I’m 68 years old and have diabetes, which I’ve been controlling very well with oral medications since I was in my late 40s. When I was 52, I started having terrible perimenopausal symptoms and so my doctor put me on hormone therapy. Eleven years later he had me quit HRT, which I did, but I still have hot flashes and don’t understand why he took me off medication that was working so well for me. I’m also worried about bone loss: I understand that the absence of estrogen increases the risk of osteoporosis even with exercise and calcium supplements. And now calcium is being scrutinized! If I shouldn’t be taking either hormones or calcium supplements, what can I do to prevent osteoporosis? I’ve never broken a bone, used steroids, or been on chemotherapy, and my last bone density value for the hip was a T score of -1.5.

Peg

 

Dear Peg,

The Women’s Health Initiative, a study of 16,000 women between the ages of 50 and 70, began in 1991 to evaluate the hypothesis that hormone therapy was beneficial in preventing heart disease after menopause. Half were given hormone therapy, half were not. The study was halted when emerging data suggested that the risk of hormone therapy for women was greater than the benefit. Now it is generally thought that women who are older and women who have risk factors for cardiovascular and peripheral vascular disease should not use systemic hormone therapy. In your case, even though you don’t have a history of heart disease, your diabetes means that you’re at least twice as likely as someone who does not have diabetes to develop heart disease or suffer from a stroke. That’s why your doctor asked you to stop hormone therapy. In fact, the current thinking is that women who don’t get relief from significant menopausal symptoms with non-hormonal treatment and have no contraindications for systemic hormone therapy are advised to use the lowest dose of hormones for the shortest period of time and that they begin treatment early in the menopausal transition.

It’s great that you’re concerned about your bone health. The idea that calcium supplements would help to protect against bone loss and osteoporosis has never been thoroughly evaluated, because it was generally believed that calcium supplements weren’t harmful. Now large retrospective studies are questioning this assumption; a vast amount of data suggests that calcium might be implicated in an increase in heart attacks. No one yet knows if this is so, or why it might be. One hypothesis is that the calcium in supplements may bond to the soft plaque that narrows the arteries in many people as they age, making these arteries more vulnerable to clots.

Now to your concern that your family history of osteoporosis means you should still be on estrogen and your questions about calcium supplements. The greatest bone loss occurs within three years of hormone loss or stopping hormone therapy. The good news is, you’re now five years away from hormone use, and according to your one bone density measurement you’ve had very moderate osteopenia (bone loss).There is a continuous gradual loss of bone density in most people as they age, however, so a more complete evaluation at this time is a good idea. Here’s what I suggest you do next to protect your bones:

  • Ask your doctor to do blood tests to measure your levels of calcium, vitamin D, and parathyroid and thyroid hormones.
  • Have a repeat bone density test in which your forearm is measured along with your hip and spine. This more comprehensive measurement will allow your doctor to see if you have a special kind of bone loss issue.

If your bone density numbers are all stable at the current level of osteopenia, your blood test results are all normal, and you don’t have a history of kidney stones, there’s no need for further evaluation. You can treat your moderate osteopenia with exercise, 1200 mg of calcium each day (get as much of it from your diet as possible; if you think you aren’t getting enough, talk to your doctor about a 600 mg calcium supplement), and do take 2000 IUs of vitamin D3.

However, if you have had an increase in bone loss, then further evaluation is necessary with a urine test. Urine NTX is a measure of bone turnover. It is measured from the second voided urine specimen of a given day. A low number is reassuring; a high number means that your doctor may suggest a medication to slow bone breakdown.

A 24-hour urine collection to measure calcium excretion is an important test if it turns out you have severe bone loss. If you have an increased loss of calcium in the urine you are not only at risk for kidney stones but the calcium you consume is not available to be incorporated into the bones. There are well-tolerated medications that can prevent this loss of calcium and increase bone density over time

I understand that everyone wants medical information to be true and permanent.  This is understandable. But medical science is ever changing as new information appears, old hypotheses are disproved, and new ones take their place. I hope that this discussion lessens your disappointment with science and medical recommendations for treatment that must change over time as new information is available.  Thank you for reading www.womensvoicesforchange.org, and for sending in your question so that this important conversation could take place.

Dr. Pat