Have a question about women’s health or menopause? Dr. Patricia Yarberry Allen may have the answer. Click here to send in your question to be posted on WVFC.


Question:
I am 55 years old and have not had a period for three years. My physician asked me to get my first bone density test last month.

I looked up the risk factors for osteoporosis, and I don’t really have any of them so I was surprised when my bone density showed that I have osteopenia.

My doctor explained that this is not osteoporosis, but he suggested that I take a drug once a month, Boniva, to prevent osteoporosis. He gave me a prescription and told me to "take a calcium pill with some vitamin D in it twice a day and get off the couch." 

I know you need the numbers on my test so here they are: T score -1.6 in the spine and -1.3 in the right hip. I am from an Italian American family. My grandmothers, aunts and mother never had osteoporosis and never had kidney stones. I never smoked but I do have two glasses of wine most nights. I have two cups of coffee a day and one espresso.   

I do not have any medical illnesses. I have always been told that I have good posture and I don’t have any pain in my back or hips. I have not lost any height, I eat well and never really bothered with vitamins and supplements. I have to confess that I am 20 pounds overweight and have never been an athletic kind of person. I am addicted to diet sodas and have struggled with weight loss and gain for most of my life after my three children were born.

I know that you can’t treat me over the internet, but I would be grateful for your opinion. Should I take this drug to keep from getting osteoporosis? I have to tell you, I prefer changing my life instead of taking drugs that cost a lot of money, and I am always concerned about unknown side effects with these drugs that might not show up for years. –Gina

Dr Pat: This is such a great question. First of all, it is good that you have been given a baseline bone density. Now you and your doctor have a measurement of bone density that can be used to follow the results of the treatment program that you choose.

The greatest bone loss typically occurs in women in the first three years after menopause, unless the woman has a disease process that is associated with more aggressive bone loss that will certainly lead to osteoporosis without treatment. So this bone density that you have just completed gives you a realistic picture of what you have to work with for the rest of your life.

Estrogen is a bone-building hormone, so when estrogen declines during the menopausal transition and is depleted over the course of months during the postmenopausal state, women who have not focused on lifestyle to build healthy bones are at a greater risk of osteoporosis.

Most osteoporosis is due to loss of estrogen and to age. A small amount of bone mass is lost each year as we age. The good news for you is that if a woman arrives at your age and stage with only moderate osteopenia on her baseline bone density, she may be able to stabilize the bone loss and improve bone formation without drugs.

A bone density measurement is just one of the tools that we use to diagnose the state of bone health.  There are some basic tests that need to be done to serve both as a baseline and to determine if you have underlying deficiencies of bone-building minerals and calcium, or some abnormalities in certain hormones that could accelerate bone loss.

Please ask your doctor to measure urine NTX (second urine sample of the morning). This test lets the doctor know if you are actively breaking down bone and is another test to follow as you change your behavior in an attempt to avoid drugs to prevent worsening bone health.

The other tests that are important are parathyroid hormone level, vitamin D levels, calcium, magnesium and phosphorus. There is, of course, an extensive and expensive workup for osteoporosis that involves many other blood and urine tests, but these are the basic tests that will help you to make a decision about what to do now.

If these tests are not unusual, then it is very reasonable for you to change your life and repeat the bone density in 18 months.

Do get three servings of calcium-rich, low-calorie foods in your diet every day, but make sure that these are low fat because often dairy products are high in saturated fats, and these are not good for heart health. 

If you are able to get 1000 mg of calcium from dietary sources (and no cheating on this), then take only one calcium supplement a day. Do, however, make sure that you get 2000 IU of vitamin D3 five days a week. Take the vitamin D3 with a non-fiber, higher-fat snack to enhance absorption.

Vitamin D supplements in these slightly higher levels requires some ongoing monitoring. I would suggest that you have your doctor monitor both blood and urine levels of calcium after three months of the higher vitamin D use, since vitamin D in some cases can elevate the blood and urine levels of calcium.

Most of the time these levels are normal, and certainly vitamin D is crucial to your program to prevent the medical treatment of osteopenia.

If you can not tolerate dairy and can not realistically get enough calcium from your diet, the following calcium supplements are generally well tolerated and absorbed:

– Citracal plus D 600 mg, twice a day with food
– Cal-Mag with 600 mg of calcium, twice a day
– PremCal Regular strength has both calcium and the right amount of daily vitamin D in one pill, take one
twice a day with food

Some people find that calcium can cause constipation, so start slowly with the supplements and add two tablespoons of ground flax seed daily to foods, drink six glasses of water and add a stool softener if necessary. If you develop constipation, don’t just give up. Discuss this condition with your physician if you find that the calcium is having an impact on bowel function. Do avoid foods that are normally constipating.

Take one magnesium tablet every night. This mineral is necessary for bone-building and may decrease the constipation that some patients have when they begin to take calcium supplements.

The next part of your program involves daily weight-bearing exercise (walking, cycling, climbing stairs); muscle-strengthening exercises using small weights; and working on stretching and balance as well. It is important that you have some medical advice before you begin an exercise program so you know what is safe for you to do.

Many hospitals, community groups and gyms offer group classes led by specialists who understand the special needs of a woman beginning to exercise for perhaps the first time when she is over 50. Do remember that if you injure yourself, your bone-strengthening program could be delayed indefinitely in addition to the management of the injury.
 
The most important thing is that you must not lie to yourself. If you are really committed to improving bone health without drug therapy, then you must commit to a new way of living.

Calcium and vitamin D supplements daily, along with dietary modifications to add the bone-building nutrients and removal of drinks and foods that will steal calcium from your bones or prevent its absorption, are essential. A daily exercise program is as important as the addition of the calcium and vitamin D.

After 18 months, repeat your bone density and urine NTX. If these tests are not unusual, then stay the course. If they are worse, then it will be time for work-up to decide what medical treatment is right for you.

* * * * *
Dr. Patricia Yarberry Allen, director of the New York Menopause Center, is a gynecologist affiliated
with New York-Presbyterian Hospital and a board certified fellow of the American College of Obstetrics and Gynecology.

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  • Wendy Lawson May 6, 2008 at 12:35 pm

    This is good information and very timely. Recently, there have been a number of research studies examining the connection between biphosphonates (Boniva, Fosamax, Actonel) and severe jaw pain, bone pain and irregular heartbeats. (I’ve summarized the findings and provided links on http://www.menopausetheblog.com)It’s good to know that there are alternatives to taking these drugs.

    Reply