Osteoporosis Ask The Expert

Transcription

Published on OBGYN.Net (http://www.obgyn.net)
November 14, 2007 | Osteoporosis [1], Pregnancy and Birth [2], Contraception [3], ObGyn Nurses
[4], Integrative Medicine [5]
By Maria Luisa Bianchi, MD [6]
Questions this month have been answered by: Maria Luisa Bianchi, MD, Italy, OBGYN.net
Osteoporosis Editorial Advisor
Q: I am a 39 year-old mother of two children (ages 2 and 5) and have just
suffered my 4th spinal fracture in the thoracic region (T7, T8, T9 and T10,
confirmed by MRI). The T value for my lumbar spine is -2.56, indicating
osteoporosis. The T value for my left hip is -1.55, a value consistent with
osteopenia. These values were obtained by Dexa scan. I have lost 1 1/2 inches in height.
I am currently under the care of an endocrinologist specializing in osteoporosis and an orthopedic
surgeon. I am currently taking Fosamax (70 mg/wk) and 1200 mg of calcium citrate daily. It has been
recommended that once PTH is available, that I start hormone treatments. It has also been
suggested by oneof my doctors that I consider kyphoplasty, while the other is concerned that I am
too young for this procedure.
I am very concerned that the underlying cause of my condition has yet to be determined. I have
never used steroids or any medications that might lead
to premenopausal osteoporosis. I have never had an eating disorder and have always had and still
do have regular menstrual cycles (except while pregnant and lactating). There is no family history of
osteoporosis and I have always been an active person. My diet has always included dairy products
and I’ve taken calcium supplements on a fairly regular basis. None of the tests I’ve had thus far have
detected any abnormalities. While I know that management of my condition is important to my
health, I feel that it is even more critical to find out why I have this disease. Toward this end, I am
appealing to medical experts to find out whether they have ever treated premenopausal women with
osteoporosis and spinal fractures or if they know of any rare conditions that might precipitate this
disease. Do you have any suggestions for how I should proceed with my health care? I am in terrible
pain from my latest fracture. I cannot pick up or play with my two year-old, and I am scared for my
future. Thank you for your concern.
A: You are perfectly right. The problem is not only the management of your actual condition but
also to try to discover its cause, because treating the cause can have a positive effect on
osteoporosis.
You already excluded many causes of osteoporosis in premenopausal women (i.e. long-term steroid
therapy, anorexia, sex hormone deficiency).
There are many other possible causes, and they must be excluded as well, with the appropriate
tests. Among them:
1) diseases severely affecting intestinal calcium absorption, including in particular "celiac disease"
(gluten enteropathy) which is relatively common and is often quite asymptomatic
2) endocrine diseases: hyperthyroidism, hyperparathyroidism, Cushing's disease
3) chronic use of antiepileptic drugs
4) bone diseases such as osteogenesis imperfecta
5) post-gravidic osteoporosis (it's normal to lose bone mass during pregnancy, but it is normally
recovered within 1 year; however there are cases of persisting osteoporosis
6) severe vitamin D deficit
(I think that hepatic or renal insufficiency can be excluded).
Finally, there are forms of osteoporosis that may affect the young without an apparent underlying
cause. They are called "idiopathic".
In general, your therapy is the standard therapy for osteoporosis and you should go on with it. PTH
therapy, which can also stimulate bone formation, could be indicated in your case, but it requires a
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skilled doctor and a very careful follow-up.
Regarding kyphoplasty, it's a relatively new technique and I think there are not too many
experiences in young people. You must evaluate the risks and benefits with your orthopedic surgeon.
Q: I am 53 years old, weigh 124 lbs small frame and European. Two years ago I was diagnosed with
osteopenia in my left hip and lower lumber spine and the doctor prescribed 5 mg of actonel daily,
also 1200 to 1500 mg of calcium daily. At that time my result was -2.1 . I have had no pain and no
side effects to any of this treatment and I exercise and have a healthy diet and drink at least a gallon
of water a day.
I went for my 2nd test last week and the result was -1.5 , the doctor now wants me to take Evista
daily and continue with the actonel and calcium. I was quite disappointed in the results after using
the actonel for the two years. My questions are, how safe is Evista, what are the percentages of
people getting blood clots from the use of Evista and what are you thoughts on taking Evista and
Actonel together?
