Millions of American women are being diagnosed with
osteopenia, which is not truly a disease, and many
are told to take medication they may not need to
prevent broken bones they might never get.
At the same time, millions of others are never
properly diagnosed - or treated – for osteoporosis,
a serious condition that can lead to potentially
devastating fractures.
The widespread confusion about what degree of bone
loss really is a red flag for future broken bones
and what is simply a sign of normal aging has been
rampant since, in 1994, the World Health
Organization defined “osteopenia” and
“osteoporosis” as certain ranges of scores on a bone
density test.
Some doctors consider this range skewed, labeling
too many -- 34 million -- Americans as having
osteopenia, and too few -- 10 million -- at risk for
the broken bones of osteoporosis. (Osteoporosis is
generally considered a disease of women, but men can
get it, too.)
Things have become even more muddled since 2002,
when many older women stopped taking hormone therapy
-- which can help prevent bone loss – after a major
study showed that it also raised the risk of breast
cancer, heart disease and stroke. Between 2002 and
2003, sales of Fosamax, a drug used to prevent bone
loss soared 19 percent, to $2.7 billion.
In essence, nobody quite knows what, if anything, an
older women whose only sign of potential problems is
mild bone loss should do. Should a woman at 50 start
taking drugs like Fosamax, Actonel or Evista to
guard against possible fractures in her 80s, when
most fractures occur? Or should she wait until her
bone tests get worse or there is a very real red
flag, like having a fracture triggered by a minor
fall?
The problem comes from “calling osteopenia a disease
when it is not,” said Dr. Robert Neer , director of
the osteoporosis center at Massachusetts General
Hospital. The WHO defined osteoporosis too narrowly,
leading many people to think they are not at high
risk, and osteopenia too broadly, encouraging too
many women to take medication, he said.
"We are overtreating a large number of healthy women
who have a relatively minor risk of fracture and we
are ignoring a sizable number of individuals at high
risk of fracture,” Neer said.
The term “osteopenia” has “nomedical meaning," added
Dr. Steven Cummings, an epidemiologist at the
University of California, San Francisco, who has led
a number of large studies on osteoporosis and
osteopenia. "I’ve seen patients who come in scared
that they will become disabled soon because they
have this ‘disease’ called osteopenia, when in fact
they are normal for their age.”
Other critics, like Gillian Sanson , a women’s
health educator in New Zealand and author of “The
Myth of Osteoporosis,” go further. The medical
establishment, she said, is “manufacturing patients”
by over-medicalizing the normal bone loss that
occurs with aging.
For the record, osteopenia is defined by the WHO as
a score of minus 1 to minus 2.4 on the so-called
DEXA test, which stands for dual energy X-ray
absorptiomety. Osteoporosis is defined as a DEXA
score of minus 2.5 or worse. Osteopenia can, but
does not necessarily, progress to osteoporosis.
Indeed, while osteoporosis clearly raises the risk
of fractures, many fractures also occur in people
without it. A 2003 study showed that the proportion
of fractures attributable to fragile bones was
“modest” -- somewhere between 10 and 44 percent.
“Low bone mineral density does raise the risk of hip
fracture, but it’s only one of several factors like
bad eyesight, bad coordination, use of Valium or
similar drugs, overactive bladder and other
conditions that contribute to the falls that can
lead to broken bones,” said Dr. Nananda Col , an
internist and women’s health expert at Rhode Island
Hospital in Providence, RI.
In other words, a finding of mild osteopenia on a
bone density test is not, by itself, enough reason
to take medications. If there are no other risk
factors, even a bone density test score as low as
minus 2 “in an otherwise healthy young person may be
normal,” said Dr. Eric Orwoll , an osteoporosis
specialist at Oregon Health Sciences University in
Portland, OR.
On the other hand, because osteopenia can, though
does not always, lead to osteoporosis, many doctors
believe it’s important to start treatment early to
avoid broken bones later in life.
Dr. Joel Finkelstein , an osteoporosis specialist at
Massachusetts General Hospital, said he
sometimes prescribes medication to postmenopausal
women with bone density scores of minus 1.5 to minus
2, even if they are still in their 50s.
“I do believe in treating a lot of these people to
prevent the development of osteoporosis….I may be
more aggressive than some other physicians.” Dr.
Suzanne Jan de Beur , director of endocrinology at
the Johns Hopkins Bayview Medical Center, said she
prescribes medication to women with scores of minus
1.5 to minus 2 if there’s a family history
of osteoporosis or other risk factors.
Dr. Joseph L. Melton, III, an epidemiologist at the
Mayo Clinic in Rochester, MN, put it this way:
Doctors who advise women to ignore osteopenia "are
wrong, and people who advise everybody to treat it
are wrong. It's a personal decision based on family
history and personal values."
So, when should a woman be screened for potential
bone loss? And how safe are the drugs for long term
use?
In 2002, the US Preventive Services Task Force, a
panel of independent experts convened by the
government’s Agency for Healthcare Research and
Quality, concluded that women aged 65 and older
should be screened routinely for osteoporosis. It
said screening should begin at 60 for women at
increased risk, which includes a family history of
hip fractures, current smoking, thinness and use of
steroids such as Prednisone.
As for drug safety, a study published in March, 2004
in the New England Journal of Medicine showed that
Fosamax (alendronate) appears to be safe for as long
as 10 years. But a 1998 study showed that while
Fosamax helps prevent fractures in women with
osteoporosis, it does not do so in women with
osteopenia and no previous fractures.
Fosamax and Actonel can cause small ulcers in the
esophagus, or food tube; Evista can cause hot
flashes, and rarely, blood clots.
There is no evidence yet that the widespread use of
Fosamax and Actonel is causing any problems, said
Col of Rhode Island Hospital. But the drugs do get
incorporated into bone. “If 10 years down the line,
it turns out that something is dangerous, it will be
sitting in a lot of people’s bones. The benefits of
treatment need to outweigh the risks.”
That applies to another drug, too: Forteo, the only
medication that actually increases bone growth. The
catch with Forteo is that it carries a special
warning because, in rodents, it can trigger bone
cancer.
Bottom line? Try to prevent thinning bones in the
first place. Do weight-bearing exercise several
times a week and walk briskly for 30 minutes a day
or more. Get enough calcium –- 1,200 to 1,500
milligrams (but not more) a day, plus 800
International Units of vitamin D, from food and, if
necessary, supplements. Minimize use of Valium-type
drugs. If problems like overactive bladder or poor
eyesight are raising your risk of falls, get those
treated, too.
And if one doctor recommends drugs to protect your
bones on the basis of mild bone loss, consider
getting a second opinion. Obviously, no one wants a
broken hip. But no one should take any drug for
decades without careful thought, either.
Judy Foreman’s column appears every other week. Past
columns are available on
www.myhealthsense.com.
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