Speaking of Women's Health
The Speaking of Women's Health Podcast is excited to bring you credible women's health information from host and Executive Director, Dr. Holly L. Thacker. Dr. Thacker will interview guest clinicians discussing relevant women's health topics and the latest news and tips.
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Speaking of Women's Health
Boosting Bone Health
Your bones are silently changing beneath the surface, and for women entering menopause, that change accelerates at an alarming rate. Did you know you could lose up to 30% of your bone mass in the first 5-7 years after menopause? This silent thief works without symptoms until a fracture occurs, often when it's too late for prevention.
In this episode, Speaking of Women's Health Podcast Host Dr. Holly Thacker reads Chapter 12 of her book, "The Cleveland Clinic Guide to Menopause," and offers additional insights and tips you won't find in the book.
This isn't just about preventing fractures – it's about maintaining independence and quality of life as you age. Breaking a hip after 65 carries a 40% one-year mortality rate, yet this risk is preventable with proper screening and treatment. Whether you're approaching menopause, recently diagnosed with bone loss, or simply planning for healthy aging, this episode provides crucial knowledge to keep your skeleton strong for decades to come.
Welcome to the Speaking of Women's Health podcast. I'm your host and author of the Cleveland Clinic Guide to Menopause and I am back in the Sunflower House with you going over chapter 12. This is March 2023, and this is about boosting bone health, and I'll certainly encourage you to tune in to an April Speaking of Women's Health CME podcast with one of our Specialized Women's Health fellow graduates, a very successful osteoporosis expert physician, dr Christy Tuff-DeSapri. So on to boosting bone health.
Holly L. Thacker, MD:Midlife is a critical turning point for a woman's bone health. There's a direct relationship between menopause and the development of bone thinning disorder, termed osteoporosis. In the five to seven years following menopause, which is the final menstrual period, or loss of making eggs and ovarian function, a woman can lose up to 20 to 30 percent of her bone mass, and when a woman experiences early menopause, she is especially at risk for rapid bone loss. So this makes midlife a prime time to both prevent and treat low bone mass, so that we can stay strong, healthy and in charge in our later years. And yet so many women don't realize, or they're just not advised by their health care folks, to begin testing for bone loss early. Alyssa's experience is far too common. This is Alyssa's story.
Holly L. Thacker, MD:I'm 52 years old and I have officially entered menopause, so I thought it would be a good idea to see a physician who specializes in women's health. But when my new doctor suggested that I get a bone mineral density, a BMD, also called DXA, I was skeptical. My former doctor always told me that getting a bone density test before age 65 was just a waste. He said no risk factors, no reason to get the test. Well, my new doctor explained that this was kind of old-fashioned thinking. She said that even without risk factors, every woman should have a bone mineral density assessment within two years of menopause. She told me that being female is a risk factor for bone loss because of the metabolic changes and the marked estrogen deficiency that we experience after midlife. So I got the test my new physician ordered, and the results really surprised me. I was diagnosed with osteopenia. The doctor explained, though, that this didn't necessarily mean I had a quote disease. It just meant that I have lower bone density than other women my age, and it also meant that I could be losing bone and that I'm potentially at higher risk than an average woman for bone breakage, also known as fracture, as I get older, if this new doc hadn't tested my bone mineral density, I would just continue to assume that my bones were strong, because you can't see or feel a loss in bone density. So it turns out that the past doctor's claim that I didn't display risk was just dead wrong. This brush off game that he gave me about not needing a bone mineral density at my age was kind of scary, and I wonder how many other women simply trust what they're told without getting another opinion.
Holly L. Thacker, MD:So what is osteopenia? Osteopenia is a condition characterized by decreased calcifications or deposits of calcium salts which are needed to form bone. And when you lose the calcium or you lose the architecture of the bone, you have reduced bone density and this may warrant not just preventive but also therapeutic pharmacologic treatment. So being told that you have osteopenia simply means that you have less bone mass than the average woman, and having less bone mass than average isn't necessarily a problem. But it is important to establish your baseline bone density because if you lose bone density rapidly, it's a problem and needs to be addressed.
Holly L. Thacker, MD:The less dense your bones are, the more likely you are to break a bone. So half of all women have osteoporosis by age 55. And I describe how much calcium you have in your bones is kind of like how much money you have in the bank. So if you have a lot of money in the bank, you can make withdrawals at a much faster rate than putting deposits in before you go bankrupt. So if, genetically or because of other medical conditions or past hormonal or vitamin deficiencies or other conditions like celiac there's so many different things that can negatively affect your bone If you tend to have less bone density than average, you just can't make as many withdrawals as deposits, or you're going to reach a critical bankruptcy phase, which is bone breakage.
Holly L. Thacker, MD:And so many women think that breaking a bone is just part of aging, or because they fell off their bike or because they were running on black ice. But that's not so. If the bones break after age 40, it's different than childhood, when the bones are growing and soft and haven't fully mineralized and reached their peak bone density. But in any person over 40, male or female, if you break a bone it needs to raise a red flag. So what exactly is osteoporosis? Well, it is the loss of the bone density, mass and strength, leading to both increased porosity and vulnerability to bone breakage. So type 1 osteoporosis is related to menopause and is generally almost always preventable with hormone therapy or other non-hormonal agents that affect the bone breakdown rate, whereas type 2 osteoporosis is related to aging and it affects older women over the age of 65 as well as men, but it's still modifiable and manageable as well.
Holly L. Thacker, MD:So our focus today is mainly on type 1, and it's important to note that osteoporosis is not a normal part of aging. It can be prevented and treated, though there is no specific cure. The key is to identify rapid loss in bone density during the peri and postmenopausal years, especially those first five to seven years, so that you can take action to slow the process and, in some cases, stop it and even rebuild bone. This is very important, as it's going to protect you from debilitating bone fractures. There's a number of approved options to both prevent and manage osteoporosis, one of which is menopausal hormone therapy. If you've recently started into menopause, knowing your bone status may affect your decision about whether to use hormone therapy or use additional treatments or other treatments, and whether to continue hormone therapy treatments or other treatments and whether to continue hormone therapy.
