potentially treatable cause for your pain, but in       order to figure it out you need to be seen at an expert multi-disciplinary       spine center with orthopedic surgeons and non-operative physiotherapists.       Good Luck!                                                

       Can I take 7 fosamax 10mg tablets at one time?

       The dosage for Fosamax when prescribed for the treatment of osteoporosis       is 70 mg. weekly. You can take each week one 70 mg. pill or alternatively       seven 10 mg. pills. In both situations you would ingest the same total       amount of the drug.                                                  

Two years ago I was sent for a bone density         test as my sister has bones of an 85 year old. My doctor did not tell me any numbers other         than I tested at 65 years of age & he put me on 1500 mg of calcium.

I exercise 3 times a week, quit smoking,         take 1500 mg of calcium & 400 units vitamin D, eat a healthy diet.          Recently took bone density test again & nothing has changed so my         dr. precribed didrocal & told me only side effect may be heart burn.          From the internet I discovered a variety of possible side effects &          long term effects are still unknown.  I believe I am peri-menopausal,         but from the blood tests my dr. says no.  My body tells me         otherwise.  I fear I will lose even more bone mass as menopause         approaches.

My questions are - will this drug help         me & do I need to stay on it long term.  At what risk am I to         have a fracture if I cannot live with the side effects.  Is there         anything else I could take if this does not work?

       You have low bone mass and you are perimenopusal       given your age. Your doctor has prescribed Didronel (I am not familiar       with 'didrocal'...) and you take calcium and vitamin D. Your bone density       has not changed on a repeat test. If you are taking Didronel, the drug is       safe an useful for bones if taken every 3 months. There are 2 other       similar drugs commonly used for the prevention and treatment of       osteoporosis, risedronate (Actonel) and alendronate (Fosamax). If Didronel       causes side effects then you may want to try and see if one of the other       drugs is better tolerated. Fosamax can be given once a week. These drugs       should be taken as long as the risk of fracture is increased and that can       be long term depending on the degree of low bone mass.

The increased risk of fracture depends on the T       score (or % young adult) measured in your bone densitometry study. It can       vary in different sites of your body. Roughly, if the T score is less than       -1 the risk of fracture increases by more than 2 fold. For a T-score of       less than -2 the risk can increase by more than 4 fold. For a T score of       less than -3 the risk of fracture can increase by more than 8 fold.

Also, please be aware that no change in       sequential bone density studies can still be good news since it could mean       that bone mineral density is not getting worse and whatever intervention       was used it is protectin g the bone from losing more density.

My sister       is 48 years old and premenopausal.  Her only risk factors for       osteoporosis are poor dietary intake of calcium and lack of weight bearing       exercise.  Her recent DEXA showed her lumbar spin to be at -1.24 SD       and her femoral neck at -1.97 SD.  Her physician started her on       Calcium and Vit D and Actonel and will repeat her DEXA in a yr.  Is       he being too aggressive using this medication to prevent osteoporosis?        Should my sister try Calcium, diet and exercise for a year and then see if       the DEXA improves or stays steady?  I am concerned about the possible       long term effects of Actonel.   Thanks.

       The treatment recommended by your sister's physician       is within the realm of what would be reasonable given the information you       provided. Often times, more than just the results of a DEXA study go into       making a decision to recommend medical treatment. Certainly risedronate (Actonel)       is a fairly safe drug to prevent and treat osteoporosis so your sister's       risk of fracture will decrease after its use.                                                       

I am 44 years old, and recently diagnosed with Osteopenia.        My OB/GYN increased my calcium intake to 1200mg, and to do weight bearing       exercises, along with prescribing fosomax.  I am still having       periods. Is this safe?                                                              

The       management plan as recommended by your physician is safe. Fosamax is       fairly well tolerated especially when taken once a week. As the drug is       excreted by the kidney, patients with severe kidney disease may need to       have the dose adjusted.                                                             

 I       am a 41 year old female, I have been on Actonel for  four months       now and seem to be on a steady weight gain, 10 to 15 pounds with no change       of eating habits and on the same exercise program. Although I don't see       weight gain on any of the info. on side affects I have read, I can't       help think that this drug seems to have slowed down my metabolsim not just       my boneloss, is that possible?, And if it is, is there anything I can do       about it, short of stopping the RX. Thank you.                                                       

There has been no       evidence to support your concern that Actonel would be the cause of your       weight gain or that it might slow your metabolism.                                                                           

I       am taking 30 mg of Actonel once a week. Bone density test found
       osteoporosis in hip. I am 57 years old. When I take it on Sundays I get a
        burning or pain in stomach. I am following all the directions of how to       take
       it. I hope this does not cause me to get ulcer later on or stomach cancer.       I
       am concerned.                                                       

It is unlikely that Actonel       will lead to "cancer" of your gastrointestinal track, but it is       possible that esophageal irritation may be occurring as a cause of your       pain as a result of Actonel.  Since you are using this product       "off-label", which means different than the FDA approved method       (which is daily dosing) one other strategy which you might speak to your       physician about is taking a proton pump inhibitor, such as Prilosec or       Prevacid, the evening before your weekly dose. Using the drug as a weekly       bolus rather than daily dosing is a general trend for these compounds and       in general has met with tremendous success; thus the idea of taking       smaller doses daily would not necessarily obviate the problem that you are       encountering but might be tried nonetheless.                                                      

