Osteoporosis, osteopenia screening and prevention are best done when we're older

September 21, 2008

Susan Brink, Los Angeles Times Staff Writer

'Fight bone loss now' was a mantra in the '90s. But osteoporosis knowledge has evolved.

JUST A few years back, it was heresy to suggest that, when it comes to protecting bones, early treatment may not be the answer.

It was no longer sufficient to get enough calcium and vitamin D and do weight-bearing exercise. Suddenly, there were drugs available, Fosamax being the first in 1995 of a class called bisphosphonates, that could put that lost bone density back, help prevent painful, even deadly, fractures and reduce the number of women going through old age with crooked backs.

A combination of new technology and clever marketing was pushing fear of fractures from geriatric reality to midlife worry. Meanwhile, women were hit with a new word, osteopenia, which sounds like a fearsome disease. The pre-osteoporosis, non-disease condition, named by the World Health Organization in 1992, has a broad enough definition to include about half of all women over 50. "The average bone density for a 60-year-old Caucasian woman would put her in osteopenia," says Dennis Black, an epidemiologist at UC San Francisco who studies the effectiveness of osteoporosis treatments.

Confused about what the new label actually meant, young, healthy women suddenly seemed more worried about their bones than did their mothers and grandmothers -- who really had something to worry about. "Women don't understand what their risk is, one way or the other," says Dr. Ethel Siris, director of the Toni Stabile Osteoporosis Center of Columbia University Medical Center in New York.

Things have changed.

Studies have shown that most women will lose no more than 7% of their bone mass within the decade after menopause. Bisphosphonates have been shown to replace about 8% of bone within five years, so waiting will cost most women nothing. Counter to just about every other preventive healthcare message out there, when it comes to osteoporosis drugs, it's probably better to hold off. "Wait until the risk gets high enough," says Dr. Bruce Ettinger, adjunct clinical investigator at Kaiser Permanente, Northern California.

Even the drug marketers seem to be getting more realistic. "If you look at the TV ads, it's no longer the 45- or 50-year-old who's just finished her workout," says Ettinger. "It's a 65-year-old doing some stretching or gardening."

The current recommendation is that most healthy women get checked for bone loss with a bone-density test at age 65, not the minute they hit menopause, according to the U.S. Preventive Services Task Force. Those with risk factors, such as a family history of the disease, a fracture of their own, smoking, heavy alcohol use or a history of taking corticosteroids, should get a bone-density test around age 60, the 2002 recommendation said. And men should be tested at 70.

A drug's effect

This dramatic shift from early prevention to later prevention is an attempt to save healthy women from decades of pill popping to prevent a disease many may well never have. Like all drugs, these have side effects that can include upper gastrointestinal irritation, ulcers of the esophagus, upset stomach, bone pain and skin rash. But what has many people concerned is that the long-term effects are unknown. One sign of potential trouble is that dentists are seeing more jaw disease among women taking bisphosphonates.

Women, meanwhile, are still confused by the original messages. "Women in their 50s and 60s have grown up in a major transition time in terms of osteoporosis," says Ettinger. "They heard that when you hit 50, you lose bone and you won't get it back. Fosamax was promoting this whole thing, and most of the ob-gyns were on the bandwagon."

The drug arrived on the scene just as the baby-boom generation of women was about to reach a biological turning point, determined to head off the natural decline that comes with aging. Fosamax was the first bisphosphonate approved by the Food and Drug Administration for treatment and prevention of osteoporosis. And it promised to not only stall bone deterioration, but to actually replace bone that was already lost. Women looking no more than 45 years old began warning, through the television screen, "Don't wait for a fracture."

The message was aimed at viewers who probably didn't need the drug. In fact, in 1997 and 2001 letters to Merck & Co., maker of Fosamax, the FDA warned the company, which then changed its promotional language, that its ads were misleading and that its website overstated the benefits of the drug, while understating the risks. The criticism has been unfair, says Ronald Rogers, a Merck spokesman. In an e-mail message, he said, "Merck has consistently marketed Fosamax in accordance with its FDA approved label."

As the risks of drugs became better known, doctors and researchers came to more thoroughly assess the significance of osteopenia -- that new classification that is not a disease. Although women with the condition may be at higher risk than average, the label comes from the world of statistics. At an international conference on osteoporosis in 1992, experts agreed that "normal" bone mass was represented by the average 30-year-old woman, the age of peak bone mass. Below that level, regardless of her age and on a statistical sliding scale, a woman potentially entered a bone danger zone. Using that formula, a 70-year-old woman is measured against the healthy bone mass of a woman four decades her junior. The World Health Organization, at that same 1992 meeting, calculated what are called T-scores and determined that if a woman's score is negative 1 or higher, her bone mass is normal. The closer the negative number is to zero, the healthier the bone. If the T-score is negative 2.5 or lower, she has osteoporosis. And in between those two negative numbers, it's called osteopenia, an indication that bone mass is below the statistical norm, possibly putting the person at increased risk of a future fracture.

By that definition, about a third of women 50 to 64 have osteopenia, as do about two-thirds of those 65 and older, according to an analysis in the November/December 2007 journal Health Affairs.

Osteopenia, by definition for post-menopausal women, is just another word for normal.