What You Don't Know About Osteoporosis

This time we'll look at one of the most controversial and misunderstood treatments for osteoporosis -- hormone replacement therapy. We'll also answer the question as to whether being obese can actually reduce your risk of osteoporosis.

Bioidentical Hormones for Women

Prior to the publication of the Women's Health Initiative (WHI) study, hormone replacement therapy was the first choice in preventing and reversing osteoporosis. After WHI the bisphosphonates became number one (such as Fosamax, Boniva, Actonel and for those with bone cancers, Zometa). And this is for good reason. These drugs are effective in reducing risks of fracture in well conducted studies.

But long term studies of bisphosphonates have also revealed side-effects which, though only occurring in a small minority of patients, can be serious. These include jaw bone deterioration and ulceration of the esophagus. One comprehensive long term study of over 12,000 women with osteoporosis also showed it would be necessary to treat approximately 66 women to prevent one fracture (1).

Other, though possibly less effective, medications are also available for use if the bisphosphonates are unsuccessful.

But what about hormones? Why did they fall out of favor when they consistently helped prevent fractures?

Well, it was reported they also resulted in increased risks of blood clots, strokes and breast cancer, as was reported in the WHI studies. But a large part of the problem wasn't the hormones -- it was the study itself. There were major flaws in the WHI trials. Such prestigious institutions as the University of Massachusetts Medical Center, journals such as the Annals of the New York Academy of Sciences and even the WHI researchers themselves have criticized almost every aspect of the WHI studies done (2-4).

That certainly let a lot of air out of the balloon. Even so, there still is good evidence that women who use the synthetic hormones do increase their risks of side-effects and adverse events.

The one area which was not criticized, however, was the 30% reduction in all types of fractures and the 40% reduction in hip fractures in particular with the use of HRT (hormone replacement therapy) (5).

But who wants to risk adverse effects if these can be reduced?

Did you notice I wrote synthetic hormones have increased risks associated with their use? Synthetic hormones such as Premarin, Estratest, FemHRT, Prempro and Provera are all molecules which have been altered. They are not found in nature, nor are they made in our body. It is this alteration which most researchers believe accounts for the significant differences causing increased risks and adverse effects experienced with the synthetics in many women.

As it turns out, the risks associated with synthetic hormones are not seen to the same significance with the Bioidentical hormones as shown in a number of excellent studies.

Bioidentical hormones are the exact hormones which our bodies produce. To the last atom, they are identical in every way to that which nature gives us.

Bioidentical hormones have a much different -- and safer profile. This evidence comes for example, from studies which have looked at the risks of breast cancer with synthetic HRT to the significantly reduced risks with bioidentical hormones (6-7).

There is also good evidence that transdermal estrogen (patch or cream applied to the skin) has no increased risk of causing breast cancer or blood clots -- especially potentially fatal blood clots which can travel to the lungs, heart or brain (8-9).

Moreover, comprehensive reviews of the safety and effectiveness of Bioidentical HRT have also concluded that, from all the clinical evidence we have to date, they are an excellent choice for protecting against fractures in women with osteoporosis (10-11).

Bottom Line: Bioidentical hormone replacement therapy for women is a valid and viable option for protecting against osteoporotic fractures. There will always be a need for further studies to add to our knowledge, but the track record to date is excellent. They must be used by a knowledgeable practitioner, accompanied by periodic testing and all preventive medicine care. I appease my obsessive need to keep patients safe by tracking these things rather closely. And any hormone therapy should always be used at the lowest effective dose, using estrogen and progesterone together. This combination of the bioidenticals offers the best benefit and protection against problems.

In my clinical practice -- over 15 years of experience in the use of Bioidentical hormone replacement therapy -- I regularly see that we not only halt, but we reverse osteoporosis. For women, I require annual gynecological evaluations, mammograms and pelvic ultrasound as well as periodic lab testing to ensure we are achieving optimal ranges of therapy. Bone mineral density evaluation is also periodically required as appropriate.

Most importantly, you want to know you are in safe hands while benefiting from all the positives of this exceptional therapy. Therapy should be individualized and tailored to the specifics of each patient's needs and risk profile.

Well, that's great for women. But what about men and testosterone replacement for bone health? Which would also be terrific for the libido in older guys.

Except for one big problem. Doesn't testosterone cause prostate cancer? So for all the good it does, aren't men just helping one part and hurting another? Bummer. What's a guy to do?

