Although I have taught women about osteoporosis for years, my mother's diagnosis brought home the frustrations of prevention and treatment. True, she was probably not the model of prevention. She tried to take her calcium supplements as regularly as possible but admitted missing doses and days. Her treadmill was gathering cobwebs. Yet, she took hormone-replacement therapy for several years and had no other risk factors for osteoporosis besides being Asian. When I looked at her bone mineral-density test results, I couldn't believe that she had lost so much bone strength.
Despite everything we have learned and try to do to prevent osteoporosis, it often requires more extreme measures than calcium, vitamin D and weight-bearing exercise to protect our bones. Before the Women's Health Initiative (WHI) study demonstrated that the risks of hormone-replacement therapy (HRT) clearly outweighed the benefits, HRT was our best defense against osteoporosis. We knew that HRT was the best treatment for preventing the high rate of bone loss seen at the beginning of menopause. So what should women do now?
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Without HRT, we need to become more aggressive about testing and treating osteoporosis and its warning sign, osteopenia. You should get a bone mineral-density test if:
- You are postmenopausal and over the age of 65.
- You are postmenopausal and under the age of 65 with any of these additional risk factors:
- Being Caucasian or Asian
- Being thin
- Taking prednisone
- Entered menopause younger than the age of 50
- Family history of osteoporosis
- Excessive alcohol use
- Tobacco use
- An overactive thyroid (hyperthyroidism)
- Primary hyperparathyroidism
- An intestinal problem that prevents calcium and vitamin D absorption
- You have had a fracture of the wrist, spine or hip from a simple fall.
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Decide on the Best Test
Ideally, for both prevention and monitoring, the best tests are the DEXA scans of the spine and hip. Women are most concerned about painful spine fractures and potential life-changing and life-threatening hip fractures. But because of the high demand for hip and spine DEXA scans, other scans have become available including for the arm, fingers and heel. If these are the only scans available to you, they can reliably diagnose osteopenia or osteoporosis. The disadvantage of these other scans is that they are not as accurate when retesting in the next year or two for the effectiveness of treatment. If you are diagnosed with osteopenia or osteoporosis by a scan of the arm, fingers or heel, you should ask for a spine DEXA to check the effectiveness of your treatment in a year or two.
If you have evidence of osteoporosis by a bone mineral-density test, you should also have blood tests to measure calcium, phosphate, vitamin D and parathyroid hormone levels, as well as tests to measure protein electrophoresis, thyroid function and urine free cortisol. These tests rule out other conditions that can lead to osteoporosis. If another condition is found, treating it will help to restore and maintain your bone strength. Vitamin D deficiency is common in the United States, and an important cause of osteoporosis that shouldn’t be missed because it is so easy to treat.
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The reason HRT is no longer used to prevent osteoporosis is that there are other, nonhormonal agents that are safer to use. In the era after the Women's Health Initiative results, the main agents to learn about are the bisphosphonates (such as alendronate, ibandronate and risedronate) and selective estrogen receptor modulators (SERMS, such as raloxifene).
Bisphosphonates have been shown to increase bone strength and reduce the incidence of fractures. The evidence suggests that bisphosphonates work better than SERMS. However, SERMS have some other potential advantages. While raloxifene acts on estrogen receptors, it reduces the risk of breast cancer and heart disease, and it lowers cholesterol levels.
A newer treatment is also available, a form of parathyroid hormone, teriparatide (Forteo). This is the only treatment that actually builds bone. The downside is that it must be given through an injection every day. Right now, it is only being used for people with severe cases of osteoporosis or for people who have not responded to other treatments. But in the future, you may be hearing more about this new drug.
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The Importance of Vitamin D
As women get older, surprisingly, estrogen deficiency becomes less important than vitamin D deficiency. Vitamin D not only helps the body absorb calcium but must be present to block hormones that break down bone. Taking vitamin D and calcium together has been shown in studies to improve bone density more significantly after the age of 60. This is likely because many people over the age of 60 are vitamin D deficient. Getting less sun exposure due to being less active is the likely explanation, along with dietary changes.
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So, back to the Chang family story. My mother was treated with a bisphosphonate and she has had follow-up bone density tests.
As she correctly pointed out to me, she did not start HRT right at the beginning of menopause, and she may have lost most of her bone mass in the first five years of her menopause before starting hormones.
I am also doing my part to help myself — so take heed, all you daughters out there. Since I am lactose intolerant, I cannot rely on three servings of dairy products to meet my calcium requirement. Instead, I focus on taking a calcium supplement with two of my meals each day, in addition to a multivitamin and what I get from my diet.
Don't wait until menopause to start taking calcium and vitamin D. Everything you do now can help you increase your stores and bone strength to protect you later on in life. And for your daughters, for the same reasons, make sure they get enough vitamin D and dietary calcium.
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Alice Y. Chang, M.D. is a former instructor in medicine at Harvard Medical School. She is currently associated with University of Texas Southwestern Medical Center. Her clinical interests and experience are in the fields of primary care, women's health, hospital-based medicine and patient education.