Osteoporosis: Answers to your questions

Q: What is the difference between a heel scan screening and a more comprehensive bone density test?

A: Bone density tests of the hip and spine can be used to diagnose osteoporosis, determine whether treatment is indicated to prevent fractures and to monitor response to therapy. Hip bone density is the best predictor of fracture risk in women over age 65.

Heel measurements can also predict fracture risk in older women. Unfortunately, heel tests are poor predictors of bone density values in the hip or spine. Up to 1/3 of women with osteoporosis do not have low heel values, and many women with low heel values do not have low bone density in the hip or spine. Because of these differences, we are uncertain how to interpret a heel bone density test. When we are serious about osteoporosis assessment, we must rely on values in the hip or spine.

My mother has severe osteoporosis and is 74 years old. She has tried Fosamax, and also the nasal spray but was unable to tolerate either of these medications. Recently her specialist retired and her new physician put her on PremPro estrogen.. My mother has breast cancer and a family history of other types of cancer. Is Raloxifene a better fit? I realize that Raloxifene does not build bone but it does strengthen it.

A: For women with known osteoporosis, Fosamax and its new cousin Actonel are currently the best treatments to reduce the risk of fracture of the spine and other skeletal sites. Taking the full week’s dose of Fosamax on just one day each week has recently been shown to be as effective as taking the regular daily dose (Schnitzer T, McClung M, Bone HG et al. Therapeutic equivalence of alendronate 70 mg once-weekly and alendronate 10 mg daily in the treatment of osteoporosis. Aging Clin. Exp. Res. Jan. 24, 2000, vol 1, pp 1-12).

This may be useful in women who do not tolerate standard Fosamax therapy. Actonel is often tolerated by women who have difficulty with Fosamax. Evista (Raloxifene) is a good alternative to treat osteoporosis, but has only been shown to decrease spine fractures – not other osteoporotic fractures. The safety or effect of Evista has not been evaluated in women with a previous history of breast cancer. The use of PremPro or other estrogen treatments in women with previous breast cancer remains controversial. My personal preference in cases like this is to explore alternative ways to use Fosamax or Actonel.

Q: Can I get risk assessment and bone testing without a referral from my primary care physician(PCP)?

A: Risk assessment, based on clinical risk factors like age, body size and family history, can be done without a physician referral. For any bone density that uses X-rays (hip, spine, forearm and some heel tests), Oregon law requires a physician’s referral to a licensed center. Heel testing by ultrasound can be done without a referral and is available at various health fairs and some pharmacies (see first question above, about heel tests).

Q: I have heard that weight bearing exercises like walking and weight lifting are good for you and your bones. How do these exercises help prevent osteoporosis?

A: Weight-bearing exercise and weight lifting in adults may slow the natural rate of bone loss or, in some patients, can cause a slight increase in bone density. The combination of exercise and calcium, however, will not prevent bone loss in the first few years after menopause.

For women at high risk for osteoporosis, exercise is not a substitute for drug treatments to prevent fractures. The most important effects of exercise is to increase muscle strength, balance and flexibility in older adults. These effects decrease risk of falling and fractures. The optimal treatment of osteoporosis is a combination of adequate calcium and vitamin D, the use of a drug to increase bone strength and regular exercise to prevent falls and injuries that result in fractures.


Q: What are the forms of "natural’ estrogen and do they get the same results as other options?

A: The real "natural" estrogen is estradiol – the hormone made by the ovary. Estradiol and other prescription forms of estrogens are very effective in preventing bone loss in postmenopausal women. So-called ‘natural’ estrogens or phytoestrogens are derived from plants. Some have weak estrogen-like effects on the skeleton. These agents cannot be recommended as a treatment when osteoporosis is known to exist. There is no good evidence that they prevent bone loss.

These answers reflect the opinions of Dr.McClung, based on knowledge from clinical research studies and his experience in caring for patients with or at risk for osteoporosis. They do not necessarily reflect the policies of Providence Health & Services or Providence Health Plans. The responses are meant to provide information. Specific treatments should be discussed with your health care provider.

Osteoporosis information from Providence