I had a bone density test (do not remember number results)       but my doctor prescribed Fosomax.  I took it daily for about a year.        Then at my doctor's suggestion I changed to the one-a-week Fosomax.        After two weeks I coughed up blood three times one morning.  A chest       x-ray showed my lungs were clear.  I was afraid of Fosomax after that       and have been taking nothing except Premarin, which I have been taking for       several years, and 1260 mg of Citracal and 800 IU of Vitamin D.  I       also take Synthoid as I had my thyroid surgically removed.  Do you       think I am getting enough calcium?  I also drink soy milk.        Thanks.                                                               

It       appears you are getting sufficient calcium and vitamin D, which answers       your only question.  The premarin is also likely contributing to       diminishing your bone loss over time.  The coughing up blood is a       worrisome event and the relation to Fosamax ingestion certainly was not       established firmly in your case from the information you provided. Perhaps       there remains another explanation and further workup may be in order-       please continue to discuss this with your physician.                                                               

 Can you please explain the results of my         Dexa? The T score is -2.7 and the Z score is -1.8 in the spine. I am 53         yrs. old and in menopause. I know that the T score is compared to         healthy young women and the Z score to women of my age.  What I am         having trouble figuring out is which number is most important. Thank         you.                                                                    

 We believe that the       T-score is more important with the premise that normal bone mass is what       we achieve as a young adult and every effort needs to be made to maintain       that optimal bone mass in effort to keep our stature and minimize       fractures for the remainder of our lives. Hence, the degree to which you       measure up to that optimal young adult bone mass gives you a more precise       picture of your risks.                                                      

I started to take medication for osteoporosis 6 months ago,       and started Actonel  9 weeks ago. I have fibrocystic breasts. After 2       weeks my breasts hurt so bad I could hardly touch them, they even hurt       when my clothes touched them. I called the Dr., they told me to wait two       weeks and see. They got better, but I called the company that makes Actonel       and they had never heard of breast pain when taking Actonel. They sent me       a paper for the Dr. to fill out with information on me. I'm 72 years old,       and I had scleroderma 28 years ago. The Dr. told me in Jan. 2002 that it       is coming back.  I would like to know if the medication I'm taking       for osteoporosis is causing Scleroderma to come out of remisson? My legs       are getting hard so far to the middle of my calf. Could that be from the Actonel?                                                                

There is no clinical       data or theoretical reason that Actonel would have any effect on your       breast tissue or your scleroderma.  This drug rapidly binds to       skeletal tissue at areas where calcified bone is exposed to the blood or       else gets excreted out of the body.  The scar tissue in areas of       scleroderma involvement or in your breasts would not be areas that Actonel       would bind and be biologically active.  That said, we always have       more to learn and listen carefully to what our patients tell us.        Your physician(s) will need to help you sort this out further.                                                        

                I am 34 years old and was diagnosed with osteoporosis 16 months         ago.  Upon diagnosis, my doctor immediately put me on Fosamax.          I was on it for 4 months when I began to see an endocrinologist.          That doctor said that if I wanted to have another child that I         should immediately cease taking Fosamax and get pregnant.  I         ceased taking the medication for almost 1 year, remained on estrogen,         and increased my bone density by 6%.  I am now considering becoming         pregnant.  I am concerned about the information my new doctor gave         me regarding the fact that Fosamax stays in your system for up to         10 years and is slowly released during that time.  Have you heard about premenopausal women taking Fosamax, stopping the         medication, and then having healthy children?          Thank you for any information you are able to supply.                                                                

In response to your       question, there has been very little experience with
       pregnancy in individuals who have taken Fosamax.  Theoretically, and       based  on a large amount of animal experimentation (including       primates), the follwowing can be construed.  Although Fosamax does       "hang around" for more than a decade in the body, most all of       this is bound within the skeleton and not "bioavailable".        In other words, very small amounts enter the blood stream and thus       potentially pass through the placenta into a developing fetus.  It       has been estimated to be in the "parts per million" range, which       is highly unlikely to have any untoward effects on the fetus or its       development.  Hope this is helpful and encouraging, even though there       has been little actual experience with this situation.                                                                     

        I am 55 years old have just been diagnosed         with osteopenia based on my first bone density test. My mother also just         had her first test at age 77 and also has osteopenia.  I have not         menstruated for about 4 years. I took HRT for the first 3 but stopped         due to lack of evidence for cardiovascular health and concern about         cancer.  The bone density was done about 4 months after I stopped         the HRT.

I have severe GERD and am on Prilosec and         therefore do not want to take Fosamax. I am reluctant to take Actonel as         well for the same reason.  Evista is a concern for me due to the         high level warnings about blood clots - this does not seem to be a great         trade off for a broken hip in 20 years.  What do you think about         Miacalcin or other calcium products?  thank you.