Holly L. Thacker, MD:So who gets osteoporosis? Well, 80% of people with osteoporosis are women, but osteoporosis is mistakenly thought of a disease of only older white women or a problem of skinny, frail women. But neither of these assumptions is completely true. In fact, in the United States, osteoporosis and low bone density affect millions of women and men over age 50. So according to the National Osteoporosis Foundation, that's well over 55% of people. So at least one in every two white women over the age of 50 will have an osteoporotic-related bone breakage or fracture in her lifetime. Now women of color may be less likely to develop osteoporosis, but they're still potentially at risk, and 10% of women of color over age 50 have osteoporosis and an additional 30% have low bone density. So that does still put them at risk for osteoporosis and unfortunately, women of color who sustain a hip fracture are more likely to die from it than white women and, just like men, are less likely to have osteoporosis because they don't lose their sex hormones. They tend to develop denser bones and muscles compared to women and they don't rapidly lose bone at midlife like half of all midlife women do. But if a man breaks his hip, he's actually more likely to die than a woman. So this is a serious problem for our society, but too many people just don't realize that women and women of color and men are potentially at risk for osteoporosis, so you might have to speak up for yourself or switch doctors. Fast fact over 1.5 million fractures per year are due to osteoporosis.
Holly L. Thacker, MD:Well, what if I exercise and take calcium supplements? Can I avoid osteoporosis? Some people think if they simply exercise, drink enough milk or take a calcium supplement that they will be protected from osteoporosis. Be protected from osteoporosis and certainly these what I call hygienic lifestyle measures of weight-bearing, exercise, getting enough calcium in the diet, and supplements if needed to augment the diet and separate vitamin D3. And I usually like to add K2 to that. That's not potassium, it's K2, also known as M7. It's not in very many foods. If you like Asian, korean, japanese natto, well then you're getting plenty of K2 in your diet. But there's not that many foods that have K2. Pork, dark chicken meat and a few cheeses Swiss, gouda, blue and I like some of those foods, but I don't eat them every day. And K2 is what helps drive calcium into the bone as opposed to getting deposited in the arteries.
Holly L. Thacker, MD:So all of those things are a good start and they're necessary, but they're not sufficient and a lot of women are perplexed when I say that that's not treatment. And then I use the example of well, you know, if you were having pneumonia or an asthma attack and you came into the emergency setting, we wouldn't just simply say, oh, you just need some fresh air and oxygen. Well, of course everyone needs fresh air or oxygen to breathe. That's necessary, but it's not sufficient. You might need something to open up the lungs, you might need antibiotics or steroids. So that's treatment of a disease. And I think, because osteoporosis is so common that people just think, oh well, if I just have good hygiene and lifestyle, that that will be enough and certainly it helps. Just like when I see women who are eating right and exercising and they're frustrated that they're gaining weight or that they haven't lost weight even, I'll say, if you weren't doing those good things, it would be even worse. So I know sometimes that's not the best consolation, but knowledge is power and you and your doctor should take into account not just diet and exercise but your family history.
Holly L. Thacker, MD:Any biological blood relatives with a history of hip fracture, dowager's hump compression, fractures of the spine, wrist fractures after age 40, all of those things are red flags. Also, what is your body mass index or weight? Women who tend to be very slender, under 127 pounds tend to have lighter bones. Smoking is very bad on the bones as well as so many other things. A history of eating disorder, even if you've recovered from it. If you went a period of time in your younger years restricting calories maybe not having your period that can affect your peak bone mass Kidney stones.
Holly L. Thacker, MD:If you've personally had a history of kidney stone, there's a high chance it was calcium oxalate and that you're leaking out too much calcium from your kidneys. And the answer to that is not reducing calcium in your diet, like some people erroneously tell men and women. It's stopping that excessive calcium leak, because 99% of our bones, or rather our calcium, is stored in our bones and we will always steal it out of our bones to maintain that 1% level in our bloodstream that we need. And if our blood is being filtered by the kidneys and leaking out calcium, not only can it lead to kidney stones, which are very painful, but also broken bones. Now, if you have a history of wheat or gluten intolerance, called celiac disease and we have a great column on celiac disease on our speakingofwomenshealthcom site or even if you're just very gluten intolerant but not necessarily have overt celiac disease, this can certainly affect your bone health and it can irritate your intestines so that you don't even absorb enough iron and vitamin D. Now you can certainly get calcium from food, particularly if you like calcium-rich foods. Certainly get calcium from food, particularly if you like calcium rich foods. But for some women, especially if they avoid dairy, they may not be getting all their calcium through diet and it's even slimmer chance that you're getting enough vitamin D in your diet, and we'll talk more about supplements in a moment.
Holly L. Thacker, MD:So bone basics you might associate bones with just a hard, lifeless skeleton, like you see at Halloween time, but this is farther from the fact. Your bone tissue is complex, living, active, regenerating tissue and the bone's innermost layer, the bone marrow, makes cells that are blood cells that help keep us alive. It's a very important organ and the bones provide structural support for our muscles. They also protect our vital organs and, importantly, they store calcium. And our bones are not the same bones that we were in seven years ago. They're in a continuous cycle of repeated breakdown, buildup, breakdown, buildup, known as remodeling, and during the phase of the cycle called resorption, the bones release some calcium into the blood, which results in bone breakdown. In the formation phase, new bone is built up to replace the old, potentially damaged bone. Just like your skin, the skin that you see on your arm is not the same skin you had last month. So this ongoing cycle of replacing old bone with new bone gives the body the calcium it needs in the bloodstream and muscles, while keeping your skeleton hopefully strong, and muscles while keeping your skeleton hopefully strong. When the bone formation exceeds the resorption, the bone mass increases. But if your resorption breakdown is faster than the formation, which happens to half of women when they lose estrogen, then there's a reduction in your bone mass and when the bone mass is continually reduced, it leads to osteoporosis.
