November 16, 2007 By Harvey S. Marchbein, MD [1] This month's questions answered by: Osteoporosis Editorial Advisory Board Are there any exercises that will target that area and prevent the fractures that cause the hump? My mother was recently diagnosed with osteoporosis and is taking Raloxifen. Her mother had a severe hump and lost many inches over the last years of her life. Naturally, my mother is anxious to avoid the same fate. Is there anything she can do? Are there any exercises that will target that area and prevent the fractures that cause the hump? Thank you! Answer from Dr. Marchbein: At any age, an exercise program is most helpful for a variety of reasons. Raloxifen, adequate calcium (1500 mg of calcium in 3 divided doses), Vitamin D 800 IU and weight bearing exercise (with appropriate instruction to make the exercising safe) are what works best in combination to give her the best chance of staving off more serious complications of osteoporosis. A question about the side affects with increased Fosamax. My fosamax has been increased to 40 mg. twice a week. I have been on this dosage for three weeks and have had increased pain and swelling and weight gain. Is this normal? Will the pain decrease? I walk daily and am becoming discouraged by the weight gain. Answer from Dr. Marchbein: Newer therapeutic regimes for Fosamax including the one that you are on seem to work quite well. It is a substitute for the standard 10mg per day dose. the symptoms you describe are not common. The pain is the symptom of concern. If it continues any length of time, you may wish to have a discussion with your doctor about returning to the older dosage if no such symptoms were noted. As far as the swelling and weight gain, this is not generally related to Fosamax in general, and Fosamax 40 mg twice a week or Fosamax 80 mg once a week, specifically. The latter dosages were originated to reduce gastrointestinal upset and esophagitis after noting that Paget's disease patients on larger doses of Fosamax didn't seem to have the complaints that Osteoporosis patients had with the lesser dose. Am I missing some essential enzyme or chemical? I was 38 years old when I was diagnosed with osteoporosis. My T score in September 1998 was -3.02. I am being treated for Hashimoto thyroiditis. My endocrinologist thinks I may have been hyperthyroid at some point in my life and this may be why I have osteoporosis. No other explanation for the osteoporosis has been provided. I am physically fit, took Calcium supplements between the ages of 16 and 28, and have no other known risk factors for osteoporosis. I lifted weights for several years and have always performed some sort of cardio work. I started taking Calcitonin in September 1998. I had a second bone density test in April or May 1999. I had improvement in my bone density. I just had another bone density test (October 1999) and my results were the same as a year ago. My doctor has put me on 10mg Fosamax. I am wondering if there is some explanation why the bone density improved and then decreased. Am I missing some essential enzyme or chemical? Should my doctor be conducting other tests? Do you know of an osteoporosis specialist in the So. California area? Is anyone studying premenopausal osteoporosis? I am also having problems getting my Page 1 of 5
thyroid levels up to normal. I am too low, despite increasing my Armour thyroid medication. My cholesterol was also very high the last time it was tested. It was normal several months ago. I take testosterone and progesterone in cream form. Are all these factors related? My doctors checked me for multiple myeloma and Cushing's (?) syndrome. I do not have either disease. My doctor seems baffled and so am I. Any assistance you could offer would be greatly appreciated. Thank you. Answer from Dr. Marchbein: Thyroid irregularities have, indeed been associated with osteoporosis. In a 38 year old, it would be interesting to confirm normal absorption of calcium and Vitamin D. Malabsorption can be another reason. Calcitonin in the form of Miacalcin nasal spray is currently recommended for women at least 5 years post menopausal in that prior to that time, the same advantages have not been noted. Fosamax has also not been approved for re-menopausal osteoporosis although it has been approved for steroid induced osteoporosis. Since you don't give the density results (numbers), it is impossible to know if there was an improvement. A 3% variation may be normal and not considered an improvement. Using different machines may also lead to erroneous results. Contact your closest University hospital to see who their osteoporosis experts are. There is no definitive data that I'm aware of. Was Synthroid tried? Many experts would use birth control pills since estrogen is a very potent osteoporosis therapy. Interestingly enough, progesterone and testosterone can help there too, if absorbed. The osteoporosis expert is going to be what you need. This is complex problem and needs someone who knows the latest literature, innovative therapies and the latest finds presented at conferences. My question is, could I take Fosamax despite a GERD problem? Should I have a different test done? I had a DEXA scan 1 year ago that showed osteopenia. I am 45 years old and premenopausal. For one year I have taken Evista and 1200 mg calcium daily. I had a repeat scan yesterday that shows my density is actually much worse and is now diagnosed as osteoporosis. I am very worried about what to do next. Should I have a different test done?? My question is, could I take Fosamax despite a GERD problem. Answer from Dr. Marchbein: My first question would be why a premenopausal 45 year old had a bone