August 2002: Keeping Your Bones Strong


Ask-the-Expert Online Conference

On Wednesday, August 21, 2002, our Ask-the-Expert Online Conference was called Keeping Your Bones StrongCharles L. Shapiro, M.D. and Marisa Weiss, M.D. answered your questions about how to measure the strength of your bones, how to find out your risk for osteoporosis, and what you can do to lower that risk.

What is osteopenia? What can be done?

Question from Ruth: What is osteopenia and what can one do about it?
Answers - Charles Shapiro Osteopenia is a condition of less bone density or bone mass than would be normally expected if you compare a woman to a woman or population of women her age. Osteopenia is the bone loss that, as it continues, can lead to osteoporosis, which is when you've lost so much bone that your risk for fractures is significantly higher.

The symptoms of osteoporosis can be painful skeletal fractures, loss of height, and a higher risk of breaking bones. It's actually a common problem in women, especially those older than 65.
Marisa Weiss, M.D. Dr. Shapiro, can you tell us a little more about how bone builds itself up and keeps itself strong over time.
Charles Shapiro All people, men and women, build bone mass up until age 35, and then bone mass starts declining. There are two kinds of bone loss. There's age-related bone loss, which means after age 35 you can actually lose a little bone each year. And there's also estrogen-related bone loss. Women have a heightened bone loss when they go through menopause, because it turns out that estrogen helps keep bone mass up, and when you transition through menopause, the estrogen levels go down. This situation leads to accelerated bone loss, which is why osteoporosis is a much bigger problem in women than men; although as men age and are living longer, some do experience significant bone loss.

Bone is a very active organ. It might be misleading because it's hard, but the bone is very metabolically active and there's a balance between cells that break down bone and cells that form new bone. Keeping that balance is a very carefully regulated process. In fact, that's one of the problems of space flight without gravity. Gravity influences the bones and mechanical stresses on the bones keep that balance normal. You lose bone in space because you're free from gravity and gravity's effect on the mechanical strength of bone.
Marisa Weiss, M.D. I guess that's why weight-bearing exercise, getting gravity to help you, helps you keep your bones strong.
Charles Shapiro And that's why it's important for the astronauts in Skylab to exercise!

Risk factors for osteoporosis?

Question from Josepha: I have a family history of osteoporosis after menopause, and fully expected to have to deal with it eventually. Does being thrown into menopause with my chemo put me at a greater risk, or an earlier one than I'd have anyway?
Answers - Charles Shapiro Risk factors for osteoporosis include, first of all, family history. If your mother had osteoporosis you're at higher risk for having osteoporosis. Another thing is the timing of menopause. Going through early menopause—whether it's related to chemotherapy or some other problem where women lose their ovaries and become postmenopausal—is a risk factor for osteoporosis. Smoking and drinking alcohol are also well-described risk factors for osteoporosis. Exercise and weight-bearing exercise help to maintain bone strength. Lack of exercise means more risk of bone loss, and having a sedentary lifestyle will only worsen the problem.
Marisa Weiss, M.D. If your mother had osteoporosis and was also a big smoker, for example, then your risk may not be affected by the family history alone. You and your doctor need to consider all these factors together to see if you are at increased risk or not. There have been significant advances in the detection of bone loss, which can help you understand how your own bones are doing.
Charles Shapiro Another risk factor is the lack of calcium and Vitamin D. One thing we failed to mention is all post menopausal women should have supplemental calcium and Vitamin D because you can't take in enough calcium through dietary sources. The recommendation is 1,000 - 1,500 mg of calcium in combination with 400 IU of vitamin D.
Marisa Weiss, M.D. That's a good point. Plus everyone needs at least a little bit of sunshine in order to process the Vitamin D properly. Only rarely is this an issue. Women who cover their bodies completely with cloaks or other long clothing on a regular basis need to be careful to get a little bit of light intermittently in order to metabolize the vitamin D and calcium properly.

How often to have a bone density test?

