Should bone loss always be treated?

July 7, 2005

June 13, 2005 latimes.com

# Osteoporosis is a serious disease, but the milder osteopenia may just

be a sign of normal aging.

Even as millions of American women go undiagnosed — and untreated — for

osteoporosis, a serious condition that can lead to devastating

fractures, millions of others are trying to prevent broken bones they

might never get.

Diagnosed with a milder form of bone loss called osteopenia, which is

not truly a disease, they take medication that might not be necessary.

Confusion about what degree of bone loss is a red flag for future

broken bones — and what is simply a sign of normal aging — has been

rampant since the World Health Organization, in 1994, defined

osteopenia and osteoporosis as certain ranges of scores on a bone

density test.

Some doctors consider this range skewed, labeling too many — 34 million

— Americans as having osteopenia, and too few — 10 million — at risk

for the broken bones of osteoporosis. (Osteoporosis is generally

considered a disease affecting women, but men can get it too.)

The problem comes from " calling osteopenia a disease when it is not, "

said Dr. Neer, director of the Osteoporosis Center at

Massachusetts General Hospital. " We are over-treating a large number of

healthy women who have a relatively minor risk of fracture and we are

ignoring a sizable number of individuals at high risk of fracture, "

Neer said.

The term osteopenia has " no medical meaning, " added Dr.

Cummings, an epidemiologist at UC San Francisco, who has led a number

of large studies on osteoporosis and osteopenia. " I've seen patients

who come in scared that they will become disabled soon because they

have this 'disease' called osteopenia, when in fact they are normal for

their age. "

Other critics such as Gillian Sanson, a women's health educator in New

Zealand and author of " The Myth of Osteoporosis, " go further. The

medical establishment, she said, is " manufacturing patients " by

over-emphasizing the normal bone loss that occurs with aging.

In essence, nobody quite knows what, if anything, an older woman whose

only sign of potential problems is mild bone loss should do. Should a

woman at 50 start taking drugs such as Fosamax, Actonel or Evista to

guard against possible fractures in her 80s, when most fractures occur?

Or should she wait until her bone tests get worse or there is a very

real red flag, like having a fracture triggered by a minor fall?

For the record, the WHO defines osteopenia as a score of minus 1 to

minus 2.4 on the DEXA test, or dual energy X-ray absorptiometry.

Osteoporosis is defined as a DEXA score of minus 2.5 or worse.

Osteopenia can, but does not necessarily, progress to osteoporosis.

Although osteoporosis clearly raises the risk of fractures, many

fractures also occur in people without the disease. A 2003 study showed

that the proportion of fractures attributable to fragile bones was

" modest " — between 10% and 44%.

" Low bone mineral density does raise the risk of hip fracture, but it's

only one of several factors like bad eyesight, bad coordination, use of

Valium or similar drugs, overactive bladder and other conditions that

contribute to the falls that can lead to broken bones, " said Dr.

Nananda Col, an internist and women's health expert at Rhode Island

Hospital in Providence, R.I.

A finding of mild osteopenia on a bone density test is not, by itself,

enough reason to take medications. If there are no other risk factors,

even a bone density test score as low as minus 2 " in an otherwise

healthy young person may be normal, " said Dr. Orwoll, an

osteoporosis specialist at Oregon Health Sciences University in

Portland, Ore.

On the other hand, because osteopenia sometimes leads to osteoporosis,

many doctors say it's important to start treatment early to avoid

broken bones later in life. Dr. Finkelstein, an osteoporosis

specialist at Massachusetts General Hospital, said he sometimes

prescribed medication to post-menopausal women with bone density scores

of minus 1.5 to minus 2, even if they were in their 50s.

" I do believe in treating a lot of these people to prevent the

development of osteoporosis…. I may be more aggressive than some other

physicians, " he said.

Dr. Suzanne Jan de Beur, director of endocrinology at the s Hopkins

Bayview Medical Center, said she prescribed medication to women with

scores of minus 1.5 to minus 2 if they had a family history of

osteoporosis or other risk factors.