You do not provide       information as to how severe your osteopenia as this
        would factor into advising you (i.e., whether it is extremely mild or       severe). Miacalcin would probably not be a good choice as clinical trials       have indicated it is ineffective within the first 5 years after menopause       (or in your case, after discontinuing estrogen).  At best, it is a       weak agent.  Evista has an incidence of blood clots about as frequent       as estrogen itself and evidently that did not influence your initial       decision to use it.  More important, the incidence of blood clots is       elevated only during the first several months of use- then it is no more       frequent an event than by chance in the general population. So if you were       to decide to use Evista, you need not worry for long about developing a       blood clot.  Although you have "severe GERD", weekly dosing       of bisphosphonates such as Fosamax or Actonel seem well tolerated and only       rarely cause additional problems.  These drugs work well and may be       among the best agents currently available.
       
       In summary, depending on your level of osteopenia, you do have many       different reasonably safe and effective options in addition to keeping       adequate calcium and vitamin D intake.  Hope this has been useful.                                              

I       am a 65 year old white female that has borderline osteoporosis  of       the spine.  I have taken "bone up" --- 500 mg daily--- this       has a more adsorbable CA than regular CA and is extracted from Australian       bovine.   For 1 year I took acetenol and then had a bone density       test performed. The results for my spine were identical to the 3rd decimal       place from the bone density test performed a year ago.  However, my       hip reading was down approximately 4 %.  It is still osteopenic. I       have been trying to figure out where I went wrong.  I took the       actenol on a full quart of water (2 continuous glasses then the remaining       2 within 20 minutes) and  waited an hour before eating.  I       exercised 5 days a week by walking approximately 2 miles each day.  I       put weights(1 1/2 pounds each) on my ankles when I walked.

I have had 3 bone density tests.  The second test showed a slight       improvement from the first. During this period, I used progesterone       cream approximately 1/4 gm for 27 days per month.  I took premarin       (.3 gm --- green pill) days 1 -25.  I also took the "Bone       Up" supplement and exercised 5 days a week.

I am switching to Citracal --- is it a good choice?  My       gynecologist has suggested fosamax for a year then repeat the bone density       test. What is your opinion?

  Alterations in bone mass       measurements from time to time as means of
       monitoring the "success of treatment" are frought with serious       limitations.  It is always nice to see steady, progressive gains.        But frequently we note more undulating values which may relate to       limitations in the technology, calibration problems of the machine,       different technicians, etc.  It may also reflect changes in bone       density, but not necessarily bone strength.  In clinical trials,       patients who lost bone while on these drugs still fractured less than       their counterparts on placebo.  It is also conceivable that you might       have lost more had you not been on Actonel.  Progesterone cream or       oral preparations are unlikely to influence bone strength in any       meaningful way, from data derived out of good clinical trials.        Calcium is important, but great differences among products are not       supported again by clinical trial data- most of this is marketing hype.       Lastly, Fosamax is a well-tolerated and effective approach to the problem       and would not be a bad option to try.                                                        

I am       a lady 68 years old.  I have been told I have Osteo in my hips. I was       put on Fosomax.  I began to have chest pain and was put in the       hospital for testing.  I was told not to take any more of the       medicine. When I was dismissed my doctor told me if I needed him to call.       I was not put on any medication.  I know I  am not doing       anything for my bones except taking calcium. They did not recommend any       other medication.  Is there any I can take to help?                                                                

              It is difficult to advise you, when the results of       your tests are not
       described and specifically whether the cause of your chest pain was
        determined to be esophagitis by endoscopy.  In this case, then
       sufficient concern would be raised concerning the possibility that
       Fosamax was the underlying cause of this problem.  But if that were       not
       the case, then resuming Fosamax once weekly or using Actonel seem
       reasonable alternatives.  Another less ideal option but still       effective
       would be to consider Evista.
        
       In summary, without sufficient details about your case and your workup,
       it is very difficult to advise you soundly.  You might discuss these
       factors in detail with your physician or seek a specialist in       osteoporosis. Hope this is helpful.                                                                    

 I       would like to know if there is any difference between Fosamax and
       Actonel and is one better than the other in treating osteoporosis. I have       been diagnosed with osteoporosis and brought it up to osteopina by taking       Fosamax for several years.  I started to get some heartburn and       decided to discontinue its use and the doctor stated that as long as I       continued with my HRT regimen that that should be OK.  I have not       used Fosamax for 2 years. I just had another bone scan and it showed that       it had returned to osteoporosis and the doctor prescribed Actonel. Will I       have to take this medicine for the rest of my life?  Are there any       other alternatives besides these drugs and weight bearing exercise? I am       60 and in excellent health otherwise. Thank you.                                                               

Questions this month have been answered by:Simon Kipersztok, MD, OBGYN.net Osteoporosis Editorial Advisor Alice Rhoton-Vlasak, MD, OBGYN.net Osteoporosis Editorial Advisor Barry L. Gruber, MD, OBGYN.net Osteoporosis Editorial Advisor

Author | Simon Kipersztok, MD

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