A: If the result that you give (from -2.1 to -1.5) are the T-score, they are positive results, and
indicate that the actonel + calcium therapy was effective, and that your bone mass actually
increased. If so, I don't see any reason to add another drug. However, if I misinterpreted your
numbers, and they are not the T-score but something else, all this is not valid.
Evista could be taken with Actonel, although this is very rarely done, in cases where there is no
response to a single drug. It is a safe and widely used drug. The risk of venous thromboembolic
diseases appears to be increased by about threefold (similar to that of estrogen therapy). Women
with past episodes of thrombophlebitis should preferably use another drug.
Q: I am a 37 year old woman with hyperprolactinemia/ hypothyroidism. My endocrinologist has been
concerned about my bone density ( I am osteopenic bordering on osteoporotic) and has
recommended actonel. I am concerned because it does not appear to be recommended for
premenopausal women. I am curious if this is simply because of potential pregnancy issues or if
there are other reasons. Our family is already complete and my husband has had a vasectomy, so
pregnancy is no longer possible. I would appreciate any information you can provide.
A:
Actonel, as all bisphosphonates, is not recommended in premenopausal
women, essentially because of the possible risk for the fetus in case of pregnancy. Bisphosphonates
do cross the placenta and animal studies demonstrated toxicity for the fetus (even if only at
extremely high dosages).
Many doctors - including myself - currently used bisphosphonates also in
young women (with strict contraceptive measures) when severe osteoporososis is present. The drug
has the same efficacy on bone in the young as in the post-menopausal women. So, if you don't want
a pregnancy you can safely use Actonel.
Q: Eight months ago I was told I needed to start a prevention for osteoporosis, my doctor chose
actenol. Since that time I have gained over 10 pounds eating salads, is it possible actenol does put
weight on perhaps like I hear some hormone treatments do? Help, I don't need overweight problems
too....this is a total of 20 pounds I have gained in one year?
A:
Actonel is not a hormone, but a drug acting exclusively on bone, reducing the bone resorption
process. In this way less bone is lost.
Actonel doesn't influence weight nor appetite. I suppose that your problem of overweight is related
to menopause. You should control your caloric intake (quality and quantity of food - salads per se are
not a problem, but many salad dressings are) and your needs (job, physical activity...).
Q:
I am a 68 old male with osteoporosis and prostate cancer. Bone density indicates 25% bone loss.
Fosomax & Actonal side effects are too much for me. I am taking CA&D. Does dosages of CA&D
affect prostate cancer growth? Increase it?
A:
Calcium supplements and vitamin D don't affect prostate cancer. Regarding the dosage
you must follow your doctor indication. In general you will need about 1200 mg of calcium a day, be
it from normal diet or from supplements. However, calcium and vitamin D alone are less effective on
bone loss and on the risk of fragility fractures than bisphosphonates (like Fosamax and Actonel). In
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general, if these drugs are taken following ther urles, they are well tolerated. Fosamax is also
available in a once-a-week dosage (Fosamax 70), which is preferred by many.
Q: I am a 46 year old woman who had a hysterectomy in my late twentys. I have been on premarin
since that time. I have been diagnosed with osteoporosis, I was having trouble with my neck, my
doctor took xrays and found that my bones were compressing , the result is it just keeps going,
(kyphosis) is there any thing I can possibly do, any surgery that I could get to stop the terrible out
come.I have been exercising and planning on joining a wellness center to try and slow this
down.Would a Kyphoplasty work for me? I am taking citracal 1200 mgs. a day, plus i have been on
fossamax for about 6 months I have lost quite alot of my height,and my ankles and wrists are so
much smaller now..Any help would be greatly appreciated.
A: You are now taking a full therapy for osteoporosis, and hopefully it will stop further vertebral
compressions (fractures). The actual effects of therapy can be evaluated after at least one year.
Exercise is good for you, but it must be carefully adjusted to your condition, as you must avoid too
much stress on your vertebral column. I think a 30-minute walk 5 to 7 days a week would be the
easiest and possibly the best kind of exercise. Go to the wellness center only if they are expert in
dealing with osteoporosis. Regarding kyphoplasty, you should consult an orthopedic surgeon. This is
relatively recent procedure which allows to restore the height of crushed vertebrae. Generally it is
performed soon after the vertebral fracture (1-2 months later).