Holly L. Thacker, MD:Now I tell women if you're only planning to live to age 50, 55, chances are you've got enough bone. But when I see women, since the field of menopause is really anti-aging, we're trying to improve not just the quality of life, which is very important, of course, but also the longevity and the functionality. And too many women outlive their bones. So what is a broken bone, not a broken bone? Well, if you or your child had a broken bone that healed well, all this talk about bone breakage may strike you as a little odd. Bones break, they're set and they heal right, not necessarily when we're older. Statistics show that almost 40% of older people who have a hip fracture die within the following year. They can die from complications of the fracture or its treatment or have been immobilized during that recovery, and certainly those who survive have pain, hospitalization, expense, rehabilitation and they also run the risk of losing their independence.
Holly L. Thacker, MD:And so when I see women ages 65 plus, my focus changes in some part in terms of plus. My focus changes in some part in terms of screening for diseases that might shorten their lifespan. The focus turns more to functionality and preserving independence, and preserving and preventing preserving their independence and preventing them from having to go to assisted living or a nursing home, necessarily. So how is your bone mass built up? Well, from infancy up until age 30 to even 35, we humans build more bone than we lose, and after 30 to 35, we hope to maintain our bone density pretty stable until later in life when we try to prevent the rapid loss. So think of it this way Each of us maintains this lifelong bone bank and we constantly make deposits and withdrawals, and this depends on our lifestyle choices, such as getting enough calcium and protein, vitamin D and exercise, and some of us who have family histories of osteoporosis who are naturally very thin or small-framed or who get any bone breakage after the age of 40, may automatically start with a lower balance in that bone bank and we have to work harder to keep it full.
Holly L. Thacker, MD:The catch by age 30, which I assume many of you are who are listening when most of us have already acquired most of our skeletal mass, we can't really make any more significant deposits, and we all know that. Since, thankfully, most of us live long enough to reach menopause, that's the time when those ovaries stop producing eggs and estrogen, which then causes lack of the hormone we need to protect our bone and this, in half of women, rapidly increases the rate of withdrawals from the bone bank and over time, without treatment, the increased withdrawals do take their toll. So osteoporosis increases the risk of fracture and in the serious cases can completely reduce mobility, which brings its own set of problems. But the good news is that you can increase bone mass during midlife and certainly prevent the loss with hormone therapy in the vast majority of women and or other non-hormonal pharmacologic options that have been well studied and designed for women and in some cases for men who are at high risk or who've had actual bone loss.
Holly L. Thacker, MD:So what are the risk factors for osteoporosis? Well, you can't always tell whether someone has osteoporosis, especially when it's in the early stages, and there's some active midlife women who just don't look the part. And osteoporosis causes really no symptoms unless you break a bone. So just like we don't want to wait until someone has a heart attack to diagnose and assess their risk for heart disease, the same thing is we don't want you to have a bone attack and break your bone. Certain women are definitely more likely to develop osteoporosis and frailty fractures. In fact, just being a woman, your risk for low bone density automatically increases and the metabolic changes, such as the menopause-related estrogen loss, increases your risk.
Holly L. Thacker, MD:And if you've been ignoring your daily calcium and vitamin D intake, you're not doing your part to give your bones the basic building blocks. So early awareness, weight-bearing exercise, such as walking or lifting small weights, and making sure that your vitamin D 25 hydroxy vitamin D level is at least 32. I like it higher than 50 for other reasons, but for bone health you need at least 32. You cannot tell if your calcium balance is normal by simply checking your blood work. The only way to find out your calcium balance is to do a 24-hour collection of your urine on a typical day that you're on your regimen.
Holly L. Thacker, MD:Here are the risk factors for osteoporosis Estrogen deficiency after menopause. Having a thin or small, petite frame. A family history of osteoporosis, especially a history of a fracture in a close relative. A personal history of breaking a bone after age 40. If you've had a history of missing your periods because of hormonal problems, an absence of a menstrual period excluding pregnancy for several months at a time. If you've had a history of disordered eating. If you smoked cigarettes or used nicotine. If you've imbibed too much alcohol that's hard on the bones. If you've had a lifetime intake of low calcium, low vitamin D. If you've had kidney stones because you're peeing out too much calcium and it hasn't been treated. If you have an inactive lifestyle. If you have advanced age age.
Holly L. Thacker, MD:Now there are certainly chronic medical conditions that also dramatically increase the risk of osteoporosis rheumatoid arthritis, autoimmune diseases requiring prednisone or steroids, celiac disease, diabetes, anorexia nervosa, and there's many medications that can be very bad on the bones, including glucocorticoids, which have several mechanisms of action that are harmful to bone health long-term. The aromatase inhibitors which totally wipe out estrogen, such as aromacin, also known as X-Mistane, or Femera, known as Letrozole or Arimidex, known as Anastrozole, as well as Depolupron, which is an injectable treatment that suppresses the ovaries Other medicines that may stop monthly periods or wipe out all estrogen puts women at risk for osteoporosis. Now, this is in contrast to hormonal contraceptives that are taken continuously so that the woman doesn't have like a withdrawal period, but still give a daily continuous estrogen and progesterone dose and most women actually protects the bone. Now, if you have the presence of some GI problem malabsorption, celiac disease, wheat protein intolerance that can also affect your bone health. So how do we assess bone health? Certainly, your history is important, or family history and exam looking to see if you've lost more than an inch and a half of height from your maximum height at age 21,. Looking to see if you have hunched over, hunchback kyphosis, which could mean compression, fractures of your upper thoracic spine.
