This is long but worth reading. It was in the paper today:
Originally published May 20, 2005
Millions of American women are being diagnosed with osteopenia, which is not truly a disease, and many are being told to take medication they may not need to prevent broken bones they might never suffer.
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. That's when 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 Americans (34 million) 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.
As a result, 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 woman should do when her only sign of potential problems is mild bone loss. Should a woman at 50 start taking drugs such as Fosamax, Actonel or Evista to guard against possible fractures when she reaches her 80s, when most fractures occur? Or should she wait until her bone tests get worse or there is a very real red flag, such as 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 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 "no medical meaning," added Dr. Steven Cummings, an epidemiologist at the University of California, San Francisco, who has led large studies of 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," he declared.
Other critics, such as 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 overmedicalizing 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 progress to osteoporosis, but doesn't necessarily.
Indeed, while osteoporosis clearly raises the risk of fractures, many fractures also occur without the condition. In fact, a 2003 study showed that the proportion of fractures attributable to fragile bones was "modest," somewhere between 10 percent 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.
In other words, a finding of mild osteopenia on a bone density test is not, by itself, enough reason to take medication. 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.
On the other hand, because there's a possibility that osteopenia can 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," he said, adding that "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, Minn., 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 U.S. Preventive Services Task Force concluded that women 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 a day (but not more), plus 800 International Units of vitamin D from food and, if necessary, from supplements. Minimize use of Valium-type drugs. If problems such as an overactive bladder or poor eyesight are raising your risk of falls, have those treated.
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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