Testosterone, Osteoporosis and the Risk of Prostate Cancer

In a comprehensive review of the subject, we see not only an increase in bone density, but significantly fewer fractures in older men with osteoporosis who are treated with testosterone replacement therapy. Moreover, this can be done with no evidence of any increased risk of prostate cancer (12).

Did we hear this right? No increased risk?

Well, quoting these authors:

"So far, there is no compelling evidence that testosterone has a causative role in prostate cancer."

And this review echoes literally a multitude of studies which have concluded exactly the same findings over the last 20 years. Testosterone replacement therapy does not increase a man's risk of prostate cancer.

Bottom Line: All men over the age of 50 should be screened for the possibility of bone loss with blood tests as well as bone mineral density testing where appropriate. Testosterone replacement therapy should be considered as first line therapy for men with bone loss or osteoporosis along with regular follow-up testing for optimal levels and a physical exam. Prostate health should be followed, these studies notwithstanding.

Moreover, men with a history of prostate cancer are not necessarily excluded from receiving testosterone therapy. In my practice, I work closely with prostate oncologists to carefully select and follow these individuals while they receive testosterone replacement.

Sweet. So now, what's the story on weight, obesity and osteo?

Obesity

There are many potential causes for osteopenia and osteoporosis. This is not one of them. Despite the fact that there are a host of diseases which anyone with obesity is at increased risk for -- such as hypertension, diabetes, high cholesterol and coronary heart disease, there are no studies which show that obesity will increase anyone's risk of developing osteoporosis. But, of course, there is a catch.

Obesity is also associated with an increased risk of falls. And even though the bone mineral density of many obese individuals is normal, there is an increased risk of fractures of the forearm, legs and spine. You heard it right. You can have a normal bone density and no osteoporosis and still have a significantly higher risk of breaking a bone if you are obese. This does not seem to be true for hip fractures, however, where there seems to be no increased risk with obesity (13 - 16).

What seems to be most likely is that the protective effect of increased body size is due to the amount of muscle we have on our bodies -- not just how obese we are. This lean tissue as it is called seems to be the most important factor in obese people which protects against fractures (17).

Bottom Line: If you are obese, start or continue working out to build muscle. Obesity will not cause osteoporosis. But it will increase your risk of breaking a bone whether or not your bone density is normal.

Remember: Osteoporosis is a reversible disease. And so is your risk of fractures due to obesity.

In our next and final installment on osteoporosis, we'll take a closer look at why I think my bones are better than my vegetarian buddy Jason's; the mineral Strontium; Vitamin K; fish oils (for stronger bones?); and the good, the bad and the surprising side of alcohol. Stay tuned!

Joseph Sciabbarrasi, M.D., has practiced Integrative Medicine in West Los Angeles since 1993. In addition to his work with Osteoporosis, Bioidentical hormone replacement therapy, Cardiovascular and Chelation therapies, he also lectures, writes and celebrates his weekends with his wife, Kathleen and their 8 year old son, Kieran. Join him at his website: www.drjosephmd.com

References

1. Wells GA, et al. Alendronate for the primary and secondary prevention of osteoporotic fractures in postmenopausal women. Cochrane Database Syst Rev. 2008 Jan 23;(1):CD001155.

2. Klaiber EL, et al. A critique of the Women's Health Initiative hormone therapy study. Fertil Steril. 2005 Dec;84(6):1589-601.

3. Mastorakos G, et al. Pitfalls of the WHIs: Women's Health Initiative. Ann N Y Acad Sci. 2006 Dec;1092:331-40.

4. Manson JE, et al. Estrogen therapy and coronary-artery calcification. N Engl J Med. 2007 Jun 21;356(25):2591-602.

5. Anderson GL, et al. Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: the Women's Health Initiative randomized controlled trial. JAMA. 2004 Apr 14;291(14):1701-12.

6. Fournier A, et al. Unequal risks for breast cancer associated with different hormone replacement therapies: results from the E3N cohort study. Breast Cancer Res Treat. 2008 Jan;107(1):103-11. Epub 2007 Feb 27.

7. Fournier A, et al. Breast cancer risk in relation to different types of hormone replacement therapy in the E3N-EPIC cohort. Int J Cancer. 2005 Apr 10;114(3):448-54.

8. Opatrny L, et al. Hormone replacement therapy use and variations in the risk of breast cancer. BJOG. 2008 Jan;115(2):169-75; discussion 175.

