Fear of fracture
“I spend a lot of time allaying concerns among women whose risk of osteoporosis is not high but who worry,” says endocrinologist Bruce Ettinger, M.D., professor emeritus at the University of California, San Francisco. “The medical term for them might be ‘the worried well.’ They worry because they’ve read about osteoporosis or heard about it or received alarming information from a friend. These women want to be able to estimate their risk.”
By the time women are in their 50s, most of them will be classified as osteopenic, Ettinger says. The condition is not a disease but a marker for the risk of fractures. It’s found in more than half of all postmenopausal white women in North America and 35 percent of African American women over 50. Most experts say that osteopenia does not need to be treated with drugs.
People think of their chances of breaking a bone differently once they work out the numbers using FRAX, says Lisa Schwartz, M.D., associate professor of medicine at Dartmouth Medical School in Hanover, N.H. “Taking all the risk factors into account to figure out when treatment might make sense is a much more rational approach.” For example, she continues, the chance of the average 55-year-old woman with osteopenia fracturing a hip within the next 10 years is less than 1 percent. That’s hardly a risk that calls for drug treatment, she says.
Furthermore, she adds, there’s no evidence that long-term use of drugs in women with osteopenia will cut down on fracture risk.
Charles Barr, M.D., international medical leader for the osteoporosis medication Boniva at Roche, the drug’s manufacturer, has a different take. “Treatment has been shown to be effective in preventing fractures in women with osteoporosis, and treatment has been shown to be effective in stopping or reversing bone loss in women with osteopenia,” says Barr. “One of the issues is whether it’s better to wait until bone loss is severe before starting treatment, or is it better to start treatment early to maintain good quality bone,” he says. So far, “we have no definitive answers.”
Charting the best course
There’s no good information on how long people should take these drugs, according to the American College of Physicians, so some researchers argue that it makes more sense for a woman to delay taking medications until she crosses the line from osteopenia to osteoporosis.
“The less time a woman’s on drug therapy, the less chance for adverse events,” says Bess Dawson-Hughes, M.D., director of the Bone Metabolism Laboratory at Tufts University and chair of the committee that updated the NOF guidelines.
Many experts caution that waiting too long to start bone-strengthening medications isn’t wise. Bone loss is a serious issue, and drugs can act quickly to lower fracture risk in people with osteoporosis. Even if there’s some uncertainty about side effects from long-term medication use, once the possibility of a broken hip is in the picture, the benefits are real. “Hip fracture can often be the start of a spiral of terrible events,” Schwartz says.
In the meantime, exercise, eat right, don’t smoke and if you drink, do so moderately. That’s advice the medical community agrees on.
- Keep moving. Weight-bearing and muscle-strengthening activities like jogging, tennis, dancing and weight training build strong bones and help prevent fractures. Exercise also helps develop balance and prevent falls.
- Calcium and vitamin D. Vitamin D helps the body absorb calcium, which helps bone strength. Consider supplements if you don’t get enough vitamin D from your diet and sunshine. If you’re over 50, federal guidelines recommend 1200 mg of calcium and 800 to 1000 IU of vitamin D a day.
- Reduce alcohol. Heavy alcohol use can reduce bone formation. Limit yourself to no more than two drinks a day.