Q: Thank you for your time. Why must we stand up for 30 minutes after taking Actonel? What effect
would it cause, if I took it 2 hours later, still on an empty stomach except for 1 cup of coffee with
non-dairy cream? Do we know the long term effects of taking this medication? It's doing a number on
my stomach and causes some real frightening bone pains in my legs. I had breast cancer in 97, and
cannot take hormones due to the type of cancer, so that option is out. And Fasomax was too harsh
on my stomach.
A:
The reason for standing up after Actonel or Fosamax is to avoid reflux of the drug into the
esophagus, as they are irritating. The reason to take them on an empty stomach with only a glass of
water is that they are poorly absorbed in the presence of food, particularly calcium or magnesium
rich food. This is the best way to take this kind of drugs: Coffee is irritating for the stomach. After
taking the pill, you should not take anything for at least 30 minutes. Allow 3-4 hours before taking a
full meal. If you have persisting stomach problems, ask your doctor if you could try the once-a-week
alendronate (Fosamax 70). The rules are always the same, but it's only one pill instead of seven.
Bone pain is reported as a very rare complaint with this kind of drugs and usually disappears after a
while. If it's severe or persisting, tell your doctor.
Q: I just turned 50 last month. I was diagnosed with Osteoporosis three years ago. My bone
density test came back showing my left hip was in the condition of a 70 yr.old and my spine was that
of a 63 yr. old. I have been placed on Fosamax (alendronate) and Premarin in attempts to stabilizing
and hopefully replacing some bone mass. I had a total hysterectomy at 25 yrs. of age. I was
wondering if ovary transplant has ever been used to treat Osteoporosis and if so how the success
rate would be. I would be very interested in this procedure if it would be possible. If you could email
me back with any information I would appreciate it. Thanks.
A:
Ovarian transplants are not allowed, to my knowledge, in any country, and will not be allowed
in the foreseeable future for ethical reasons (transplanted ovaries - or testicles - would carry the
hereditary characters of another person!). Apart from this, no transplant can be a solution for
osteoporosis! After any transplant you must undergo immunosuppressive therapy, which always
induces severe bone loss. Your current treatment is a standard treatment for osteoporosis and
should give good results.
Q: I would like more information about the T score. Will being diagnosed with osteoporosis at a
relatively young age increase the risk of fractures as I get older thereby making this disease more
serious? I am 46 years old, have had a total hysterectomy last november, have hypothyroidism and
have been on eltroxin for the past 5-6 years. I was just diagnosed with osteoporosis. Thank you in
advance.
A:
The T-score is a comparison of a person's bone mass (mineral content of bone) with that of a
healthy person of the same sex in the "young adult" (20-30 years) age range, the moment of
maximal (peak) bone mass.
A negative T-score means that the subject has less mineral content in his/her bones than the
average young adult. Until a T-score value of -1, it's considered within normal limits. Between -1 and
-2.5 it's within the "attention area" (osteopenia) and below -2.5 it's osteoporosis. The lower the
value, the more serious the condition and the higher the fracture risk.
To follow your bone mass (and T-score) over the time the best is to perform bone scan always in the
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same place with the same device. In this way, it is possible to precisely calculate (the machine does
this automatically) the bone mass change.
If a correct diet (adequate amount of calcium!) is followed and a suitable therapy is regularly taken,
there should be no significant worsening of the osteoporosis, and of the fracture risk, over the years.
You should ask your doctor which kind of therapy, if any, is best suited to you. If I understand well,
you are under a therapy with thyroid hormone for hypothyroidism. It is important to maintain a
normal level of thyroid hormone, because high levels (such as in the hyperthyroidism) may induce
bone loss. So regular monitoring of thyroid hormone plasma level is necessary.
Q: I am 57 years old and my bone density test showed -2.5 SD in lumbar spine and -1.9 SD in left
hip. I am post-menopausal and began the Combi-Patch and Estring 4 months ago. I had some
break-through bleeding and was given an endometrial biopsy which showed simple hyperplasia and
an endometrial polyp which was benign. She said if the hyperplasia progressed it would become
pre-cancerous. She told me she could either increase the progesterone dosage or stop using HRT
and take Evista and Fosamax instead. I'm also taking Citracal. She said it was safe to continue the
Estring to treat the vaginal dryness. I told her I thought that you weren't supposed to take
unopposed Estrogen. She said the Estring was alright because it wasn't "systemic". She wants me to
have another endo biopsy in 6 months.