Holly L. Thacker, MD:Your physician should help determine whether you need a bone density test based on your clinical history and risk factors. A bone density test will do the following it measures the amount of calcium in your bones and it compares it to the soft tissue around the bones, the soft tissue around the bones and the amount of certain minerals. How much calcium you have in your bones is an indicator of health and strength. It helps assess your risk for fracture and it can be used in serial fashion every two years to determine your rate of bone loss or bone gain and monitoring the effects of any therapy. Now, generally speaking, the lower your bone density, the higher your risk of fracture and osteoporosis.
Holly L. Thacker, MD:Now a recent enhancement to just measuring the calcium in your lower lumbar spine and your non-dominant hip, once you're over 65, we usually do both hips, because there's arthritis in the lower spine and sometimes a hardening of the arteries of the aorta, which falsely elevate the bone density in your spine. Sometimes we'll do the distal one third of the non-dominantray exortiometry, dexa, and wherever you have your bone density, the person reading the bone density should be ISCD certified. I am a certified bone densitometrist and have specialized in osteoporosis for decades, and my techs bone techs are also certified and currently although hopefully that will change soon and again you're listening to this in March of 2023, I am the only one in my healthcare system that has trabecular bone scoring. Tbs and trabecular bone scoring is a software program that's able to analyze the connections of your bone, because bone is not just a solid block, it's porous and there's interconnections and your bone architecture is either assessed as being normal, partially degraded or degraded. So obviously the best category to be in is normal amount of calcium, normal density and normal architecture. And the worst category, which is very high risk for fracture, is to not only have thin bones and osteoporosis by the bone density T-score, but also to have completely degraded bone and of course there's different combinations in between.
Holly L. Thacker, MD:So what happens when you get a bone density test? Well, let me assure you it's quick and painless and there's various methods of measuring bone density. Some people use peripheral x-ray machines that just measure the density in the wrist or kneecap or shin bone or heel, but the best bone densities are central dual energy x-ray absorptiometers or DEXAs, and that gathers the density from the hip, spine and potential total body, which is the gold standard of measurement. During a test, you lay flat on your back on a padded table and a very precise x-ray machine projects the beams onto the target bone density area and the amount of the beam that's blocked by the bone indicates the density and that enables the physician to compare the results with bone density standards and you get two scores. You get a score that compares you to 30-year-old Caucasian women and a lot of my patients say well, I'm not a 30-year-old white woman, but the Z score compares you to people your own age, sex and ethnicity and body weight. So the Z score is not used for diagnosis but it's used for us to find out if you're more than a standard deviation and a half below your peers, if there might be something more than just age or menopause. But the cut point for diagnosing osteopenia, osteoporosis or simply having a normal bone density is to compare you to the 30-year-old Caucasian average. So bone density and the decision for hormone therapy Well, the estrogen and hormone therapy can improve or stabilize your bone health.
Holly L. Thacker, MD:So knowing your status and knowing your rate of bone loss can help. Many recently menopausal women decide, especially if they don't have hot flashes or other symptoms, that they want to begin hormone therapy. And, as I mentioned, there's different ways to measure bone densities. The portable ones tend to not be quite as reliable as the larger models. But even the larger models, if they're removed from one room to another, maybe aren't able to be compared to your prior scan and you cannot compare between scans. You can go to one lab and get a blood sugar and go to a different lab the next month and get a blood sugar and your doctor may compare the trends. But bone density is very highly precise and every day we take out a phantom spine and scan it and we measure our text precision of error, because if you got on that table 10 times, there's going to be 10 different numbers and we need to know if the scatter is significant, just like if I take your blood pressure 10 times when you're sitting down relaxed. I'm not going to get the exact number every time.
Holly L. Thacker, MD:So a woman that has severe menopausal symptoms hot flashes, night sweats, can't sleep, is not happy about her skin or hair, or has vaginal dryness or changes in bladder function or sexual function she may want hormone therapy anyway. But it's important to know that most of these standard regimens also prevent that rapid bone loss. Now, when should I get a bone mineral density test? Well, I recommend getting a bone density test within two years of menopause and maybe right at menopause if there's a history of fracture or high risk or a family history, or certainly in women who are on prednisone or steroids or aromatase inhibitors, women that have certain medical conditions that put them at increased risk, women who've broken bones.
Holly L. Thacker, MD:Now, scoring your test we talked about that T-score and Z-score. So the T-score compares you to an ideal number, a typical healthy 30-year-old female. So if your bone density is the same as an ideal, then your score is zero, but if it's less than average, it's measured in a standard deviation, that's negative. So most normal people are between minus one and plus one. It's the old bell curve that you might remember from school, and the World Health Organization lists criteria for normal being above plus 1 to as low as minus 1, whereas osteopenia cut point is minus 1.1 to minus 2.1.
Holly L. Thacker, MD:Osteoporosis is a T-score equal to or less than minus 2.5. And severe osteoporosis is when your T-score is minus 2.5 or worse and you've had an osteoporotic fracture. Now the National Osteoporosis Risk Assessment Trial did reveal, though, that postmenopausal women who had peripheral T-scores of minus 1.7 were at risk for fracture. This is why age body weight history, combined with a T-score, can further quantify your risk of fracture and treatment needs, and there is a score that we calculate, called the FRAX score. I don't usually consistently do it in people under age 60, because just based on your young age, even if your bones are thin, based on your young age, your fracture risk doesn't necessarily hit the 20% fracture risk in 10 years cut point or 3% risk of hip fracture in 10 years. So you just don't want to only go with a T-score.
