Osteoporosis Prevention & Treatment - Exercise & Estrogen

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EXERCISE, CIGARETTE SMOKING, AND ALCOHOL

MedicineNet: How important are life style modifications in preventing or treating osteoporosis?

Dr. Truong: In addition to good nutrition with adequate calcium and vitamin D intake, regular exercise, stopping smoking, and curtailing alcohol consumption are very important in preventing and treating osteoporosis.

It is known that young men and women who exercise regularly generally develop stronger bones with higher bone density than those who lead sedentary lives. After 35 years of age, men and women start to lose bone. Adequate nutrition and regular weight-bearing exercise can slow this age-related bone loss.

Furthermore, regular weight-bearing exercises have been shown to increase bone density in both premenopausal and postmenopausal women. Regular exercise means exercising at least 30 minutes three to four times per week. Long term commitment to regular exercise is important, as the benefits of exercise on the bone are quickly lost once the person stops exercising.

The best exercises for the bones are weight-bearing exercises (exercising aga

inst gravity). Examples of weight- bearing exercises include walking, jogging, dancing, stair climbing, hiking, low impact aerobics, tennis, etc. On the other hand, swimming and stretching are not weight bearing exercises that may not have the same beneficial effect on the bones as weight-bearing exercises.

Prudent exercise is important to avoid injury to already weakened bones. In patients over 40 and in those with conditions such as heart disease, obesity, diabetes mellitus, high blood pressure, types and levels of exercise should be prescribed and monitored by their doctors.

Finally, extreme levels of exercise (such as marathon running) may not be healthy for the bones. Marathon running in young women that leads to weight loss and loss of menstrual periods can actually cause osteoporosis.

MedicineNet:Tell us more about other life style issues such as smoking, alcohol, and caffeine.

Dr. Truong: Smoking one pack of cigarettes per day throughout adult life can itself lead to loss of 5% to 10% of bone mass. Smoking cigarettes decreases estrogen levels and can lead to bone loss in women before menopause. Smoking cigarettes can also lead to earlier menopause and increase the risk of osteoporosis. Smoking cigarettes can also negate the protective effect of estrogen replacement therapy on bone in postmenopausal women. Therefore, nobody should smoke, regardless of the current condition of their bones.

Data on the effect of regular consumption of alcohol and

.medicinenet.com/caffeine/article.htm" rel="sub" onclick="wmdTrack('embd-lnk');">caffeine on osteoporosis is not as clear as with exercise and cigarettes. More than two drinks of alcohol a day may increase bone loss. More than 2 cups of coffee daily can also cause bone loss. These effects do not seem to be as powerful as other factors. Nevertheless, moderation of both alcohol and caffeine is prudent.

ESTROGEN REPLACEMENT THERAPY

MedicineNet:Who should receive estrogen replacement therapy? What are the benefits and risks of estrogen replacement therapy?

Dr. Truong: As women enter menopause, the normal estrogen production by the ovaries decreases. Lower estrogen blood levels leads to accelerated bone loss and osteoporosis. This process occurs right after the onset of menopause and lasts for about 10 years. The bone loss can vary from less than 1% per year to above 5% per year, with an average of 2% per year. Estrogen replacement therapy (ERT) has been shown to prevent bone loss, increase bone mass, and prevent bone fractures. It is useful in both preventing osteoporosis in postmenopausal women and in treating women who already have developed osteoporosis.

Most hormone specialists (endocrinologists) now believe the benefits of ERT in postmenopausal women outweigh the risks, and are recommending ERT to postmenopausal women who do not have risk factors of taking long term estrogen.

MedicineNet:What are the other benefits of estrogen replacement?

Dr. Truong: The benefits of estrogen replacement include:

  1. Relief of menopausal symptoms of hot flushes, emotional irritability, and dryness and tenderness of the vagina.
  2. Reduction of risk of heart attack by lowering blood levels of LDL cholesterol (the "bad" cholesterol) and increasing the blood levels of HDL cholesterol (the "good" cholesterol).
  3. Increasing bone density in postmenopausal women and reducing bone fractures, thereby both preventing and treating osteoporosis.
  4. Possibly delaying onset of symptoms of Alzheimer's disease.

