~ You regularly use anticonvulsant medication or benzodiazepines such as diazepam (Valium), chlordiazepoxide (Librium), or lorazepam (Ativan).27 These drugs have been found to interfere with bone metabolism.
~ You’ve had at least two consecutive bone density tests at least six months apart, done on the same machine, that reported scores more than 2.5 standard deviations below normal for your age.
~ You’ve begun to lose height. Be sure to have your doctor or other health care practitioner measure your height regularly. A 2010 study done in Paris on women age sixty and older showed that most of the women did not correctly estimate their current height. Knowing if you’ve lost height, and if so, how much, is vitally important information, the researchers found, because women losing 4 cm or more have a significantly higher risk for vertebral fracture.28
~ You have a thyroid disorder. Women who suffer from hyperthyroidism are at risk because the excess thyroid hormone (thyroxine) that their bodies make stimulates the osteoclasts to break down bone. Those with hypothyroidism may also be at risk if their dose of thyroid medication is too high. If you have thyroid disease, make sure you are on the lowest dose of thyroid replacement possible for your situation, and follow a sound program for maintaining bone health.29 (For a holistic approach to thyroid disease, see The Thyroid Solution: A Mind-Body Program for Beating Depression and Regaining Your Emotional and Physical Health [Ballantine Books, 1999], by Ridha Arem, M.D.)
Whether or not you are at high risk for osteoporosis, understand that, like the rest of your body, bone is a living work in progress. That means that there is always something you can do—ranging from drugs to dietary change—to help yourself build bone.
MEASURING BONE DENSITY
Women with no risk factors for osteoporosis do not need bone density screening. Those that do should get a baseline bone density screening either before or during perimenopause. Though bone density screenings cannot measure the quality of bone, they can measure quantity. And low bone mineral density is statistically associated with an increased fracture risk. Although fractures aren’t likely to show up until a woman is in her seventies and eighties, now is the best time to do something about any potential problems. Unfortunately, many insurance plans won’t pay for bone density screening unless you’ve already had documented osteoporotic fractures. This is typical of the Western crisis approach to medicine, which too often neglects prevention. However, I urge you to make this investment in your health.
Heel Bone Density
Heel bone density testing, with a machine such as an OsteoAnalyzer, is an accurate and cheap method of screening for women of all ages. For example, it is being used to do baseline screening on teenage girls who are at risk for not achieving maximum bone density because of dieting. Heel density tests do not require a doctor’s prescription and may even be offered at your local drugstore. They are not as accurate as a full-scale DEXA test (see below) because they measure only one area of your body. But they are a valuable early warning system.
DEXA Testing
Dual-energy bone densitometry (DEXA) is the current gold standard. It uses a very low dose of X-rays to measure bone density both in the spine and in the hips. A woman’s bone density is then charted on a graph to see how it stacks up against normal bone densities for a given age. The National Osteoporosis Foundation (NOF) and World Health Organization (WHO) both rate bone density according to a standard curve on which 0 equals the norm. Severity of bone loss is then determined by how far a given measurement falls below that mean. As you can see from the chart below, WHO and NOF differ slightly in their classifications of osteopenia and osteoporosis.
Like heel bone density, DEXA is a static test—a snapshot in time. One reading won’t tell you whether your bone density is increasing, decreasing, or remaining the same. You need at least two successive tests at least six months apart to determine what the trend is and whether or not you need to make adjustments in your bone health routine. For example, small-boned women may register on the low end of a DEXA test even if their bones are not at risk.
DEXA testing is available at all major medical centers and in many doctors’ offices. It requires a doctor’s prescription. Because readings vary from machine to machine, try to have your consecutive measurements taken on the same machine.
Skin Thickness Testing
A number of studies have shown that ultrasound measurement of skin thickness (which is dependent upon healthy collagen) predicts fracture risk as accurately as conventional bone density testing.30 The accuracy increases when both skin thickness and bone density are combined. Unfortunately, this test has not caught on widely in the United States. But it’s worth asking your doctor about it; you may be near one of the medical centers that perform it.
