Your doctor breaks the news that you've got osteopenia, an early state of bone loss that he says is often a steppingstone to osteoporosis. He's advising bone-strengthening drugs. Should you take them?
It's a question that a huge swath of American women may eventually face, since according to a 2001 study published in the Journal of the American Medical Association, some 40 percent of those who've hit menopause have the condition. All sorts of doctors, from rheumatologists to gynecologists to internists and geriatricians, diagnose and treat it. But in the absence of clear agreement on how it should be handled or even whether it's a problem worthy of treatment, approaches vary considerably.
Some doctors recommend osteoporosis meds like Fosamax or Boniva or hormone therapy right away, to head off worsening bone loss; others opt to wait and see, prescribing exercise and calcium in the meantime. "I figured there was just a matter of time," says Andrea Goodman, 68, of Englewood, N.J., who was told she had osteopenia at 65 and calls her decision to take Actonel once a month a no-brainer, given her age, the bone thinning in her hip and back, and her mother's osteoporosis.
The skeptical view. But researchers in Spain, Canada, and Australia recently warned that many younger postmenopausal women may be taking drugs they don't need. The medical community doesn't consider osteopenia to be a disease but rather a possible marker of risk for osteoporosis—and degree of risk is a very tough call in the early stages of bone loss. Noting that most studies of the condition have focused on preventing a single vertebral fracture—when two thirds of vertebral fractures are asymptomatic, and long-bone and hip fractures are much more of a concern—the researchers raised an alert that overzealous drug marketing may have resulted in too aggressive treatment of younger women at "relatively low risk of fracture." It's been a puzzle, says Neil Gonter, assistant professor of clinical medicine at Columbia University and a rheumatologist in private practice in New Jersey. "It's entirely possible that we are overtreating this condition. But we may also be undertreating it."
Long-awaited clarity on when to treat may be coming. The World Health Organization has just offered up a tool that predicts both a person's overall risk of a major fracture and of a hip fracture over the next 10 years. By plugging in a variety of risk factors, such as age, bone mineral density test results, family history of osteoporosis, use of oral steroids, whether or not you have rheumatoid arthritis, and whether or not you smoke, a physician will arrive at a score that indicates risk. At the same time, the National Osteoporosis Foundation has revised its treatment guidelines to incorporate the results: Drugs should be considered for postmenopausal women and men ages 50 and older who have a 10-year probability of a major osteoporosis-related fracture of greater than or equal to 20 percent or a 10-year probability of hip fracture of 3 percent or more.
"The guidelines are helpful in really understanding a patient's risk of fracture," Gonter says. Younger patients may see that their risk is lower than they thought, he says. "This becomes more important in the older patients who have minimal osteopenia, yet are at great risk." Robert Lindsay, chief of internal medicine at the Helen Hayes Hospital in New York and one of the authors of the NOF guidelines, says he suspects that the new guidance will mean fewer people with osteopenia will take medications. The organization does advise that postmenopausal women and men ages 50 and older who have had hip and vertebral fractures be considered for drug treatment.
Men, too. For the first time, the National Osteoporosis Foundation guidelines directly advise men, suggesting that all men ages 70 and older have bone mineral density testing. (The same applies to all women ages 65 and older.) Starting at 50, men and postmenopausal women who have other risk factors should be tested. Disagreement about osteopenia doesn't suggest that bone loss is not a serious issue, with aggressive treatment necessary in many cases. But "the big problem is people with true osteoporosis aren't getting treated," says Robert P. Heaney, a Creighton University professor and member of the NOF's Emeritus Board. Someone with osteoporosis can break a bone even without obvious trauma, the NOF treatment guidelines note.
Young, healthy, postmenopausal women whose doctors say they have osteopenia should certainly consider possible side effects before saying yes to drugs. The bisphosphonates (Fosamax, Boniva, Actonel) can cause gastrointestinal illness, and some women taking Evista are at an increased risk of stroke. They might do much better to commit instead to healthful lifestyle changes that include exercising, giving up smoking, choosing a balanced diet, and taking extra calcium and vitamin D. At age 65 or 70, the calculus may shift—so that, as in Goodman's case, medication may seem right.
Updated on 02/27/08: This story has been updated to reflect new guidance from the World Health Organization and the National Osteoporosis Foundation on treating bone loss.