Holly L. Thacker, MD:There's a lot of things to take into account Now. The Z-score compares your bone density to that of somebody your own age, weight and ethnic group and sex, and it can be used in premenopausal women, who generally don't need a bone density test, but sometimes we do it in transplant patients, people on certain therapies, underweight persons. And the Z-score can be used to compare the postmenopausal woman to her own peers. And if your Z-score is minus 1.5 or less certainly if it's less than two that means you're not only lower than the typical 30-year-old Caucasian woman, but you're really low compared to somebody your own age and ethnicity, and this is a warning sign that there could be other things or secondary causes of osteoporosis. So a Z-score of minus 1.5 or worse means that you should be assessed for vitamin D deficiency, low estrogen state, an overactive parathyroid there's four little tiny parathyroid glands in your thyroid gland overactive thyroid hormone or simply taking too much thyroid replacement, elevated cortisol levels or gut malabsorption of needed nutrients. Multiple myeloma can cause multiple spine fractures, hormonal imbalances, use of certain bone negative bone medications and that excessive loss of calcium through the urine, which in some people, is a common genetic defect called hypercalciuria. So get recommended daily allowances of calcium, which is at least a thousand milligrams. If you're estrogen replete and if you're estrogen deficient or have had some gut problems, you might even need up to 1500 milligrams of calcium, but you need it in divided doses because your intestines don't absorb more than 300 to no more than 500 at a time.
Holly L. Thacker, MD:Vitamin D it's not a vitamin, it's a pro-sterile hormone, and I would definitely encourage you to listen to my second ever podcast on vitamin D. Now, the so-called recommended daily allowance is not based on science. It's 400 international units, which is barely enough to prevent rickets In most countries. Most experts agree that most adult persons, especially over 40, should get at least one to two thousand units, and people with low levels may need up to ten thousand units a day to fill up their tank. Now, the reason why four hundred units was picked as the recommended daily allowance was based on mother knows best, because moms used to have their kids swallow a teaspoon of cod liver oil every day to prevent rickets, which is severe vitamin D deficiency.
Holly L. Thacker, MD:Vitamin D and weight-bearing exercises is tolerated. So walking, lifting weights, jumping rope, using resistant bands are all helpful. It's important not to smoke and to avoid excessive alcohol use and to bring in all your prescription medicines and supplements when you visit with your physician and get a bone mineral density when appropriate and if you need a follow-up bone density, trying to get it on the same machine. And if you're lucky enough to be in an area where there's experts in osteoporosis and they have that trabecular bone scoring, that can be very helpful, because in the last year I've assessed all the data in our Center for Specialized Women's Health and we found that 16% of the diagnoses got changed either to a worse diagnosis or a better diagnosis based on taking into account the trabecular bone score and the actual bone architecture.
Holly L. Thacker, MD:So, as I mentioned, over the age of 40, sometimes our skin doesn't make vitamin D. Many of us work inside, many of us like to use sunscreen to reduce sunburn and skin aging from the sun, and some of us live in Northern climates where even on a sunny day, like today in March here in Cleveland, I could run outside naked. Not that I would, um, but I'm not. My skin's not going to make vitamin D because we're just not at the right latitude. So young people who don't wear sunscreen, who drink a lot of vitamin D fortified milk and like salmon and like to eat mushrooms that have been suntanned. That has vitamin D in it. Many times those folks might get enough vitamin D, but in my practice, most midlife women I see, and even those that come from the Sun Belt to visit me, especially if they're older, even if their skin is damaged from sun exposure, I still see very low levels.
Holly L. Thacker, MD:So when should I seek treatment? Well, as I said before, I would generally and most folks recommend a bone mineral density testing within two years of menopause and earlier for people with a family history of osteoporosis, very low vitamin D levels or people who've used long-term glucocorticoids 7.5 milligrams of prednisone or more for three or more months. And the decision to treat a woman for osteoporosis should be based on the clinical risk factors, the T-score, the medical history, the FRAX and, importantly, if possible, the bone architecture and also the rate of bone loss over time. So a combination of good health and exercise and possibly a regimen of hormone therapy or other bone medicines, with or without hormone therapy, may be prescribed. But again, this is just general information to keep you strong, healthy and in charge. It is not medical advice does not substitute for care with your physician. So, bone therapies Well, depending on the severity of life of the bone loss, we need to look at options.
Holly L. Thacker, MD:And if you're at very high risk or you're rapidly losing bone, we need to start hormone therapy or some other option. And if you can't take hormones or you don't want to, there's a lot of options. I mean, when I started in this field over 30 years ago, all we had was estrogen, which you can only use in postmenopausal women, not men, and fluoride. And fluoride makes the bones denser but it doesn't reduce fracture. So the density is not the whole story. And now we have several classes of medication and it's one of the areas in women's health where we actually have more research in women than in men. And sometimes men get the short shrift. Men with broken bones over 50 or height loss or are on medications that hurt their bones. Sometimes they don't get the same attention women get. So look out for the males in your family if they're at risk for osteoporosis.
Holly L. Thacker, MD:So bisphosphonates they're so-called anti-resorptive treatments. They slow or stop the dissolving of the bone tissue without affecting the formation of new bone tissue. So that means that you have more formation over resorption, so that your bone bank increases over time. And we have several bisphosphonates. We use some off-label before Fosamax or Alendronate, which was the first one that hit the market in 1995. We have Actonel brand name, a generic residronate.
Holly L. Thacker, MD:It can be dosed 5 mg a day or 35 mg weekly, or one of the more popular ones is just 150 mg once a month and that reduces all types of fractures spine vertebral, non-vertebral fractures, which include the wrist, the pelvis, the hip and the humerus arm bone. And it's also approved to prevent glucocorticoid-induced osteoporosis. But when you only take it once a month, you only get 12 times to get it right, ladies. And hardly any bisphosphonate is absorbed through the gut less than 1%. So if you're on an oral bisphosphonate you must take it with plain tap water, not mineral water, not coffee, and you really have to wait at least 30 minutes and I usually tell my patients 60 minutes without eating any other foods except for water, no other beverages except for plain water and no other medications. And you need to be upright, meaning don't take it in the middle of the night and fall back to sleep and have it stuck in your esophagus. Now Boniva Ibandronate is also available in 150 milligram monthly dose and was previously given by injection every three months, but it's not been associated with reductions in hip fracture so we don't tend to use it very often.