Urine Test for Bone Breakdown Products
As bone breaks down, it releases minute collagen fragments into the urine that can be measured. Because a certain amount of bone breakdown is normal, everyone’s urine contains some collagen fragments. But when the breakdown products in the urine skyrocket, you may well be losing bone faster than is healthy.31 Several different types of urine tests, such as Pyrilinks and Osteomark, are available. Unlike the static measurement of the scans, these tests can give you a day-byday reading of the metabolic state of your bones long before a bone density test will register a problem. They also give you a way to monitor your progress once treatment is initiated. Test kits are available without a prescription, and results can be mailed directly to your home. (See Resources.)
The Bottom Line
Bone density screening and urine testing are a marriage made in heaven. A simple bone density assessment (either heel density or fullfledged DEXA test) will give you a baseline if you are at risk. Normally you have to wait six months to a year to know if you are gaining bone, losing bone, or staying the same. But sometimes the subsequent tests continue to read on the low side, even though you have stemmed the bone loss or begun building new bone.32 That’s where the urine test comes in. It can tell you immediately whether or not you are losing bone, and if you are, you can repeat it every month or so to make sure that the bone-building program you’re on is working. Your test will show you when you are no longer peeing out your bones! Once your tests indicate that your bones are stable, I suggest that you retest your urine for bone loss every year or two.
These tests can let midlife women know how they’re doing in time to prevent further bone loss and even increase bone density years before osteoporosis becomes evident. They allow you to create health daily, not wait until symptoms start!
HELGA: Exercise Daily, Bone Loss Daily
Helga first consulted me when she was fifty-seven, five years after her periods had stopped. Active and healthy, she rode horses nearly every day, spent long periods of time outside, and did much of the heavy stable work herself. She had never smoked, and drank only an occasional glass of wine. She wanted to avoid estrogen and wasn’t really having any symptoms that bothered her. She simply wanted to be sure that her overall health was good and that her bones were in good shape.
Helga was blond, blue-eyed, and fair-skinned and had always been trim and small-boned, weighing only 105 pounds at her 5’4" height. When her initial bone density test showed that her bones were a bit more than two standard deviations below the mean, I wasn’t too concerned, given that her slight build, not significant bone loss, was apt to be the reason for this low reading. I put her on a good supplement regimen (see below) and suggested that we repeat her screening test in six months. When that result came back, it was a bit lower than the first time but not significantly so. To be on the safe side, however, I suggested a Pyrilinks urine test. I was very surprised when this test showed that she was losing bone rather quickly.
Given her reluctance to take estrogen or other bone-building medications, I suggested a whole-soy product that delivers 180 mg of soy isoflavones per day, a dose that has definitely been shown to help preserve and build bone density. I also recommended 30 mg of natural proge
sterone per day in the form of a skin cream.
I wondered if Helga’s ongoing bone loss in the face of a healthy lifestyle could be related to depression or some other loss. Helga had emigrated to this country from Sweden when she was thirty years old and married an American with whom she had three children. She and her family had always enjoyed regular visits to Sweden to visit her mother. But her mother had recently died, leaving Helga without any remaining family in Sweden. Her youngest child had also recently left home. I told Helga that our bone health is often at risk during times when the very foundations of our lives undergo dramatic and irrevocable change. Though emotionally stoic by nature, Helga acknowledged that she had been feeling a great deal of grief in the past year.
Though we can never replace our families or go back to “the way it was,” it is possible for all of us to re-create sustaining relationships in our lives. So in addition to adding the soy estrogens and progesterone cream to her regular exercise and supplement program, I suggested to Helga that she seek out some new social ties with other friends of Swedish descent in order to reconnect with her heritage. Within two months, her Pyrilinks tests returned to normal and she stopped losing bone.