density done. Next would be what were the areas of osteopenia. Evista is not presently approved for usage in premenopausal osteopenia. You had a repeat scan. If it was at the same institution and the same machine, comparisons are more reliable. I wonder why a still premenopausal female now has osteoporosis. Poor calcium intake in the past, thyroid abnormality, long term steroid usage, long term amenorrhea, gastrointestinal malabsorption, extremely sedentary life and small, thin frame are just some of the risk factors. Appropriate follow up would be to see an osteoporosis specialist to see exactly why you have osteoporosis at this point and determine the best therapy for you. With GERD (Gastro-Esophageal Reflux Disease) there is a relative contraindication for the use of Fosamax, not an absolute contraindication. What is your opinion on the use of Raloxifen for prevention or treatment of osteoporosis in women with a history of breast cancer? Answer from Dr. Marchbein: The FDA has recently approved Raloxifen for treatment of osteoporosis. The bigger question is can Raloxifen be used in patients with breast cancer. There is great debate amongst cancer specialists and there is no concensus. Some do and feel it will decrease recurrence. Others don't and feel it will increase recurrence. Data is wanting and evidence based medicine and time will tell. Questions have recently been brought up about long term Tamoxifen too. What side effects does Fosamax present in a premenopausal woman? I am a 37 year old who has been diagnosed with moderate osteoporosis. I have been on Fosamax for one month and Page 2 of 5
1500 mg of calcium. I am premenopausal. I do not smoke, drink or use steroids. My question is what side effects does Fosamax present in a premenopausal woman. Answer from Dr. Marchbein: As of this point in time, no studies have been published for Fosamax therapy for premenopausal osteoporosis. Many experts use high dose estrogen, as in birth control pills (as opposed to lower estrogen in HRT). Premenopausal osteoporosis should have a complete workup to determine the origin or the bone loss. You mention calcium supplementation. Vitamin D is also required for absorption of calcium. Fosamax side effects should be no different in premenopausal or post menopausal patients. A request for Information about Osteopenia. I am a 55 year old woman, who had a hysterectomy. I was diagnosed with osteopenia. I want more information about this rare disease. I have looked in encyclopedias and medical dictionaries and I have not found much information. Answer from Dr. Marchbein: Osteopenia is probably one of the most common diseases in the world. All it means is less than normal bone but not as severe a loss as osteoporosis. Using standard deviations and bone density measurements (and World Health Organization definitions), a T score of 0 to -1.0 is normal. -1.0 to -2.5 is osteopenia. -2.5 and less is osteoporosis. -1.0 to -2.0 is usually treated with calcium, Vitamin D and exercise. Recent studies have indicated the advantage of medical therapy in reduced doses for T scores of -2.0 to -2.5. Diet, supplements, exercise and hormones, are they enough or is there anything else you can recommend for me at this time? I had problems with anorexia as a teen and as a consequence suffered secondary amenorrhea. I am 22 years old and have not had a normal menstrual cycle since the age of 14. I was put on HRT (Premarin 1.25 and Provera) at the age of 16. I am now at a stable weight of 115 at 5' 2'' and my body fat is 23%. I stayed on HRT until May 99 when I went off HRT to see if I could get my periods on my own. After going 6 months without HRT I didn't regain menstrual function. My estradiol levels were tested and came back very low; 23. My FSH, Prolactin, TSH, LH are all normal levels. I became very concerned about my bone density and got a DEXA. I found out that my hip is 1.65 standard deviations below the norm and my spine is 2.41 sd below the norm. I am extremely concerned by these results and am trying to find the best methods to help this problem. I have now been placed on BCP (orthocyclin) and I want to know if this is the best form of hormones to be on or if I should return to the Premarin and Provera. Also I want to know what other things I should be doing since I know at my age this is a very critical time for bones. I have been doing a weight training program for the last 3 months, of 45 min 3 times per week. I do walking at a pace of 4.5 mph everyday for 30 min -1hr. I also have a very active day walking around the university campus always taking the stairs etc. I take supplements which include vitamin D 400 mg half of which I take in the morning and half at night for optimal absorption. I get a lot of calcium from my diet; I consume at least 4 cups of yogurt and milk a day, in addition to the calcium in my supplement. My diet is very nutritional all around; eating whole grains, fruits, and vegetables. I don't consume alcohol, caffeine, or processed foods with phosphates. I also try to keep my salt intake low. I want to see if there is anything else you can recommend for me at this time. I am very worried since I am very young and I have a lot of years for this skeleton to take me through. Should I be on any other meds, are there any changes that need to be made to my diet. Thank you, Salem Answer from Dr. Marchbein: You are now doing all the right things for maximum bone growth and no changes are necessary at this time... estrogen (the birth control pill), calcium (recommended 1200 mg per day, maximum daily not to exceed 2000 mg per day), Vitamin D, weight bearing exercise. Just have your primary care doctor check and make sure you are absorbing the calcium well. Inadequate absorption, although uncommon, can lead to continued bone loss. Good luck. Page 3 of 5