Holly L. Thacker, MD:Now Fosamaxilendronate has been on the market the longest and it's got a 35 milligram weekly prevention dose or a 70 milligram weekly osteoporosis dose and it does reduce spine fractures and hip fractures and there's a brand name that has some vitamin D in it, which gives either 2,800 international units of vitamin D weekly or 5,600 international units, which really isn't that much, and most insurances are just only covering the generic form. But the generics may be absorbed at different rates and I don't tend to be a fan of the oral generics and in anyone with Barrett's esophagus or a hiatal hernia or gastric distress, I usually go to the injectable zolendronic acid, also known as Reclast, and it's a five milligram dose given once a year for osteoporosis In breast cancer patients or people with cancer. It's used in a lower dose more frequently, called Zometa, and it helps bring down calcium levels. But in 2007, the zoledronic acid was officially FDA approved to treat postmenopausal osteoporosis and Paget's disease and in 2008, it was approved for men and women who had already had a hip fracture to reduce the risk of low trauma fractures and in that group of people it was associated with the lower death rates. And it has to be infused over at least 15 to 20 minutes. So it does require the nurse finding a little vein and an office visit. But it's a solid agent. We know you're getting it and absorbing it and in those people who broke a hip it reduces death rates. Now you've got to have adequate kidney function, at least 35 cc's per minute.
Holly L. Thacker, MD:So you need a creatinine and, for any patients who finish up, any type of bone building agent like an anabolic daily shot of injectable PTH, which is now in a biosimilar option, or Timlos, also known as abalaparatide, which is also another daily injectable for two years. And we have the newest bone builder which is an anabolic agent and anti-resorptive. It's's called Avenity, also known as Romozumab, and that's given by two monthly shots by the nurse for a month for an entire year. So that would be 12 visits where you wouldn't have to give yourself the shot like you do with Forteo or Timlos or those biosimilars. Because if you're going to go to the expense and hassle and if you're severe enough to require bone building agents, we need to solidify that and I frequently will use Reclast and, like I said, reclast has shown mortality reductions in older men and women who've already broken a hip.
Holly L. Thacker, MD:So you have to get a calcium level and kidney function and a vitamin D level for your first infusion at least 30 days in advance, and every year or other year or even every third year that you may be getting future reclassed infusions. You need to have adequate kidney function and you need to be well hydrated and some physicians might recommend either acetaminophen, known as Tylenol, or ibuprofen, if no NSAID intolerance or allergies, known as Motrin or Advil, the day before, the day of and the day after the infusion, because sometimes the first infusion, if your bones are really hungry and needing to build up, you might feel flu-like symptoms or even like growing bone pain. Now, of course, once we go through puberty and the epiphyses close, we can't grow taller, but we can grow denser and stronger. So estrogen, as well as actinil and Fosamax and Reclast, have been proven to reduce spine fracture and hip fractures. Now Evista, which is raloxifin, which is an estrogen agonist antagonist which reduces estrogen-positive breast cancer diagnosis, does not reduce hip fractures in the studies but does reduce spine fracture and helps cholesterol. So it's kind of a mild agent. As I mentioned, I don't tend to favor ibandronate or Boniva too often just because it doesn't have the hip fracture reduction data.
Holly L. Thacker, MD:Now, bisphosphonates orally are usually well tolerated but they can be associated with some gastrointestinal upset and I do see that more with generics and you must take your calcium at a different time and you must avoid eating or drinking other things because otherwise you're going to flush your medicine down the toilet, because if you swallow it but you can't absorb it, it literally ends up in your poop and down the toilet instead of going to your bones where you need it. So what's all this? I hear about jaw problems. So certainly there have been news stories talking about this very rare condition called ONJ osteonecrosis of the jaw. Sometimes people call it BRONJ, bisphosphonate-associated osteonecrosis of the jaw, but this has been mainly seen primarily in people who have cancer or multiple myeloma, who are getting chemotherapy, radiation, may have poor dental status or diabetes and those who are getting repetitive intravenous bisphosphonates.
Holly L. Thacker, MD:So just as the media promoted the hormone hysteria over 20 years ago with the Women's Health Initiative, I think that there's been some jaw necrosis hysteria as well. So I'm really disturbed when a patient tells me that her dentist told her to choose between your teeth or your hips, because it's absurd. We need our hips and we need our teeth. It's just another reason to find someone who's well versed in research relating to women, who can evaluate your whole health, consider your personal history and family history and come up with an individualized best regimen.
Holly L. Thacker, MD:Actually, some research shows that actinel, like estrogen, is good for the teeth and gums. There was a study done at Case Western Reserve University that looked at postmenopausal women who had no bone therapy versus those who had Actinil, and they saw improvements in their teeth and gums. And so when I saw this research, I contacted one of the periodontists and we've published in the Journal of Menopause where women with osteoporosis who were on any kind of bone treatment hormones, non-hormones, bisphosphonates or other agents who were evaluated by three dimensional CAT scan of the jaw by periodontist dentists and had grading of their teeth and gums and plaque scores. And what we found is that if women were on any osteoporosis treatment compared to those who were not, they had better teeth and gums. And furthermore, in the Horizon Pivotal Fracture Trial, there was no increase in osteonecrosis of the jaw in postmenopausal women receiving yearly reclass through IV compared to women getting placebo injections. So only a handful of cases have been reported and I do think ONJ has been blown out of proportion and the American Dental Association has guidelines and I think the dentist by and large understand this. So the baseline risk for having ONJ is about one to two per hundred thousand persons and if you're taking bisphosphonates that risk might be two per hundred thousand. So it really pretty much is very close to placebo. So it's not zero but an.