LOUISE: Never Too Late
Louise was eighty-six when her son first brought her in for a consultation for osteoporosis. A very slight white woman who weighed no more than 100 pounds, Louise had broken her hip the year before and had twice dislocated the hip replacement that had been inserted. She had been told that she had very severe osteoporosis and her doctors weren’t sure there was much they could do for her. One even suggested putting her in a body cast for six months, which alarmed her (and rightly so—immobilization always causes further deterioration of bone).
Louise was mentally very sharp and, up until the hip fracture, had maintained a very active social life, managed a large stock portfolio, lived alone, and took care of herself. She told me the following: “Back in the early 1990s, I was part of the Women’s Health Initiative study to determine whether or not calcium was necessary for building bone. I recently found out that during all those years I was on placebo, not calcium or vitamin D. I am furious.” Indeed, Louise is the kind of at-risk woman who really needed minerals, an exercise program, and vitamin D. She was afraid it was now too late. I told her that nothing could be further from the truth. I put her on a good supplementation program (see chapter 7), as well as 1,200 mg calcium, 2,000 IU of vitamin D, and 600 mg of magnesium. I also helped Louise find an orthopedic surgeon who would repair her hip properly and not relegate her to life in a wheelchair just because of her age. Louise had the correct surgical procedure and recovered beautifully. Refusing pain medication, she entered a vigorous physical therapy program. Two months after her surgery, a doctor friend came up to her at church and said, “Louise, you might as well give that walker to me because I need it more than you.” The fact is, Louise had been walking around actually carrying her walker in front of her instead of using it. She is now building bone, growing healthy fingernails for the first time in years, and back to her former full social life—as well as driving!
Hormones That Help Build Bone
Supplementing with estrogen (which is far more common than supplementing with DHEA or testosterone) has been shown to help prevent bone loss, but given some of the risks of HT, I recommend vitamin D, minerals, exercise, and—when nothing else works—antiresorptive drugs such as Fosamax as the first line of treatment. But if you’re on HT for other reasons, it’s helping protect your bones as long as you’re on it. In fact, the first FDA-approved indication for estrogen replacement was the prevention of osteoporosis. Some studies have demonstrated a nearly 50 percent decrease in risk of fractures with conventional HT.33 The 2002 WHI study corroborated this data. But that doesn’t mean women need estrogen therapy to maintain healthy bone mass. Those women whose bodies continue to make even a small amount of estradiol or testosterone naturally have been found to have a significantly decreased risk of osteoporosis compared to those whose bodies are no longer able to make these hormones.34
Keep in mind, however, that bone mass is affected by far more than just hormones. For example, it has been demonstrated that onehalf of the total vertebral bone loss that a woman in the United States will experience during her lifetime occurs before she goes through menopause.35 In addition, some studies have failed to find any significant differences between the spine and hip bone densities between pre-and perimenopausal women and their postmenopausal counterparts. For example, research at the USDA Human Nutrition Research Center on Aging failed to show any accelerated rate of bone loss in the hip or wrist among women close to menopause. Nor did they find any significant change in bone mineral density in the group of women as a whole, a finding that has been duplicated in a Swedish study.36 Some authorities even hypothesize that only 10–15 percent of a woman’s skeletal mass is affected by estrogen.37 And some women on estrogen therapy still lose bone mass over time.38 While it is clear that hormones play an important role in bone health, they are just one factor. If you do take estrogen, for example, I recommend taking the lowest dose possible, since bone protection has been demonstrated even at very low doses.
Consider hormone therapy or other bone-building drugs if you’ve had any of the following conditions associated with decreased hormone levels:
~ History of amenorrhea lasting a year or more
~ Premature, surgical, or medical menopause
~ History of steroid use
~ Strong family history of osteoporosis (mother or grandmother with obvious osteoporosis)
~ A diagnosis of osteopenia or osteoporosis
Remember, hormone therapy or bone-building drugs help preserve bone density only as long as you take them. Once you stop, you begin losing bone. The same is true for the effect of exercise on bone.