I'm experiencing heartburn with the Fosamax and she says there are less side effects with Actonel if
I want to switch. Is this true? Also, should I be taking the Evista as well? I worry about blood clots
because I spend a lot of time sitting in front of a computer. What does the Evista do that Fosamax or
Actonel don't? She just said one builds bone and one keeps you from losing more. Would I be better
off just going back on some form of HRT? I've never had so many Rx. I'm also taking Zyrtec for
itching and Wellbutrin. Do these interact negatively with the others?
A:
I think the values you give (-2.5 and -1.9) are the T-scores. In this case, you're osteopenic at
the hip, and on the threshold for osteoporosis at the lumbar column. This you should see as an
"alarm bell" to start thinking to your bones' future health. Of course, the first thing to do, before
taking any specific drug, is to adjust your daily intake of calcium to your requirements (about
1200-1500 mg/day) and to exercise regularly (e.g. have a good 30-minute walk 5 to 7 days a week).
Regarding drugs, estrogens, Evista, Fosamax and Actonel all act on bone by stopping bone mineral
loss. They don't directly "build" bone, but as the life-cycle of bone is always a balance of building and
losing, if one reduces the losing phase, the building phase may prevail, and some net gain
(especially in the first years of therapy) can be obtained. Evista is acting on bone as an estrogen,
while Fosamax and Actonel have another kind of "chemical" action, but the result is the same.
Estring (vaginal insert) is only a locally-acting (that is, not absorbed in the system) estrogen, and it
won't have any effect on your bone. Regarding heartburn after Fosamax: you may try Actonel, or
(probably better) the once-a-week Fosamax pill (Fosamax 70). Be careful to take any of these pills on
an empty stomach, with a full glass of water, and do not lay down and eat for at least one hour after
taking it.
Regarding Evista + Fosamax. Generally, when a DXA scan shows osteoporosis, only one drug is
given (plus an adjustment of the dietary calcium and vitamin D intake if required), and the results
are evaluated with another DXA scan after at least one year of therapy. In the meanwhile, it's
possible to study a "bone metabolism marker" with a blood or urine lab test. Sometimes, an estrogen
(or Evista) can be given together with a bisphosphonate (Fosamax or Actonel). There is no
contraindication, but generally there is no need for both. There are no known interference of Zyrtec
and Wellbutrin with estrogens or bisphosphonates.
Q: I am 81 and have never taken drugs , not even an asperin, excercise several times per week
and have taken yoga classes for over 20years, and still due, I have been diagnosed with ostio in both
hips. I have been into alternative health for many years and recently been bothered with acid reflux.
Instead of drugs I have been taking MASTIC GUM,which inhibits helicobacter pylori. The results have
been fantastic. The problem now is that my MD wants me to take Acitonal which will cause me to
have further irritation to my stomach and make me very uncomfortable and unhappy. I amgoing to
try the natural way and i am taking pharmaceutical products like BONE ASSUREwhich gives me tha
calcium and magnesium plus vitamin D . in addtion Iam taking vitamin K. i am into organic foods and
no bad habits. Will I survive?
A:
You'll certainly survive and I wish you many serene and healthy years. Everything that is good
for your spirit is certainly good for your body. Calcium and vitamin D (which can be taken with foods,
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or as dietary supplements) are always most important for bones and are the first step (together with
regular exercise, e.g. a 30-minute walk 5 to 7 days a week) to fight osteoporosis. Vitamin K is
important for the production of many proteins. In bones vitamin K is essential for some proteins of
bone matrix (the network on which minerals are deposed). However, vitamin K deficiency is rare and
is generally due to malnutrition, or severe liver diseases.
When there is a diagnosis of osteoporosis, doctors generally give also a specific drug, like Actonel, to
reduce further bone mineral loss. It's true that Actonel and the other drugs in this class may be
irritating for the oesophagus and sometimes the stomach (they must be used carefully if there is
heartburn from oesophageal reflux, severe gastritis or peptic ulcer), so they must be taken following
certain rules. One of these drugs (alendronate, or "Fosamax") is now available in a once-a-week
form, which might be easier to tolerate if there are no strict contraindications.