My question is at what stage does it get to be a curvature of the spine? I am a 46 year old Caucasian female recently diagnosed with osteoporosis. I think the reason being I was on hormone replacement since 16 due to Turner syndrome. The doctor said my spine is 2.74 and my hip is 2.47. My question is what stage is this at and what stage does it get to have curvature of the spine. Answer from Dr. Marchbein: Your bone densities T scores are (-) 2.74 standard deviations below the mean in the spine (early osteoporosis) and (-) 2.47 standard deviations below the mean in the hip (severe osteopenia - just shy of early osteoporosis). Curvature of the spine can come from fractures of vertebrae causing compression of the bone. Osteoporosis is silent (no symptoms) until a fracture occurs. Fractures can occur with or without osteoporosis. The risk of fracture, however, increased with increasing levels of osteoporosis (which is decreasing bone density). Excellent question. It gave us a chance to talk about the silent disease that kills more women than breast cancer (more women die in the aftermath of hip fractures [20% of hip fracture sufferers die within 6-12 months of a hip fracture and another 50% never get back to normal activity] than die from breast cancer every year). Is there a drug (or even a shot) on the market that does not cause gastrointestinal problems or would not kick my ulcerative colitis into high gear? Are the benefits of taking calcium, or some other form of drug therapy, worth the risk of the UC? I am a 45 year old female just diagnosed with osteoporosis in the hip and osteopenia in the back. I exercise 2-3 times a week (kick boxing, aerobics w/ some light weights). There is a family history of Osteoporosis in my family (Mom and Grandmother). I do not smoke and very rarely drink. I always had irregular periods and at 30 I had a hysterectomy (endometriosis w/ both ovaries removed, HRT since the surgery), and for the last 20 years have had bouts of ulcerative colitis (taking Dipenthum 1500 mg daily). Other medications that I take daily are: Synthryroid 0.15 mcg. (hyperthyroid) and Vit E. 400 IU's. Taking calcium supplements (allergy to milk products) causes my UC to flare up. I have tried taking 600 mg calcium a day and w/in 24-48 hours the UC symptoms appear. My GYN contacted my Gastroenterologist and he stated that there are no absorption problems with UC (my concern was that the HRT was not being fully absorbed). Is there a drug (or even a shot) on the market that does not cause gastrointestinal problems or would not kick my ulcerative colitis into high gear? Are the benefits of taking calcium, or some other form of drug therapy, worth the risk of the UC? Another point about the HRT - some women need more HRT to build bone than others. Serum estrogen levels and altering doses may be necessary. If there is any concern about malabsorption, there are estrogen patches as well as a new estrogen/progesterone patch (Combipatch ). Some endometriosis patients use HRT and not ERT. I am very frightened and do not know what direction to turn. Should I go to another specialist? If so, what type of specialist? My 22 year old daughter has a few of my medical problems: endometriosis, milk allergies, and has irregular periods when she is not on the birth control pill. Should she have a bone density test at her age to use as a bench mark for later reference? Answer from Dr. Marchbein: There are different forms of calcium. One that many people can tolerate well is calcium citrate (Citracal ). It does not appear to cause the same gastrointestinal problems as does calcium carbonate (the most common calcium supplementation). Tri-calcium phosphate (Posture ) is also very helpful but may be more difficult to find. Soy milk may be a good alternative for you as well as green leafy vegetables. A consultation with a nutritionist may be helpful to delineate non-dairy sources of calcium. Lastly, have the gynecologist and gastroenterologist discuss medications for osteoporosis. Fosamax has been implicated in esophageal complaints but not ulcerative colitis and there are new medications coming out all the time. The gynecologist, gastroenterologist and nutritionist should be enough for now. Your daughter should be on adequate calcium supplementation too. That includes Vitamin D to aid in calcium absorption. A bone density at her age seems a little premature. In that she is 22 years old, she can still maximize her bone density with adequate estrogen (regular periods or the pill), adequate Calcium and Vitamin D AND weight bearing exercise to help reach her bone density potential. If a women has a history of breast cancer and was advised not to take estrogen replacement therapy, is Raloxifen recommended? If a women has a history of breast cancer Page 4 of 5
and was advised not to take estrogen replacement therapy, is Raloxifen recommended. The data from the MORE trial discusses the benefits for reduction of risk, but these were women who had never had breast cancer. Also if they have been on Tamoxifen does this affect whether they should try Raloxifen after their Tamoxifen treatment is completed? Answer from Dr. Marchbein: These are excellent questions that are plaguing both physicians and patients at the end of 1999. The answers, however, are not available yet. I, too, wish the answers were known. When they are, it will help a great many women. Source URL: http://www.physicianspractice.com/osteoporosis/osteoporosis-ask-expert-31 Links: [1] http://www.physicianspractice.com/authors/harvey-s-marchbein-md Page 5 of 5