Holly L. Thacker, MD:Embryologically the upper jaw and the lower jaw are derived from different tissue. But if you have bad dentition or you need teeth pulled or extensive dental surgery, I always recommend women get this taken care of before we start them on treatment or if they're on another excellent anti-resorptive agent, denusamab, known as Prolia, which can be very helpful for women who have impaired kidney function, because it doesn't go through the kidneys. It's basically a monoclonal antibody that helps to make up for the loss of OPG osteoporoterogen in the body, and women lose OPG rapidly when they lose estrogen. So I like to say Prolia or Denusamab is kind of like a super estrogen acting on the bone without any effects anywhere else. And the one thing about intravenous reclast and also Prolia is it seems like it is associated with slightly reduced breast cancer risk. In fact, doctors treating women for breast cancer especially if they're giving them agents that hurt their bones frequently will give them Zometa, which is just a lower dose of reclass, on a more frequent basis. So if you're on Prolia, it lasts for a little more than six months and Medicare usually only covers it for the injections. You have to be past six months and a day to get the next one, and if you don't keep getting your injections and you're not on any other treatment, there can be rebound fractures.
Holly L. Thacker, MD:Now we have a little bit more research using bisphosphonates and hormone therapy combined, because they've both been around longer than Prolia or Denosumab. In fact, I gave my first injection to a patient of Prolia in June of 2010. I think I was the first one in my healthcare system to give that first injection to a woman, and it was studied for 10 years before it hit the market, and so it's been on the market now for well over 12 years. I have people going on their like 24th injection. So what about calcitonin?
Holly L. Thacker, MD:That was a treatment that we used myocalcin spray by nasal spray and it's a naturally occurring hormone that helps regulate calcium and bone metabolism and it can improve bone density and sometimes reduce fracture pain, which I would primarily just use it for spine fractures, and it's recommended only in women five years past menopause. But it doesn't have hip fracture reduction and some reports have linked it to higher risk of cancer. And now that we have proleodenosumab, which avoids the kidneys where the bisphosphonates don't, we really don't have as much of a need for it. So one of the other anabolics the newest one on the block is Romo, also known as Avenity, and I will use this in women at very high risk for hip fracture, women who need an anabolic, women who don't want to give themselves a daily injection, and also I will not give it, though, if the woman has had a heart attack or stroke within the 12 preceding months, because one of the studies showed potentially higher risk of this, but several other studies did not. So I do think it's a very safe and effective bone building option, but I tell all my patients I'm not going to go through the trouble. Have you go through the trouble, go through the expense, have my office staff do all the paperwork to get these expensive therapies if you're going to just lose it at the end because you don't solidify the treatment. So if you're going to use an anabolic, you can't just say, oh, my bone density is so improved after two years or one year of this therapy, now I'm fine and go off into the sunset because I guarantee you when you come back for a future bone density, if you don't come back sooner because of a broken bone, you will have lost everything you gained. So you have to agree in my practice generally to either IV reclassed after you finish your anabolic, prolia denusamab every six months plus a day shots, or an oral bisphosphonate.
Holly L. Thacker, MD:And I think, for women with really low T-scores, those at very high risk, those who've had failed treatment, or people that have multiple different conditions that negatively affected their bones, like, say, hormonal deficiencies, vitamin deficiencies, celiac disease, hypercalciuria all these things that can be treated and or reversed, but who have lost so much bone who need to build up to a stable status, that's another group of women. So hormone therapy is FDA approved for both osteoprevention and management, for both osteoprevention and management, and it's a good therapy to stop that rapid bone loss. If bone density low bone density is your major problem and you really don't want hormone therapy, then there's other options for you the estrogen only arm of the Women's Health Initiative, which used conjugated estrogen and the estrogen progesterone arm, which used PremPro in women who had a uterus, interestingly showed reductions in all types of fractures in women taking hormone therapy and this is really impressive because this group of women who participated in this study were not a group deemed to be at high risk for osteoporosis. Now they were women. So again, women are at risk. But in most osteoporosis trials you have to already have osteoporosis to get into the trial. So estrogen currently is the only agent we have that reduces all types of fractures in women of varying bone densities. Now we can use uber low levels of estrogen in the Menistar patch 0.014 or half of a 25 weekly or bi-weekly patch if you're between the ages of 60 and 80 and just have osteopenia and a lot of women like this option if they don't have hot flashes and they really don't want to take progesterone and have a uterus. Although you still have to take progesterone for 12 days at least once a year if you're on Menostar, but not every month, the dose must be individualized and if you have bone loss or hot flashes then you might need more hormones, but you don't get the potential breast stimulation of progestogens. Now not all women maintain bone density with hormones, and certainly hysterectomized women who've had their ovaries out many times, especially after age 70 or 75, even if they've gone decades with stable bone density, sometimes they do lose bone and need additional treatment. Now some women who've never taken hormone therapy or they took it for a while but had side effects of breast issues or bleeding if they're not at super high risk for fracture or they don't, maybe have osteoporosis yet they have osteopenia or they're concerned about their risk of breast cancer and they don't have a history of blood clot. Maybe they've taken the birth control pill or had a pregnancy or a c-section in the past.