Q: I am currently enrolled in a medical research project involving lasofoxifene and its effects on
sexual desire. I am have been taking 70mg of Fosomax 1x weekly- Since a side-benefit of
lasofoxifene is reduced bone-loss I am wondering if I should not take Fosomax while I am in this
study- any suggestions? According to the researchers I do not have to stop taking the Fosomax but it
occurs to me that I my be getting too much of a good thing.
A: Lasofoxifene is a new drug in the SERM class which may act on bone. Generally in the research
projects there are very clear rules about the drugs that can be taken or not by the participating
subjects. Probably, either because of the dosage or the duration of the study, the study protocol
allows you to continue taking Fosamax. However, any further doubt should be reported to the
investigators, who can give you the correct answer.
Q: What supplement is best for osteoporosis without causing stomach upset? My stomach is in
bad shape from OS CAL.
A: I think you refer to calcium supplements. Calcium salts are often causing gastrointestinal
troubles, even if they are never serious. Probably the best way to reduce them is to take the daily
dose divided in three or four parts, during meals. Generally "chewing" tablets are better tolerated
than soluble or effervescent preparations. Of course, you could avoid these supplements by
changing your diet to include more milk and dairy products: one liter of milk (also skimmed) contains
1200 mg of calcium.
Q: I am 71 and have osteoporosis; 11 years of HRT did not prevent this. But Fosamax costs 14
dollars for each pill. Is there any generic form of this drug? My HMO will not pay for it, as they still
have complete faith in estrogen despite recent bad publicity.
A: I am sorry, but as I'm living in Italy I don't know the American situation.
The active principle of Fosamax is "alendronate". Perhaps you can ask your pharmacist if it exists as
a generic drug.
Editors note: The US Food and Drug Administration tentatively approved two pharmaceutical
company's applications for alendronate (the generic name for Fosomax) on May, 4, 2002 and July 24,
2002. Please contact your pharmacy and let them know that you are interested in generic
alendronate as soon as the drug is available.
Q: I'm 70 years old. I'm in the first stage of osteoporosis and was advised to take 'evista''. But as
I have trouble with my viens', and as I got twice vein infection, when I got medicine to stop having
milk (after giving birth) - I'm afraid to take the 'evista' medicine. Most of my life I suffered from
migraine. I took 'fossalan' for few months, but it does not agree with me. Is there any danger in
taking 'evista'? Thank you.
A: You should ask your doctor about your vein problems. Evista is generally contraindicated if
there is a risk of thrombophlebitis (is this your case?). I am sorry, but I don't know Fossalan. Did you
mean Fosamax? In this case, I can say that Fosamax should be taken following some strict rules, and
it generally causes no problems. It has no effect on the veins. The rules to take Fosamax and other
drugs of the same class (e.g. Actonel) are:
take your pill as you wake up in the morning, on an empty stomach, with only a full glass of
water (better if low mineral)
after taking the pill, stand up or sit (but do not lay down) and don't eat your breakfast or
anything else for at least 30 minutes (wait at least 45-60 minutes if you take a rich
breakfast).
You may ask your doctor if you could try the once-a-week form (Fosamax 70). The rules are always
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the same, but it's only one pill instead of seven.
Q: I am a 34 yr old with osteoporosis due to a ten-year eating disorder as a young adult, a family
history of the disease, and thyroid problems in my early 30s. My cycle has just returned after the
birth and breastfeeding of my 2yr. old twins. My dr. recommends birth control pills, weight-bearing
exercise and calcium. My question is about the BCP (hormone replacement therapy).
I am hesitant to take BCP because it caused the severe mental imbalance that resulted in the eating
disorder (and other mental health problems). After a decade of therapy, medication and
hospitalizations, my symptoms fully resolved within 60 days of being off the pill. Interestingly, three
female members of my family have had similar episodes of neuroses or psychoses that stopped
when the pill was discontinued, leading us to believe that there is some reason we should not take it.
Since HRT seems so integral to bone preservation, I am both afraid to take the pill and afraid not to. I
have become interested in so-called “Natural” Hormone Replacement Therapy as a substitute. I was
wondering if there have been any studies that would indicate that such a treatment would be as
effective as conventional HRT, and if you believe it would reduce the likelihood of an adverse
reaction.
Finally, I would like to know if Fosomax is recommended for pre-menopausal women, and (as I still
nurse my children to sleep at night) if it can be taken while breastfeeding.