9. Canonico M, et al. Hormone therapy and venous thromboembolism among postmenopausal women: impact of the route of estrogen administration and progestogens: the ESTHER study. Circulation. 2007 Feb 20;115(7):840-5.

10. Moskowitz D. A comprehensive review of the safety and efficacy of bioidentical hormones for the management of menopause and related health risks. Altern Med Rev. 2006 Sep;11(3):208-23.

11. Holtorf K. The bioidentical hormone debate: are bioidentical hormones (estradiol, estriol, and progesterone) safer or more efficacious than commonly used synthetic versions in hormone replacement therapy? Postgrad Med. 2009 Jan;121(1):73-85.

12. Bassil N, et al. The benefits and risks of testosterone replacement therapy: a review. Ther Clin Risk Manag. 2009 Jun;5(3):427-48. Epub 2009 Jun 22.

13. Premaor MO, et al. Obesity and Fractures in Postmenopausal Women. J Bone Miner Res. 2009 Oct 12.

14. Pirro M, et al. High weight or body mass index increase the risk of vertebral fractures in postmenopausal osteoporotic women. J Bone Miner Metab. 2009 Jul 4.

15. El Maghraoui A, et al. Body mass index and gynecological factors as determinants of bone mass in healthy Moroccan women. Maturitas. 2007 Apr 20;56(4):375-82. Epub 2006 Nov 28.

16. Barrera G, et al. A high body mass index protects against femoral neck osteoporosis in healthy elderly subjects. Nutrition. 2004 Sep;20(9):769-71.

17. Travison TG, et al. The relationship between body composition and bone mineral content: threshold effects in a racially and ethnically diverse group of men. Osteoporos Int. 2008 Jan;19(1):29-38. Epub 2007 Jul 28.

 

Comments

[jmontgomey rph]

As a pharmacist I thank you for posting this article and starting the conversation about the many choices available for the treatment and prevention of osteoporosis. Since the advent of direct to consumer marketing- advertisements bombard us daily about Boniva and other bisphosphonates as the wonder drugs for osteoporosis. Yet, as you mentioned in your article they appear to have little benefit when you take into account how many people must take them to prevent just 1 fracture. Their relatively low effectiveness combined with the growing awareness of severe side effects in small numbers of patients should lead us to seek additional alternatives to prevent and treat osteoporosis. Bio-identical hormones can be an excellent choice and I am continually baffled at the confusion and mis-information surrounding them. I find one of the most difficult pills to swallow, at least for many of us, is the realization that usually medicine alone is not enough- we still need to make essential lifestyle changes particularly as we age.
If anyone is interested a free report on osteoporosis and the drug industry is available here: http://www.aheadofthecurveatmidlife.com/

[sfharper]

Thanks for sharing this important message. I'm on HRT and my doctor insisted to go without meant osteoporosis. I thought it pretty awful that they just quit studying HRT instead of making revision to the tests that could provide menopausal and post-menopausal women advice.
:)

[KuanShiYin]

What about Forteo? Do you know of any adverse long-term effects associated with teriparatide injections?

[Eleka bobV]

Thanks for this article

[simplify]

What I thought would be mentioned here would be the devastating effect of a diet of dairy and animal protein based diet.
For example milk's main selling point is calcium, and milk-drinking is touted for building strong bones in children and preventing osteoporosis in older persons. However, clinical research shows that dairy products have little or no benefit for bones. A 2005 review published in Pediatrics showed that milk consumption does not improve bone integrity in children. Similarly, the Harvard Nurses’ Health Study, which followed more than 72,000 women for 18 years, showed no protective effect of increased milk consumption on fracture risk. While calcium is important for bone health, studies show that increasing consumption beyond approximately 600 mg per day—amounts that are easily achieved without dairy products or calcium supplements—does not improve bone integrity.

[Caru]

Oh your one of those.

[NoSillyName]

Doctor, you mentioned Estratest. I understand that Estrace is bioidentical. Is it the testosterone in Estratest that changes its status?

Personally, I would rather use compounded hormones, but if Estrace is affordable and the others are not, if that an acceptable option, in your opinion?

[demockracy]

As a person close to someone diagnosed with osteoporosis, I've done a little research. IMHO, the definitive word is in "The China Study" by Colin Campbell -- the Columbia biochemist who discovered aflatoxin, and was commissioned to produce the largest study of the correlation between diet and health ever done (commissioned by Chou En Lai as he was dying of cancer, as it happens).