If you can’t use estrogen or androgen, consider natural progesterone, as either a 2 percent transdermal cream, a prescription pill (Prometrium), or from a formulary pharmacy. Synthetic progestin (medroxyprogesterone, or MPA) has been shown to stimulate osteoblasts (bone builders), and natural progesterone may have the same positive effect on bone density.39 Double-blind, randomized, placebo-controlled studies show that low-dose MPA with estrogen prevents hip and other fractures.40 Further controlled studies show low-dose MPA with lower-than-normal doses of estrogen significantly increases spinal bone density.41
Endocrinologist Jerilynn Prior, M.D., founder and scientific director of the Centre for Menstrual Cycle and Ovulation Research (CeMCOR) in Vancouver, British Columbia, believes progesterone therapy is just as effective as the bisphosphonates, the strongest bone medicines available. (See “What About Bone-Building Drugs?” later in this chapter.) Dr. Prior recommends dosages of either 10 mg per day of synthetic progestin or 300 mg a day of natural progesterone (taken at bedtime because it promotes sleepiness)—enough to get blood levels up at least 18 or ideally 45 nmol/l.42
Calcium Is Only Part of the Story
Doctors have long recommended high-calcium diets and calcium supplements for bone health, based on studies demonstrating that such supplementation helps build bone mass and prevent fractures.43 But other studies now coming out show that the connection isn’t so clear after all. For example, a 2003 study of more than 72,000 women followed by Harvard researchers for eighteen years showed that a high-calcium diet did not reduce fracture risk.44 And a 2007 meta-analysis also done by Harvard researchers following a total of 170,991 women found total calcium intake was not related to risk for hip fracture.45 Some experts don’t find this all that surprising, considering that fracture rates in Africa and Asia are generally 50 to 70 percent lower than they are in the United States, despite the fact that typical African and Asian diets generally include little or no dairy and women in these areas don’t usually take calcium supplements. In fact, the highest fracture rates belong to the most industrially advanced countries, where consumption of dairy products is the highest.
In their book Building Bone Vitality: A Revo
lutionary Diet Plan to Prevent Bone Loss and Reverse Osteoporosis (McGraw-Hill, 2009), Amy Lanou, Ph.D., an assistant professor of health and wellness at the University of North Carolina–Asheville, and medical writer Michael Castleman reviewed 1,200 studies on the dietary risk factors for osteoporosis. Of the 1,200 studies, they further analyzed 136 that specifically looked at dietary calcium’s effect on osteoporotic fracture risk. Two-thirds of these showed that a high calcium intake does not reduce the number of fractures—even in those who took calcium (with vitamin D) during childhood. On the other hand, 85 percent of the studies that looked at the effects on bone density of eating fruits and vegetables showed a positive correlation.
Clearly, calcium is important, but it’s not all we need to be concerned about when it comes to bone health. As Castleman explains in a 2009 article in Natural Solutions, “Think of calcium as the bricks in a brick wall of bones. Bricks are essential, for sure, but without enough mortar—which comes in the form of about 16 other nutrients—the wall can’t hold itself up.”46
Lanou and Castleman found that the key to preventing osteoporosis is more complicated than just making sure you eat one type of food or take a particular supplement. It actually has to do with the effect of your diet on the acidity of your blood—and for bone health, you want to eat a relatively low-acid diet to maintain a slightly alkaline pH level in your blood. Eating animal protein (including meat, poultry, fish, milk, and dairy), grains, and high-glycemic-index foods (refined carbs) makes blood slightly more acidic. The body tries to neutralize the blood’s extra acid content by leaching some of the calcium compounds stored in bone (which are alkaline). Consuming three servings of fruits and vegetables (which make blood more alkaline despite the fact that some of them, such as citrus fruits, taste acidic) neutralizes the acid you’d eat in just one serving of animal protein (roughly the size of a deck of cards), and two servings neutralize the acid you’d eat in one helping of grains. (You might think that eating dairy wouldn’t hurt your calcium balance since you’d be adding and leaching calcium at the same time, but the calcium in animal food sources such as dairy is actually highly acidic, so it still leaches more than it adds.)
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