A: First of all I think that for the health of your bones it is time to stop breastfeeding. After at
least 6 months, check your osteoporosis by DXA in order to evaluate if there was any change in bone
mass over this period.
Your doctor was right in prescribing you weight-bearing exercise and calcium. The birth control pill is
not the same as the hormone replacement therapy (that can be prescribed only after menopause). I
suppose that the pill was just suggested to avoid another pregnancy just after 2 years of
breastfeeding your babies, considering your bone condition.
If in the past estrogens had such a negative effect on your mood, you'd better discuss this with your
doctor and find an alternative method for birth control. Re "natural" hormones, they are always
estrogens. If they are taken in the effective doses for osteoporosis control they will probably have
the same adverse effects of the synthetic estrogens.
Fosamax (alendronate) MUST not be taken during lactation (it is secreted in the milk) and it is not
recommended in premenopausal women unless unavoidable. In this case, rigorous contraceptive
measures MUST be taken, as the drug crosses the placenta and might harm the fetus.
Please check-out the following article related to your question, "OBGYN.net Menopause &
Perimenopause Advisor.
Q: I have read that fosamax is not well absorbed, even when taken as directed. My question is
about the 70 mg/ 1Xweek dose. Is it time-released or do you get all 70 mg. at one time? If it is not
time-released, would taking 10 mg/1Xday give better absorbtion of the drug even though it is less
convenient. Also, I have read that 5 mg/day can be taken for prevention of osteoporosis or
osteopenia or taking 10 mg/day for a total of 50 mg/week. Please advise.
A: Clinical studies have shown that 70 mg of alendronate once a week give the same results as
10 mg a day. The absorption of oral alendronate (from 5 to 80 mg) is a constant fraction of the total
dose introduced. Approximately 80% of the absorbed alendronate is taken up by bone. Once within
bone tissue, alendronate remains active for up to several weeks, reducing bone reabsorption (i.e.
bone distruction). The absorption of alendronate is decreased in presence of food and especially
calcium rich food (or beverages, including water). For this reason the drug must be taken on a empty
stomach with a glass of low-mineral water.
Regarding dose, different dosage (5, 10, 20 mg/daily) have been studied. Also 5 mg of the drug are
effective in increasing bone density, but 10 mg of oral alendronate appears to be the most favorable
dose in the treatment of osteoporosis. Many studies were performed on large number of patients
showing an increase in bone density of spine and hip, and a reduction in the number of fractures due
to osteoporosis. Recently the dose of 70 mg once-weekly has become available. This dose has been
studied in order to enhance the patient's compliance with therapy, which is very important in the
long-term management of osteoporosis. The possibility to use alendronate only once weekly is
offered by the long duration of effect in bone. The studies so far have demonstrated that the
increase in bone density is similar with 70 mg weekly or 10 mg daily.
Q: I am a 53-year old female just diagnosed with osteoporosis. I am in the beginning stages of
menopause (no periods for 5 months) and recently started HRT (Activella). I also have pretty
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significant arthritis in my fingers and toes but they don't bother me too much. With the osteoporosis
diagnosis, my doctor put me on once weekly Fosamax. By my second week of dosage I began
noticing my toes and fingers were aching as well as my jaw on the right side. By the 3rd dosage I am
almost unable to walk because of the pain in all the bones of my feet and toes. I can't sleep at night
because of the throbing pain in my wrists and fingers now.
One of the side effects listed on the Fosomax package is bone and joint pain. But it doesn't say
whether it will get better or if I should stop treatment. Because of the severity of the pain I am
thinking of not taking my next dose. What are my alternatives? I do not want my osteoporosis to get
worse; however the pain from my bones is very significant and seems to be flaring up all my arthritis
areas on my body.
A: I don't know the severity of your osteoporosis (i.e.the value of the T-score of your bone scan).
However, if your osteoporosis was diagnosed just at the beginning of menopause, it is generally
treated with HRT. Generally a second drug like alendronate (Fosamax) is added only when the bone
loss is still continuing notwithstanding HRT.
My general suggestion (but I repeat, I don't know the actual severity of your osteoporosis, so you'd
better discuss this again with your doctor) is to check your bone mass with DXA after at least one
year of HRT before adding Fosamax.
For osteoporosis management, it is also important to have a good intake of calcium (1200 mg daily
during HRT therapy), and to have a regular physical activity (at least a 30-minute walk 5 to 7 days a
week).
