Osteoporosis — An Important Consideration for Women Discontinuing Hormone Replacement Therapy
Michael S. McGarrity, M.D.
Clinical Endocrinologist Hanover Medical Specialists, PA
Following the recent reports of adverse effects of hormone replacement therapy, there are many menopausal women who will be contemplating the discontinuation of estrogen therapy. These women and others who will elect not to take estrogens at the time of menopause will be at high risk for developing osteoporosis as they get older.
Over 1.3 million fractures attributable to osteoporosis occur each year in the United States. Half of these fractures are in the vertebrae or spine and the others are divided equally between the hip and the wrist. One third of all women surviving to age 90 will suffer a hip fracture. Pelvic and hip fractures are associated with a one in six chance of death within a year of the fracture. Women who do not die following a fracture are likely to suffer pain or lose functional status.
Risk factors for osteoporosis and osteoporotic fractures include; history of fracture in the patient or a first degree relative, current cigarette smoking, low body weight, advanced age, female gender, Caucasian race, menopause either natural or surgically induced, lifelong insufficient calcium intake, repeated falls, frail health status, dementia, and impaired vision. Certain medications can also contribute to bone thinning including overuse of thyroid hormone, seizure medications, and corticosteroids.
Women who are at risk for fractures because of osteoporosis far outnumber the women who actually have fractures. Thirty percent of women over the age of 50 have low bone density and are at risk for fractures and this percentage increases with age. Most of these women at risk have no symptoms unless a fracture occurs and are unaware of the low density status of their bones at the time of menopause. Since estrogen (the female hormone) is protective for bones and since this hormone is lacking at menopause, it is at this time of a women's life that she is most vulnerable to losing bone mass and developing osteoporosis. Therefore, screening for osteoporosis at or after menopause in women at risk is very important.
All postmenopausal women who are not taking hormone replacement therapy (HRT) or are taking HRT and have at least one additional risk factor for osteoporosis should be screened for osteoporosis. Screening with measurement of the hip and spine bone density directly with a DEXA (Dual Energy X-Ray Absorptiometry) is preferred by most doctors.
Treatment for osteoporosis includes basic healthy lifestyle practices, sufficient intake of calcium and vitamin D, prevention of falls, and drug therapy if needed. Everyone at all ages and especially women should exercise regularly with weight-bearing exercise such as walking or jogging for at least 30 minutes daily for five days each week. Avoidance of smoking is also important. A calcium intake of at least 1000 mg daily for premenopausal and at least 1500 mg for postmenopausal women is recommended including the calcium in the diet and in supplements combined. A simple rule of thumb to calculate calcium in the diet is the “rule of 300” which states that most servings of dairy products such as an 8 oz glass of milk or a cup of yogurt each contain approximately 300 mg of calcium. In addition, green vegetables, especially spinach and broccoli contain calcium. The diet should also contain 400-800 International Units of Vitamin D. This is especially important in the elderly who have limited exposure to the sun as sunshine helps us produce vitamin D in our skin.
Therapeutic alternatives to HRT or estrogen therapy for the prevention of osteoporosis include the use of “designer estrogens” such as raloxifene (also known as the brand-name “Evista”) and also the bisphosphonates alendronate (brand name “Fosamax”) and risedronate (Actonel). Raloxifene, although in the estrogen class, does not increase risk for cancer or heart disease, but unfortunately does not relieve menopausal symptoms. Treatment options for diagnosed osteoporosis includes the drugs above and also nasal calcitonin (“Miacalcin”). In addition, there are new treatments on the horizon that have not yet been approved by the FDA including parathyroid hormone.
It is often said that hypertension is the “Silent Killer”. If this is true then osteoporosis should be called the “Silent Thief”. This disease silently and without symptoms steals bone from a woman after menopause and puts her at risk for fractures as she ages. For all women who are contemplating the decision to either stop or not take hormone therapy at or after menopause, it is wise to see your doctor to be screened for this disabling and deadly disease.