Dr. ph L. Melton III, an epidemiologist at the Mayo Clinic in

Rochester, Minn., put it this way: Doctors who advise women to ignore

osteopenia " are wrong, and people who advise everybody to treat it are

wrong. It's a personal decision based on family history and personal

values. "

So, when should a woman be screened for potential bone loss? And how

safe are the drugs for long-term use? In 2002, the U.S. Preventive

Services Task Force, a panel of independent experts convened by the

government's Agency for Healthcare Research and Quality, concluded that

women 65 and older should be screened routinely for osteoporosis.

Screening should begin at 60 for women at increased risk, which

includes a family history of hip fractures, current smoking, thinness

and use of steroids such as prednisone.

As for drug safety, a study published in March 2004 in the New England

Journal of Medicine showed that Fosamax (alendronate) appears to be

safe for as long as 10 years. But a 1998 study showed that although

Fosamax helps prevent fractures in women with osteoporosis, it does not

do so in women with osteopenia and no previous fractures.

Fosamax and Actonel can cause small ulcers in the esophagus, or food

tube; Evista can cause hot flashes, and in rare cases, blood clots.

There is no evidence that the widespread use of Fosamax and Actonel is

causing any problems, said Col of Rhode Island Hospital. But the drugs

do get incorporated into bone. " If 10 years down the line, it turns out

that something is dangerous, it will be sitting in a lot of people's

bones. The benefits of treatment need to outweigh the risks. "

That applies to another drug too: Forteo, the only medication that

actually increases bone growth. However, Forteo carries a special

warning because, in rodents, it can trigger bone cancer.

Bottom line? Try to prevent thinning bones in the first place. Do

weight-bearing exercise several times a week and walk briskly for 30

minutes a day or more. Get enough calcium — 1,200 to 1,500 milligrams

(but not more) a day, plus 800 international units of vitamin D, from

food and, if necessary, supplements. Minimize use of Valium-type drugs.

If problems such as an overactive bladder or poor eyesight are raising

your risk of falls, get those treated.

And if one doctor recommends drugs on the basis of mild bone loss,

consider getting a second opinion. Obviously, no one wants a broken

hip. But no one should take any drug for decades without careful

thought, either.

July 7, 2005

This was an interesting article. I'm 65 and have osteopenia. I take

Evista for that and also to try to prevent breast cancer from recurring.

I thought it weird that they say that some falls are caused by

overactive bladder. Is that because these people have to run to the

bathroom a lot, LOL? I do have a somewhat overactive bladder, but I

don't usually have to run to the bathroom. Sue

On Thursday, July 7, 2005, at 08:40 PM, a wrote:

> June 13, 2005 latimes.com

> Should bone loss always be treated?

> # Osteoporosis is a serious disease, but the milder osteopenia may just

> be a sign of normal aging.

> ........................

> " Low bone mineral density does raise the risk of hip fracture, but it's

> only one of several factors like bad eyesight, bad coordination, use of

> Valium or similar drugs, overactive bladder and other conditions that

> contribute to the falls that can lead to broken bones, " said Dr.

> Nananda Col, an internist and women's health expert at Rhode Island

> Hospital in Providence, R.I.

July 7, 2005

This was an interesting article. I'm 65 and have osteopenia. I take

Evista for that and also to try to prevent breast cancer from recurring.

I thought it weird that they say that some falls are caused by

overactive bladder. Is that because these people have to run to the

bathroom a lot, LOL? I do have a somewhat overactive bladder, but I

don't usually have to run to the bathroom. Sue

On Thursday, July 7, 2005, at 08:40 PM, a wrote:

> June 13, 2005 latimes.com

> Should bone loss always be treated?

> # Osteoporosis is a serious disease, but the milder osteopenia may just

> be a sign of normal aging.

> ........................

> " Low bone mineral density does raise the risk of hip fracture, but it's

> only one of several factors like bad eyesight, bad coordination, use of

> Valium or similar drugs, overactive bladder and other conditions that

> contribute to the falls that can lead to broken bones, " said Dr.

> Nananda Col, an internist and women's health expert at Rhode Island

> Hospital in Providence, R.I.

July 7, 2005

Geez... if YOU are taking meds for Osteopenia, maybe I should be too?

I am 42 with osteopenia and Osteoarthritis and degenerative disc

disease. I am especially at risk for osteoporosis because:

1) I went through menapause early - and chose to " half-heartedly "

take replacement hormones as I had had " lacunar infarcts (i.e.,

little " strokes " in the white and gray matter of the brain secondary

to Lupus). I was 38 when, after NO periods for 6 months, was dx w/

fibroids and had a total hysterectomy -turned out to be a good thing

too, as they discovered precancerous cells through-out the

endometrium of the uterus.