Finally, bone and joint pain is not frequent, but in a few cases it has been reported during
bisphosphonate treatment. It is probably related to an overproduction of inflammatory substances
(cytokines). I think you'd better stop alendronate for a while, to see if joint and bone pain disappears,
and then reconsider with your doctor the actual need of the drug.
Q: I am a 32 y/o gravida 0, para 0 WF with endometriosis. My OB/GYN has recommended a second
round of Lupron. DEXA after 1st round was NL and I take calcium daily and exercise regularly. I have
been unable to find any studies on taking Fosamax, Miacalcin, or Actonel concurrently with Lupron
for the prevention of osteoporosis - do you have any ideas or data? Thank you.
A: Lupron acts by suppressing ovarian production. In other words, it means that it induces a
chemical menopause, which is reversible upon discontinuation.
If you had to use and will use Lupron only for a limited period, and if your bone mass (DEXA test) is
normal, in my opinion there is no need to add any drug. The correct intake of calcium and regular
physical activity are however essential.
There have been a few studies (on relatively small numbers of patients) using bisphosphonates and
calcitonin against bone loss induced by drugs acting on sex hormones production (lupron, goserelin,
danzol). They seemed able to reduce this bone loss.
Q: I had a hysterectomy when I was 20 due to severe endometriosis. I am not 38 and have been
finding that my bones are breaking with alarming frequency. My ribs seem to be the most
susceptible. I have had broken ribs at least 3 times this year and it seems to be easier to break
them. I had a bone density test done approx. 3 years ago and it showed I was first generation osteo.
I have been on premarin -625 for ever it seems. I have tried the patch, injections, you name it. I am
very afraid that my condition will only get worse and I was wondering if there are any radical
treatments available? Thanks very much.
A: I am not sure about what you mean as "first generation osteo", but I suppose you mean an initial
degree of osteoporosis. I assume that you underwent not only hysterectomy but also bilateral
ovariectomy (so that you are in surgical menopause), and that the result of the bone density test
was that you have osteoporosis.
My reply is based upon these assumptions.
Premarin is a replacement estrogen and it should protect your bones. If this doesn't happen and your
tests show that the bone density is decreasing notwithstanding estrogens, then something else must
be considered.
The first thing to do to fight osteoporosis is to take the correct amount of calcium (almost) every
day. For you this is 1200 mg per day (e.g. 1 liter of milk contains 1200 mg of calcium).
The second thing is to have regular physical activity (e.g. walking 30 minutes at least 5 days a week
and some other moderate activity - e.g. gymnastics - for 1 hour two times a week).
Stay outdoor as you can in the good season, because sunlight is essential to synthesize vitamin D in
the skin.
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If you are getting the recommended daily dose of calcium, exercize regularly, and take Premarin
following your doctor's prescription, but your bone loss is still continuing, then you should undergo
further evaluation to find if there is another underlying cause of osteoporosis.
For example, intestinal malabsorption (celiac disease, Crohn disease, etc), hyperthyroidism and
many other diseases are relatively common causes of bone loss.
If there is no apparent cause for your osteoporos except ovariectomy, then there are these choices:
1) adjust the hormone replacement therapy (the therapy is regularly assumed?)
2) add another drug, such a bisphosphonate
In any case, I think you should make an evaluation of the 24-hour urinary excretion of calcium, the
measurement of one of the "bone reabsorption markers" in your urine, and an evaluation of plasma
calcium and phosphorus.
Bone density should be measured again (please go to the same place and have it on the same
device in order to have a good comparison), to see the change (if any) over these 3 years.
References: **Note: Opinions expressed here are for educational purposes only and, as such, do
not constitute a physician patient relationship. This information is not intended to supplant the need
for you to consult with your physician prior to choosing therapeutic options and/or interventions.
Source URL: http://www.obgyn.net/osteoporosis/osteoporosis-ask-expert-2
Links:
[1] http://www.obgyn.net/osteoporosis
[2] http://www.obgyn.net/pregnancy-and-birth
[3] http://www.obgyn.net/contraception
[4] http://www.obgyn.net/obgyn-nurses
[5] http://www.obgyn.net/integrative-medicine
[6] http://www.obgyn.net/authors/maria-luisa-bianchi-md
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Osteoporosis Ask The Expert

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