Campbell notes that animal protein, in particular dairy, is behind many modern, Western diseases. Given agribusiness's massive marketing campaign to the contrary, that sounds backwards, since dairy has lots of calcium, but the net calcium absorbed is really what matters. Dairy acidifies the blood, which leaches calcium from the bones as the body tries to buffer the lower blood pH. All these "medications" (really scams run by big PhRMA) are futile if you don't change your diet.

So get soy milk (or rice milk).

See http://www.drmcdougall.com/med_hot_osteoporosis.html for more.

[NoSillyName]

Beware of soy products processed with HEXANE, a byproduct of gasoline production.

http://www.cornucopia.org/2009/05/soy-report-and-scorecard/#more-1375

It seems more & more that we should just give up eating entirely!!

[ctblue]

See the film Food, Inc. You will never want to eat again!

[simplify]

Thanks

[FaaLaveLave]

I am on a regimin of natural hormones (for two years). Testerone, estrogen and progesterone IM every ten days and have had improving Dexa scans for the past two years. I was at fracture level and had to do something. Had taken Fosamax and then Premarin with essentially no improvement.
The regimen that I am on is widely used in Europe, Canada and Australia. The FDA won't recognize it. I believe it is because the hormones that I use are all natural and will not produce huge cash flows for Pharma. They are generic and cannot be patented.

[phall]

Thanks, Doc. I've been on BHRT for 5 years - and a recent bone density scan showed I have the bones of a 35-year old. I'm 54 - with a history of osteoporosis in my family.

[oxygen]

The active component of marijuana, Delta(9)-tetrahydrocannabinol, activates the CB1 and CB2 cannabinoid receptors, thus mimicking the action of endogenous cannabinoids. CB1 is predominantly neuronal and mediates the cannabinoid psychotropic effects. CB2 is predominantly expressed in peripheral tissues, mainly in pathological conditions. So far the main endocannabinoids, anandamide and 2-arachidonoylglycerol, have been found in bone at 'brain' levels. The CB1 receptor is present mainly in skeletal sympathetic nerve terminals, thus regulating the adrenergic tonic restrain of bone formation. CB2 is expressed in osteoblasts and osteoclasts, stimulates bone formation, and inhibits bone resorption. Because low bone mass is the only spontaneous phenotype so far reported in CB2 mutant mice, it appears that the main physiologic involvement of CB2 is associated with maintaining bone remodeling at balance,______ thus protecting the skeleton against age-related bone loss. ______Indeed, in humans, polymorphisms in CNR2, the gene encoding CB2, are strongly associated with postmenopausal osteoporosis. Preclinical studies have shown that a synthetic CB2-specific agonist rescues ovariectomy-induced bone loss. Taken together, the reports on cannabinoid receptors in mice and humans pave the way for the development of 1) diagnostic measures to identify osteoporosis-susceptible polymorphisms in CNR2, and 2) cannabinoid drugs to combat osteoporosis.

PMID: 19634029 [PubMed - as supplied by publisher]

[NoSillyName]

and I still have osteopenia.after enjoying cannabis since the 1960s.

[oxygen]

and what they won't tell you - simply go to pubmed and type in cannbnoids and __ this and just about any other ailment and you will see your own government in the united states does not want you to know this information, your own government took out a patent on them in order to keep people from having them - and many are NON psychoactive yet protect and basically cure many many diseases but alas that would bring down health costs and really, despite all you hear, it's all about making money and who's going to get it

doctors do not want you to know how to stay well unless you pay them alot of money or are related to them and why this long article, with all it's references, makes never a mention of the beneficial uses of cannabis - not even the non psychoactive forms of it - not even for this disease

here I'll make it easy for you http://www.ncbi.nlm.nih.gov/pubmed/19634029?itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum&ordinalpos=2

[MicheleCA]

The article, and others like it, are on the National Institutes of Health site because the medical community is interested in the possible therapeutic properties of cannabinoids. The purpose of all these studies is to find beneficial uses. They are discussed, not hidden.

There wouldn't be more medical dispensaries in Los Angeles than Starbucks, unless the medical community recognized benefit. Albeit stoners and profit seem to factor in.

