Many medical conditions are called by their Latin or Greek names, which describe the condition while giving it a medical-sounding name. Osteoporosis is a good example, derived from Greek, meaning condition (osis) of porous (poros) bone (osteo). Osteoporosis is thinning of bones that leads to fractures, sometimes occurring with minimal trauma or no trauma. The bones most commonly affected are the femur (hip), the vertebra (bones in the spine) and the radius (forearm). Half of women above age 50 will have a fracture related to osteoporosis. Hip fractures can be debilitating and even life-threatening. The mortality rate for women resulting from hip fractures is about 20%, meaning that one out of five women who sustain a hip fracture will not live more than one year. A much higher percentage of women are debilitated as it is often an event that leads to placement in a skilled nursing facility. The risk of hip fracture is equal to the risk of getting breast, uterine or ovarian cancer combined. The risk of dying from a hip fracture is greater than the risk of dying from any of those three cancers.
The conventional treatments for osteoporosis are not satisfactory. This is because the treatments have limited efficacy and significant side effects. The most common class of drugs used is bisphosphonates. This includes Fosamax (alendronate), Boniva (ibandronate), Actonel (risedronate) and Reclast (zoledronic acid), among others. These drugs don’t help grow bone; rather they slow the rate of bone loss. Many patients have difficulty tolerating these drugs due to gastrointestinal side effects including reflux. If one is able to tolerate this, there may be long-term side effects including osteonecrosis (wearing away) of the jaw, esophageal cancer and a femur fracture at the mid shaft. Prolia (denosumab) is another commonly used drug for osteoporosis. It has the advantage that there can be some bone growth but with significant side effects including bone, muscle and joint pain and increased risk of fracture in the spine after stopping Prolia or missing a dose. Similar to bisphosphonates, jaw osteonecrosis and femur fracture can occur.
Taking estrogen as part of a bioidentical hormone replacement program is a great strategy for treating osteoporosis. In contrast to the bisphosphonates that slow the rate of bone loss, estradiol can actually increase bone density. That is, the bones gain mass and thus become stronger. The stronger the bone, the less likely there will be a fracture. Another benefit of estrogen is that the tensile strength of bone is increased. This is more difficult to measure because such force that would measure tensile strength cannot be applied to a live person. The advantage of increased tensile strength is that for any level of bone density, the likelihood of fracture is decreased. Thus, estradiol increases bone density and seems to increase the tensile strength of bones, both of which decrease the likelihood of fracture.
In contrast to bisphosphonates, estradiol has many other benefits. For instance, with estradiol, the risk of heart disease, which is the leading cause of death of older women, is reduced by about 60%. Another potential cause of death of older women is Alzheimer’s disease. Estradiol significantly reduces the risk of Alzheimer’s. Women who take advantage of the benefits of bioidentical hormone replacement typically feel more energy, have increased libido and have better mood and sleep. While bisphosphonates can cause erosion of the jaw, estradiol increases bone strength in the mouth so women will have healthier teeth and gums with decreased loss of teeth.
Throughout life, there is an ongoing balance between bone formation and bone destruction. When women lose estrogen at menopause, bone destruction far outpaces bone formation. Thus, there is a decline in bone density. This process is painless until the bone loss is so advanced that a fracture results. This is comparable to having termites in your home. You don’t notice that they are there until the wood beams start to collapse. Until a fracture occurs, osteoporosis is painless.
Bone density can be measured with a DEXA scan. Using a small amount of radiation, bone density is measured and compared to women your age and to 20-year-old women. When the bone density declines to more than 2.5 standard deviations of the bone density of a young woman, osteoporosis is diagnosed.
Another useful diagnostic test is measuring N-telopeptide in the urine or blood. This is a metabolite that is produced when bone is broken down. It is measured as a ratio to creatinine called NTX. The useful aspect of this test is that it is more dynamic than bone density. For instance, when a woman starts estradiol, her NTX will typically start to decline within six to 12 months. Increased bone density, as measured on a DEXA scan, may not be observed for two to four years. This is because the changes in bone physiology takes a while to transform the bone structure. Since NTX is a better measure of bone physiology, it can be detected sooner.
There are other lifestyle changes that can help improve bone health. Bones respond to the load with which they are challenged. Thus, weight-bearing exercises such as walking and running will be a positive factor that promotes bone strengthening. Supplements such as vitamins and minerals can also promote bone health. Vitamin D can promote bone health. When taken with vitamin K, the effect of vitamin D on the bone is magnified. Strontium has also been shown to promote bone health. If someone has an adequate level of vitamin D, they will usually have enough calcium such that additional calcium supplementation is not necessary.
While all these measures should be part of your healthy lifestyle, it is my experience that when osteoporosis is already developed, these lifestyle changes are not enough to reverse the condition. Estradiol is needed.
In summary, osteoporosis is very common in postmenopausal women and can lead to hip fractures which can be life-threatening. The drugs available to treat osteoporosis are either ineffective at building bone and/or have severe side effects. On the other hand, estradiol helps build and strengthen bone and has many other benefits, including reduced risk of heart disease, reduced risk of Alzheimer’s disease, increased energy, better libido and even decreased risk of breast cancer. Anyone with osteoporosis should consider estradiol as a key part of their treatment program.
Dr. Slaten is a wellness physician specializing in regenerative pain treatments and lifestyle counseling. He is certified in advanced bioidentical hormone replacement. You can learn more on his website, www.hormonesnj.com.
