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Options for Protecting Bones After Menopause
By
Jane E. Brody Last summer's surprising report from a large federal study relegating the use of postmenopausal hormone therapy to short-term relief of symptoms, not long-term health maintenance, left millions of women in a quandary: what should they do to keep their bones from deteriorating to the point of fracture? Despite the serious threats to heart and breast health the study uncovered, there is no question that supplemental estrogen protects bones, largely preventing the rapid loss of bone that occurs in the first three to five years after menopause. The very same loss occurs when postmenopausal women stop taking estrogen, no matter how long they may have been on it. And stop they did. Within a month of the Women's Health Initiative report, 30 percent of long-term users stopped taking hormones, and their numbers grew with time. Yet more than one in five who discontinued hormone therapy took no substitute steps to protect their bones. That prompted Dr. James Simon, a gynecologist at George Washington University and a member of the North American Menopause Society, to predict that at least a million of those who discontinued hormones were at risk for osteoporosis. With hormones no longer an option, women should be aware of the various nonhormonal options to help maintain, and even restore, healthy bones. There are safe ways to prevent osteoporosis, with enough alternatives available to individualize treatment for every woman. Recognize Your Risk The statistics on osteoporosis should alert every woman — before and after menopause — to the need to protect her bones, which not only lose mass after menopause but also deteriorate architecturally without estrogen on board. In a study of 140,584 women to be presented this month, Dr. Elizabeth Barrett-Connor of the University of California at San Diego, found that protection against hip fracture was rapidly lost once a woman stopped taking estrogen. Protection should start in childhood with adequate bone-building calcium and vitamin D in a diet that is continued through life. Girls and young women whose diets lack adequate calcium are likely to reach midlife with a bone store that is already partly empty and that is much closer to osteoporosis when rapid bone loss begins at menopause. For postmenopausal women who do not take hormones, a bone density test and an assessment of risk helps to identify those who need continued therapy with another agent to prevent or treat osteoporosis. "Every postmenopausal woman will lose bone, even if she takes calcium and vitamin D and does weight-bearing or strength-building exercise," said Dr. Ethel C. Siris, director of the Toni Stabile Center for the Prevention and Treatment of Osteoporosis at Columbia-Presbyterian Medical Center in New York. "There are now 10 million women in this country with osteoporosis and 33 million who have low bone mass, and most have neither been diagnosed nor treated," Dr. Siris told a seminar held by the Society for Women's Health Research, a group that inspired the Women's Health Initiative studies. "Following menopause, one in two women will experience an osteoporotic fracture during her remaining lifetime, 25 percent will have a vertebral fracture, and 15 percent will have a hip fracture," Dr. Siris said. Women achieve peak bone mass by 30, then lose bone slowly until 50, or whenever they start menopause. From 50 to 60, bone loss is rapid, and then slows somewhat to age 90. Though the skeletal deterioration is worse for some than others, it is particularly bad for those who smoke or drink excessively, have osteoporosis in their families, are sedentary, have a calcium-poor diet or take corticosteroid drugs chronically. Bones are constantly being remodeled. Cells called osteoclasts break them down and osteoblasts build them up. After menopause, the action of osteoclasts outstrips that of osteoblasts. "The bones become perforated. Their horizontal struts become thin, cracked and disconnected, weakened like a bridge with its cables cut," Dr. Siris explained. Nonhormonal Options Adequate calcium (1,200 to 1,500 milligrams daily for everyone over age 50) and vitamin D (400 international units daily until age 70; 600 to 800 afterward) and regular bone-stressing exercise are necessary no matter what else is done. Good dietary sources of calcium include low-fat and nonfat milk and yogurt, hard cheeses, collard greens, tofu, calcium-fortified orange juice and breakfast cereals, as well as sardines and canned salmon with bones. Dietary sources of vitamin D include fortified milk and cereals, eggs, fish oil, salmon, herring and liver. Another source is exposing some skin (without sunscreen) to sunlight for 15 minutes a day — not a very helpful option for those in northern climes in winter. The least expensive source of supplemental calcium is calcium carbonate (products like Tums) but the best absorbed (and less constipating) is likely to be calcium citrate, for example, Citracal with D. Be sure to read the ingredients and directions carefully before buying it. Different supplements contain different amounts of elemental calcium. To foster bone mineral density, diets should contain adequate amounts of protein (15 to 20 percent of daily calories). But while animal protein sources (meat, poultry, eggs and cheese) are protective, vegetable protein sources are not, a fact that may place vegetarians at increased risk of osteoporosis. Drugs called bisphosphonates are the leading alternatives to estrogen. In fact, studies indicate that they may build and maintain bone mass even better than estrogen. The two approved by the Food and Drug Administration are Fosamax (alendronate) and Actonel (risedronate). Both drugs come in pill form and are available in daily or weekly doses. The bisphosphonates have been shown in well-designed studies to protect against fractures in the spine and hip. But their administration is tricky. They must be taken on an empty stomach (that is, first thing in the morning) with a full glass of water. Then the patient must remain upright (standing or sitting) and eat and drink nothing else for at least 30 minutes to assure absorption and to prevent dangerous irritation of the esophagus and stomach. Evista (raloxifene), a selective estrogen receptor modulator, or SERM, has estrogenlike effects on bone but acts like an antiestrogen in breast and uterine tissue, thus protecting against hormone-stimulated cancers, plus it lowers L.D.L., the harmful cholesterol. Evista can increase bone density in the lumbar spine and hip and diminish the activity of osteoclasts, and it reduces the risk of vertebral fractures. But its ability to prevent fractures of other bones has not yet been demonstrated. Early indications suggest that combination therapy with Fosamax and Evista may be more protective than either alone. A third option, calcitonin, is used to treat, not prevent, osteoporosis. Other bone-protective drugs are at various stages of development.Copyright
© 2002 Global Action on Aging
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