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A fresh look at osteoporosis

When you think about it, it's unbelievable that until a few months ago there were no comprehensive guidelines for evaluating and treating osteoporosis, which is estimated to affect more than 25 million women in this country.

An ounce of prevention
When I talk with my younger patients, I focus on what they can do to prevent the disease: making sure they get adequate calcium in their diet and engage in weight-bearing exercise. We recommend the amount suggested by the NOF, 1,200 milligrams of calcium each day. All milk and milk products are calcium powerhouses. A cup of skim milk contains about 300 milligrams of calcium. At 80 calories a cup, skim milk is a calcium bargain and actually has fewer calories than a cup of apple juice.

Plain yogurt provides 450 mg of calcium per cup, and flavored yogurt provides about 250 mg to 300 mg a cup. Frozen yogurt also contains calcium, but it costs in the calorie department. You would have to eat more than two cups of most premium brand frozen yogurts at a total of 585 calories, to get the same amount of calcium as in a cup of plain yogurt, at a mere 125 calories.

Diet supplements
Calcium supplements are widely available. There are two basic kinds: calcium carbonate, which can be refined from limestone or may come from shell sources, usually oysters, and calcium citrate. Calcium citrate tends to be absorbed more readily, but it is more expensive. There are some concerns the shell-based variety of calcium carbonate may contain lead contamination.

Vitamin D is important too since it helps the body to absorb calcium. Most women don’t need to take Vitamin D supplements since normal exposure to sunlight provides an ample amount, but for women who may be confined indoors, a multiple vitamin containing between 400 to 800 IU of vitamin D is beneficial.

Coffee drinkers take note: Caffeine interferes with calcium absorption, so pay extra attention to your calcium intake if you drink a lot of caffeinated beverages. And cigarette smoking, among its other ill effects, is also detrimental to bone.

Exercise builds bone
Weight-bearing exercise builds bone whatever your age, but whole-body exercise like walking, jogging, tennis, etc. is particularly important for women in their prime bone-building years--between 25 and 35. The higher your peak bone mass, the more bone you have “in the bank” and the less likely you'll be to develop osteoporosis as you lose bone during normal aging.

Too much of anything may be harmful, and that’s true of exercise too. Women who engage in intense, sustained physical exercise may stop having periods. Their ovaries stop producing estrogen and a lack of estrogen is a prime risk factor for osteoporosis.

Estrogen deficits
Any condition that results in lower estrogen puts women at risk for osteoporosis, including:

• Menopause: Women experience a relatively sudden drop in production of estrogen at menopause and start losing bone at an accelerated rate. For the first five to eight years after menopause, women may lose as much as 5 percent of their bone mass each year.
• The use of certain nonestrogenic birth control medications such as the long-acting progesterone, Depo-Provera^®, stops the body’s own production of estrogen without replacing it. Normal oral contraceptives have a positive effect on bone.
• Long-term use of corticosteroid medications, such as prednisone, cortisone, prednisolone and dexamethasone, is very damaging to bone. These medications are important treatments for chronic conditions, such as asthma, rheumatoid arthritis and psoriasis. If you need to take steroid medications for long periods, your doctor may monitor your bone density and advise other drugs to help prevent bone loss.
• Too much thyroid hormone can also cause bone loss. This condition can occur when your thyroid is overactive (hyperthyroidism) or when you take excessive thyroid hormone medication to treat an underactive thyroid (hypothyroidism).

Other risk factors
As the NOF guidelines outline, other osteoporosis risk factors include smoking, Caucasian race, small build, having a sister or mother with the disease, losing an inch or more of height and poor nutrition.

First line of prevention and treatment
Estrogen replacement therapy (ERT) is the single most important way to reduce a woman's risk of osteoporosis during and after menopause. It can prevent bone loss and reduce risk of spine and hip fractures by about 50 percent. ERT can prevent bone loss any time after menopause, but generally the earlier a woman starts the therapy, the more bone she'll retain.

The therapy can be continued indefinitely. Long term use–the longer, the better–provides the best protection against bone loss. As soon as estrogen is stopped, bone loss starts again.

Drugs that slow bone loss
Estrogen replacement therapy is not only the best way to prevent osteoporosis in women, it's also the best way to treat the disease. But if you can't or don't want to take estrogen, two prescription drugs can help slow bone loss and may even increase bone density over time.

• Bisphosphonates, the newest and best known of these drugs is alendronate (Fosamax^®). Studies show it can reduce risk of hip and spine fractures by about 50 percent. Alendronate is generally safe if taken properly, but can produce nausea, abdominal pain and more serious side effects if taken improperly.
• Calcitonin, a hormone produced in the thyroid, may slow bone loss and prevent spine fractures. The drug can also reduce pain after a fracture. Calcitonin is usually used to treat people with osteoporosis who are at high risk for fracture and can't take estrogen or bisphosphonates. The drug is available as an injection or a nasal spray.

Bone scans
In our practice, we usually do not recommend bone mineral density testing if a woman is already taking estrogen replacement therapy. If a patient is menopausal and is undecided about hormone replacement therapy, a test can be helpful to determine if ERT should be considered as an osteoporosis prevention therapy.

BMDs are essential for women age 50 and older who are not on estrogen replacement therapy and who have had bone fractures or who are at high risk for osteoporosis. BMDs are very effective diagnostic tests and women who are evaluated as losing significant bone mass can benefit from new, recently approved medications.

Dr. Chelouche is an attending obstetrician/gynecologist at Yale-New Haven Hospital and a partner of the County Obstetrics and Gynecology Group with offices in New Haven, Branford, Clinton and Wallingford.