2) Had thyroid cancer, taking high doses of thyroid replacement ever

since (2.5-3.0 mcg)

3)Had radiation treatment for the thyroid cancer.

All three of these things put me at high risk - and if you take meds

for osteopenia at 65, I'm really worried because I was dx three years

ago! Yikes!

(Just ANOTHER thing to worry about, huh?)

>

> > June 13, 2005 latimes.com

> > Should bone loss always be treated?

> > # Osteoporosis is a serious disease, but the milder osteopenia

may just

> > be a sign of normal aging.

> > ........................

>

> > " Low bone mineral density does raise the risk of hip fracture,

but it's

> > only one of several factors like bad eyesight, bad coordination,

use of

> > Valium or similar drugs, overactive bladder and other conditions

that

> > contribute to the falls that can lead to broken bones, " said Dr.

> > Nananda Col, an internist and women's health expert at Rhode

Island

> > Hospital in Providence, R.I.

July 7, 2005

Geez... if YOU are taking meds for Osteopenia, maybe I should be too?

I am 42 with osteopenia and Osteoarthritis and degenerative disc

disease. I am especially at risk for osteoporosis because:

1) I went through menapause early - and chose to " half-heartedly "

take replacement hormones as I had had " lacunar infarcts (i.e.,

little " strokes " in the white and gray matter of the brain secondary

to Lupus). I was 38 when, after NO periods for 6 months, was dx w/

fibroids and had a total hysterectomy -turned out to be a good thing

too, as they discovered precancerous cells through-out the

endometrium of the uterus.

2) Had thyroid cancer, taking high doses of thyroid replacement ever

since (2.5-3.0 mcg)

3)Had radiation treatment for the thyroid cancer.

All three of these things put me at high risk - and if you take meds

for osteopenia at 65, I'm really worried because I was dx three years

ago! Yikes!

(Just ANOTHER thing to worry about, huh?)

>

> > June 13, 2005 latimes.com

> > Should bone loss always be treated?

> > # Osteoporosis is a serious disease, but the milder osteopenia

may just

> > be a sign of normal aging.

> > ........................

>

> > " Low bone mineral density does raise the risk of hip fracture,

but it's

> > only one of several factors like bad eyesight, bad coordination,

use of

> > Valium or similar drugs, overactive bladder and other conditions

that

> > contribute to the falls that can lead to broken bones, " said Dr.

> > Nananda Col, an internist and women's health expert at Rhode

Island

> > Hospital in Providence, R.I.

July 8, 2005

, I am quite a bit older than you are, if that makes a difference.

I'm 65, and you're still a spring chicken at 42. But maybe that's even

more reason for you to take something; I don't know. If I were you, I'd

discuss it with my doctor. My bones were fine until I took prednisone

for a few months. I also take two 600 mg calcium with vitamin D every

day now.

The rheumy fellow that I was seeing at the time did not prescribe the

Evista. It was a decision that I made myself, and I asked my PCP for

the prescription.

Let us know what your doctor says. Sue

On Friday, July 8, 2005, at 12:14 AM, wrote:

> Geez... if YOU are taking meds for Osteopenia, maybe I should be too?

> I am 42 with osteopenia and Osteoarthritis and degenerative disc

> disease. I am especially at risk for osteoporosis because:

> 1) I went through menapause early - and chose to " half-heartedly "

> take replacement hormones as I had had " lacunar infarcts (i.e.,

> little " strokes " in the white and gray matter of the brain secondary

> to Lupus). I was 38 when, after NO periods for 6 months, was dx w/

> fibroids and had a total hysterectomy -turned out to be a good thing

> too, as they discovered precancerous cells through-out the

> endometrium of the uterus.

> 2) Had thyroid cancer, taking high doses of thyroid replacement ever

> since (2.5-3.0 mcg)

> 3)Had radiation treatment for the thyroid cancer.

> All three of these things put me at high risk - and if you take meds

> for osteopenia at 65, I'm really worried because I was dx three years

> ago! Yikes!

> (Just ANOTHER thing to worry about, huh?)

July 8, 2005