[MicheleCA]

((2))

Since the release in 2002 of a Women's Health Initiative report, hormone replacement therapy (HRT) -- used to relieve symptoms of menopause -- has generated worrisome, and sometimes conflicting, headlines. While linked to a reduced risk of colon cancer and fractures, the therapy has also been associated with an increased risk of breast cancer, stroke, blood clots and heart attack. And -- so far, at least -- there are no indications that HRT has any effect on the development of dementia.

http://www.washingtonpost.com/wp-dyn/content/article/2009/01/30/AR2009013001237.html

[MicheleCA]

((1))
The Truth About 'Bio-identical' Hormone Therapy

By Amanda Gardner
Friday, January 30, 2009

They're marketed as "bio-identical" hormones or "bio-identical hormone replacement therapy," and they claim to do everything from helping menopausal women lose weight to preventing senility.

They're touted as safer and sometimes even more effective than conventional hormone-replacement therapy.

But the U.S. Food and Drug Administration warns that these claims are "unproven" and that the products are "potentially dangerous." What's more, bio-identical hormone replacement therapy -- or "BHRT" -- is a "marketing term not recognized by FDA," the agency said.

Experts also are expressing some concerns about the products.

"We don't know anything [about these products]," said Dr. Suzanne Steinbaum, director of Women and Heart Disease at Lenox Hill Hospital in New York City. "This isn't FDA-approved. It's the same thing as a hormone.

And the Endocrine Society issued this position statement back in October 2006, expressing concerns about these products: " 'Bioidentical hormones,' particularly estrogen and progesterone, have been promoted as safer and more effective alternatives to more traditional hormone therapies, often by people outside of the medical community. In fact, little or no scientific and medical evidence exists to support such claims... Additionally, many 'bioidentical hormone' formulations are not subject to FDA oversight and can be inconsistent in dose and purity."

[NoSillyName]

I don't trust the FDA; they've sold out.

I've been on at least two drugs that were recalled: Bextra and Vioxx. A drug for IBS with constipation killed a few women. Many drugs are given a pass without enough study. It is all too frequent that another one is in the news for fatal side effects or other serious problems.

The compounded hormone products are United States Pharmacopeia verified, not mixed up by some crazy pharmacist. http://www.usp.org/

I find it hard to believe that an OK from the FDA means as much now as it once might have.

[FaaLaveLave]

The FDA is a joke. They are literally "owned" by the huge Pharma. Do as you see fit but the FDA approval is nothing to base your health on.

[MicheleCA]

I share your feelings about the FDA. I won't take any newer drugs. I call the manufacturers to see where a drug is made. And I avoid medication in general as much as possible.

I think the point that needs to be made is that because these hormones are not from a drug company, it doesn't mean they are safe.

HRT has health risks.

I winced when I watched Suzanne Somers, with her breast cancer history, touting this on Oprah.

HRT is not a preferred treatment choice for osteoporosis by the International Osteoporosis Foundation.

http://www.iofbonehealth.org/health-professionals/about-osteoporosis/treatment/hrt.html

[RevRayGreen]

Cannabis is proven to reduce osteoporosis in the elderly. It is preventive medicine for anyone 40+..

[oxygen]

Thomas Szasz said "freedom is what everybody wants for themselves but what few want for others" ... I would add healthcare and honest health care information and access to something many people used to and should be able to - grow in their own garden

would legalizing this one plant nationwide immediately "cure" the healthcare "debate" $$$ of course!

[harhar2]

Thank you for writing this article.. A few years ago I was in full blown menopause, and my test results showed that I had osteopenia which is pre-osteoporosis. Since I'd done a lot of research on menopause before I had my hormones tested by my doctor, when he wanted to put me on Prempro for menopause I refused, and then I asked him if I could try bio identical hormones. Long story short– My doctor then faxed my test results to a compounding pharmacy, and I have been on bios ever since. My bones have strengthened significantly and I'm in excellent health. Of course I maintain a healthy diet and life style, and exercise regularly too. I've never had another hot flash after being on these hormones either. Whew! Whew!

[kkdc]

Interesting new study on what kinds of weight bearing and resistance exercise help prevent osteoporosis. They tested mice. It turns out that jumping, even jumping up and down in place is good for bone, and balance. They started out with something like 40 jumps a day, and maintenance was no more than 20 jumps a week.

Sounds like jump rope could qualify as a preventive:)

[mkie]

The jumping induce vibration that effect in bone rebuilding. That exactly what I pointed in my post below about NASA research to treat Osteoporosis using vibration.
They are some vibrating plates on the market that some can stand on them every day for 10 minutes. It prove to be very effective.
It look like nature salve the bone structure repair mechanism really long time ego, may be we should follow what nature telling us