The bones of older women often get more and more brittle because they are becoming less and less dense. Osteoporosis is the disease name for this process, and people who suffer from it break bones more easily than normal.
For many years, women reaching menopause have been advised to take estrogen replacement therapy (ERT) or estrogen with a progestin (called hormone replacement therapy or HRT) to prevent this disease. But this meant taking hormones for 20-30 years -- which also has risks, including uterine cancer (with ERT alone), blood clots, gallstones, and possibly breast cancer.
There's good news, though: There may be other ways to prevent, and even treat, bone loss.
"In the past 5 or 10 years, we have recognized that osteoporosis is a very treatable disease," says Bruce Ettinger, MD, senior investigator in the research division of the Kaiser Permanente Medical Care Program in Oakland, Calif. "The old idea that you can't treat it, you can only prevent it, is out the window. We have new medications now that markedly reduce women's risk of fracture and we have other and perhaps even better medications coming soon."
Hormone Controversy
A June 13, 2001 Journal of the American Medical Association (JAMA) editorial notes that the estrogen therapies prevent postmenopausal bone loss but also that other drugs (even calcium and vitamin D) decrease the risk of fractures independently of how dense or porous a woman's bones are. For that reason they are approved by the FDA not just to prevent osteoporosis but also to treat it.
One class of drugs, the bisphosphonates -- including alendronate (Fosamax) and risedronate (Actonel) -- prevents spine, hip, and other fractures. So-called SERM (for selective estrogen receptor modulator) drugs -- including tamoxifen (Nolvadex) and raloxifene (Evista) -- increase bone density and reduce spinal fractures but not hip fractures. They may increase the risk of blood clots and hot flashes, but some reduce breast cancer risk.
Raloxifene is the SERM that is FDA approved for osteoporosis therapy. Calcitonin increases bone density in the spine and reduces the risk of spinal fractures but does not seem to reduce fractures of the hip and other bones. When injected, it may cause an allergic reaction, urinary frequency, or nausea in some people, though these side effects were not reported when calcitonin was taken as a nasal spray.
Statins like Zocor (simvastatin), Mevacor (lovastatin), and Pravachol (pravastatin) may lower the risk for hip and other fractures, may help improvej cholesterol levels, and may reduce heart attack and stroke risk, but are not yet FDA-approved for osteoporosis therapy.
Do Benefits Exceed Risk?
Estrogen has not been shown to significantly reduce fractures in women who are 60 years old or over, according to the authors of the JAMA editorial. They say, "Since women in their 50s who do not have osteoporosis have a relatively low risk of fracture, the benefit of long-term treatment with estrogen to prevent bone loss and fractures may not exceed the risks."
According to Ettinger, a woman's decision to take hormone replacement should not be based only on preventing osteoporosis, since there are other options.
But more studies need to be done: The JAMA authors say no large trial has tested what effect estrogen may have on fracture risk in women who do have osteoporosis.
"The debate surrounding the use of HRT underscores the need for a greatly expanded osteoporosis research effort, including definitive studies of HRT," says National Osteoporosis Foundation director Sandra Raymond in a June 2001 news release. "Osteoporosis is an enormous public health problem, causing 1.5 million fractures annually. Until and unless the osteoporosis research effort is greatly increased, these answers will not be forthcoming."
Women Have a Choice
Bones normally lose density as we age. Only a severe loss results in osteoporosis. Experts say many things besides estrogen decline may contribute to postmenopausal women developing the disease, including
- Family history
- Individual metabolism
- Parathyroid hormone
- Vitamin D
- Blood factors that direct cell growth
- Certain drugs
- Certain illnesses, including diabetes
According to Ettinger, "It's rare for women to be affected much before age 65 or 70 and most of the fractures we worry about occur after age 70 or 75. The average age for hip fracture is 81 and for spine fracture 72 or so. That's 25 to 30 years or so after menopause."
"Women can delay the decision to take a drug to prevent osteoporosis and instead pursue reasonable lifestyle changes," he says. "Why take a drug for years and years? Drugs cost money and have potential side effects, as opposed to doing the right thing in your life. Instead, reserve drugs for women who are at much higher risk."
Ettinger says: "I would suggest a woman ask, 'Is this going to affect me in the next five to 10 years?' If so, take some of the good medications available. We're getting better in treating the disease and the new drugs are more powerful in restoring bone strength."
Make Lifestyle Changes
Besides drugs and hormones, there are simple steps women can take to reduce their risk of getting osteoporosis, yet health advocates say such measures are often ignored.
The National Women's Health Network counsels, "We advise taking simple steps to prevent bone loss and fracture: exercise, appropriate calcium intake, home safety precautions, and avoidance of drugs and other chemicals (too much alcohol, caffeine, smoking, or excess salt) that can cause additional bone loss."
Raymond, too, points to basics: "The truth is ... that people are not taking care of their bones. In fact, our nation suffers from a major calcium deficit. Women, girls, men, boys -- hardly anyone seems to be getting the calcium they need each day."
Women can reduce their osteoporosis risk by
- Eating foods with calcium and vitamin D
- Exercising regularly
- Not using alcohol and caffeine excessively
- Not smoking
Years of such habits build strong bones that can carry most of us safely through old age.