MedicineNet: Do you mean that all postmenopausal women are candidates

for estrogen replacement therapy, regardless of whether they are at risk of developing osteoporosis?

Dr. Truong: Yes, the benefits of improving blood fats, preventing heart attacks, and preventing and actually improving osteoporosis makes a strong case for using estrogen replacement for all postmenopausal women who do not have risk factors from long term estrogen. In the United States, ERT is the standard of care for the prevention and treatment of postmenopausal bone loss. This treatment should be considered for all women after menopause unless there are risk factors from long term estrogen.

MedicineNet:Please tell me about the risks of estrogen replacement therapy (ERT).

Dr. Truong: The risks of ERT include:

  1. Estrogen stimulation of the inner lining of the uterus, increasing the risk of cancer of the uterus. This risk of cancer of the uterus can be reduced by simultaneous use of progesterone.
  2. Estrogen stimulation of the breast tissue, increasing the risk of breast cancer. This breast cancer risk is not reduced by progesterone. This risk is significantly increased if there is a family history of breast cancer.
  3. Slight increase in the risk of blood clot formation in the deep veins of the pelvis and the legs (deep vein thrombosis). Blood clots in the deep veins can break off and travel to obstruct the arteries in the lungs (pulmonary embolism). The symptoms of pulmonary embolism include chest pain, shortness of breath, and even life threatening shock.
  4. Rarely estrogen can promote gallstone formation and aggravate existing liver disease.
MedicineNet:Who should not receive ERT?

Dr. Truong: I would not routinely prescribe ERT to the following groups of postmenopausal women:
  1. Post menopausal women with a prior history of estrogen dependent cancer (such as breast).
  2. Postmenopausal women with a strong family history of breast cancer.
  3. Postmenopausal women with a prior history of deep vein thrombosis or pulmonary embolism.
  4. Postmenopausal women with liver disease.
  5. Postmenopausal women with unexplained uterine bleeding.

I am not saying doctors should absolutely withhold ERT from patients who have

higher risks from estrogen. It is important for patients to have a clear understanding of the risks as well as alternative options before making a decision.

MedicineNet:What is your approach to ERT for postmenopausal women in preventing osteoporosis?

Dr. Truong: I will ask my patients to quit smoking cigarettes, exercise regularly, and moderate their alcohol and caffeine consumption. They should have balanced nutrition and adequate calcium intake (and vitamin D in certain individuals).

In postmenopausal women who have had removal of their uterus (hysterectomy), I will prescribe long term estrogen (such as Premarin or Estrace) if they have no risk factors for estrogen.

In postmenopausal women who have an intact uterus, I will add progesterone (such as Provera or Cycrin) to estrogen. Progesterone counteracts the increased risk of cancer of the uterus from long term estrogen. But progesterone has no effect on the risk of breast cancer with long term estrogen.

In postmenopausal women who have had uterine cancer or breast cancer, who have a strong family history of breast cancer, low dose Fosamax (5 mg/day) is a reasonable alternative. In postmenopausal women who are unwilling to take long term estrogen, raloxifene (Evista) or low dose Fosamax are alternatives.

Evista is an alternative that works somewhat like estrogen for the prevention of osteoporosis in postmenopausal women. Evista belongs to a class of new drugs called selective estrogen receptor modulators (SERMs). Evista is selective because it acts like estrogen in certain tissue (strengthens bones) but not like estrogen in other tissues (it does not stimulate the uterus lining like estrogen).

Human studies have shown that daily therapy with Evista increases bone mineral density, lowers serum concentrations of total and low-density lipoprotein (LDL) cholesterol, and does not stimulate the uterus lining. Evista also does not stimulate breast tissue. Preliminary studies indicate Evista may have beneficial effects on the risk of breast cancer, but doctors are waiting for confirmatory longer- term data.

The FDA has approved alendronate (Fosamax) at a dose of 10 mg/day for the treatment of osteoporosis. Recently, the FDA has also approved low dose Fosamax (5 mg/day) for preventing osteoporosis in postmenopausal women.

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Reviewed on 12/11/2006

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