Holly L. Thacker, MD:Then relaxaphenavista, I think many times is overlooked. It's not the biggest guns to treat osteoporosis but it has these other systemic benefits and it's easy on the stomach. It doesn't irritate the stomach, it doesn't go through the kidney, so you don't have to worry about kidney function. And in 2007, it was FDA approved to reduce the risk of estrogen positive breast cancer diagnosis. And it does affect cholesterol beneficially too. In the RUTH trial, which was the raloxifen use for the heart trial women who were at increased risk for heart disease or diabetes. They didn't show any reduction in their risk of heart disease by taking raloxifan, but they didn't have any increased risk of stroke. And women on standard oral doses after age 65 do have one extra case of stroke per thousand women. In the Moores trial, the multiple outcomes of raloxifin, which looked at women with osteoporosis, and in the STAR trial, the study of tamoxifen and raloxifin, which compared tamoxifen and raloxifin for reducing breast cancer risk, these all showed reductions in breast cancer diagnosis.
Holly L. Thacker, MD:Now parathyroid hormone is available in the brand name teraparotide, brand name Forteo, and that's a daily injectable agent, and the little pen is like an insulin pen and needs to be refrigerated, where abalaparotide, also known as Timlos, is very similar similar but does not have to be refrigerated. And the PTH, which is produced in those four little parathyroid glands next to your thyroid at the base of the neck, is very important for calcium and bone metabolism, and these agents are anabolic bone builders and it's an exciting option. It's been on the market for a long time. In the past you could only use it for two years, but that has been lifted.
Holly L. Thacker, MD:If you've had bone radiation or Paget's disease, though, we cannot use this class of medication, and that includes women who had, you know, breast cancer with chest radiation, but we do have other anabolics like the Avenity Romo, which may be an option. But we do have other anabolics like the Avenity Romo, which may be an option. Now, women who have menopausal symptoms, who are on estrogen, the therapy from the bone status still might want to finish five years to reduce their risk of being diagnosed with breast cancer. But, as I mentioned, if you have Paget's disease or bone radiation, you're not a candidate for Teo or Bondensity, which is a biosimilar, or Tymlos, which is a biosimilar or timlos.
Holly L. Thacker, MD:Now a lot of women come to me asking me about natural treatments like heavy metals strontium runolate, which is a periodic element in the table of elements, and it's been used in Europe in postmenopausal women. It goes under the brand name Protolose, but it's not available here in the United States, other than sometimes people will get it in unregulated supplements, but I don't recommend it because it interferes with the reading of the bone density just from the strontium deposition in the bones and it's a heavy metal. And I think we have plenty of other options. Well, if, if I feel good, can I just stop using my bone therapy? Well, always consult a physician about your therapy. You don't want to just stop and take a vacation off your therapy, unless it's been deemed to be an appropriate time where you're being monitored.
Holly L. Thacker, MD:We talked about the supplements of vitamin D3, which helps you absorb calcium. Talked about the supplements of vitamin D3, which helps you absorb calcium, and just remember that calcium and vitamin D are like the building blocks. I call them like the nails and the two by fours. If the worker people don't show up to use those building blocks, you're not going to get that extension made to your house. Conversely, if the worker people show up and there's no supplies, no calcium, protein, vitamin D, then you're not going to be able to rebuild your bone. If you need a calcium supplement, I favor calcium citrate because that's absorbed with or without food, with or without stomach acid, but it is a little more expensive than calcium carbonate. So the cheapest option is to chew a Tums after a meal if you don't think you've gotten enough calcium.
Holly L. Thacker, MD:Be sure to not take in more than 1,500 to 2,000 milligrams of calcium a day. There's lots of non-dairy foods that are great for calcium Seaweed, blackstrap, molasses, almonds, broccoli, canned fish with bones, sardines, salmon, bone sardines, salmon, collards, dried beans, kale and, of course, spinach and all the dairy products milk, low-fat yogurt, cottage cheese, ice cream cheeses, especially the hard cheeses, and even if you're lactose intolerant, you still may be able to digest certain yogurts and hard cheeses. And there's lots of lactose-free dairy products. I really like the brand of milk that's lactose-free and higher in protein that has a longer shelf life. You could also get dairy yeast or lactase enzymes to help you digest it, and now there's so many non-dairy milks like coconut milk and almond milk and soy milk that you get high amounts of calcium without too much calories.
Holly L. Thacker, MD:Now calcium levels need to be monitored before getting Prolia, especially for the first injection, if you're on the injectable anabolics or if there's any reason to suspect you've got some calcium imbalance. If you've had kidney stones, I recommend a 24-hour urine calcium collection. And cutting down on calcium will not prevent kidney stones, but taking hygrotin, chlorthalidone, hydrochlorothiazide, maxide Many times we use these in very low doses and that fixes the leak in the kidney, so preventing bone loss. You have to be aware of medications that can be bad on your bones and that includes some blood thinners, long-term heparin medications used to treat seizures, which sometimes are used in other patients for pain and mood stabilization. Too much thyroid medicine, prednisone, steroids, many breast cancer treatments, too much alcohol, tobacco, even too much caffeine, can cause you to waste calcium in the urine and certainly drinking a bunch of sodas and diet sodas high in phosphorus are not good.
Holly L. Thacker, MD:So participate in sensible, weight-bearing exercise and certainly exercise is a surefire anti-aging remedy that we have. It's important to get aerobic exercise and weight-bearing exercise and we'll have many podcasts on this topic. For women that have osteoporosis who are engaged in activities that might result in a fall, such as skiing, there are specific hip pad protectors that can be worn If you've got osteoporosis or risk for fracture. Just everyone should be aware of slip and fall risk, like loose rugs and electrical cords and slippery surfaces, because a fall, even if it doesn't result in a bone fracture, can certainly cause head trauma, bruising pain, require a doctor visit and if you need assistive devices because of orthopedic problems or neurologic problems, it's very important to get this assessed because we want you to be strong and be healthy and be in charge.
Holly L. Thacker, MD:Thanks so much for joining me in the Sunflower House. I am your host and author of the Cleveland Clinic Guide to Menopause and I hope you subscribe to our Speaking of Women's Health podcast. Give us a five-star rating to help us move up in the charts and please join us next time for Chapter 13, abnormal Bleeding and what to Do About it.