Question from Lisa: I have been on tamoxifen for 3 years. I was told to take 1500 mg of calcium a day by my oncologist. My primary physician has indicated that this is too much and says that 500 to 1000 mg per day is enough since I eat foods, which contain calcium. What is the best thing? Also, how often should I have a bone density test to assure that I am not at risk?
Answers - Charles Shapiro Tamoxifen by itself has a protective effect on bone density and bone mass. It acts like estrogen in terms of its protective effects on bone loss. Tamoxifen is an anti-estrogen in terms of breast cancer, but it has estrogen action in the bone and that's why it tends to preserve bone mass in postmenopausal women. However, it is not as good as other treatments like bisphosphonates. As for the question about what's the right dose of calcium, I think that's individualized. You should get 1,000 - 1,500 mg; the point is there's no right answer here. You should be aware of the need for supplemental calcium.
Marisa Weiss, M.D. It's also important to know that your body cannot absorb all of that calcium in a short period of time. It can only absorb a little bit at any one time and therefore it is important to take your 1500 mg of calcium in divided doses or in various meals through the day. If you're taking it by pill, usually your body cannot absorb more than 500 mg from any one dose. Most people take it in 2-3 doses per day.
Charles Shapiro As for bone density testing, the standard test for detecting bone loss is a DEXA scan which is an easy test. It takes 15 minutes or so and it gives comparable or less radiation than a chest X-ray. A DEXA scan works by measuring bone mass and comparing that to an age-matched normal population of women, so you know where you stand relative to the norm. For a DEXA scan you usually lie on a sort of table, depending on the machine. It usually takes less than 20 minutes. The monitor moves up and down the body but there's no donut.
Marisa Weiss, M.D. Some doctors have a machine in their office that measures the density of bone. They may ask you to put your hands or your foot or ankle into this machine in order to measure the density. This is not the best way to get a good comprehensive look at the health of your bones. It is important to know that there are different kinds of bone in your body. Your backbone is one type of bone, and your long bones that are in your arms and legs are a different kind of bone. Plus, your hands and your feet take a lot of abuse and the bone strength in those areas may be affected by trauma or varied usage.

The DEXA scan is considered to be the most effective way to measure your bone strength. It measures the thickness of bone throughout the body and it also compares your bone strength to the bone strength of other women who are in your age group. In addition, it creates a standardized report, which goes into your chart and becomes a document that future scans can be compared to. This is useful over time, as your doctor charts your progress from year to year.
Charles Shapiro The recommendation for how often to be tested is once a year.
Marisa Weiss, M.D. But as we said, all of these decisions are very much individualized from one person to another. It may be that you have special circumstances that may make your doctor depart from the standard recommendations.

Multivitamins interfere with calcium absorption?

Question from Sissy: Do some multivitamins interfere with the absorption of calcium?
Answers - Marisa Weiss, M.D. You need vitamin D in order to absorb calcium properly. There are all kinds of vitamin and calcium supplements that are available in one pill. In fact, many of the calcium supplements also include vitamin D. You may need to try various kinds of calcium supplements until you find one or several that you tolerate well.

What is the best type of calcium?

Question from Lucy: What is the best type of calcium? Citrate? Carbonate?
Answers - Marisa Weiss, M.D. Both calcium citrate and calcium carbonate are effective sources of calcium. Which type is best for you is individual. We can provide more information about this when this transcript is posted.
Ronda Gates, M.S., R.Ph. There's no "better" when it comes to calcium supplements. Calcium carbonate is the most popular calcium supplement because it is so inexpensive and it is more concentrated. But now there's a lot of hype out there about calcium carbonate being hard to absorb. In fact, the top US experts in calcium bioavailability say that if taken with meals, both carbonate and citrate are well absorbed. Calcium supplements should be taken twice a day, especially by women who have a dairy-free diet. You can increase calcium absorption by drinking lots of water between meals. (Editor's Note: Information provided by Ronda Gates and Holly McCord.)
Marisa Weiss, M.D. The recommendations for calcium that we are offering tonight are general recommendations. If you have a condition like kidney stones, it's important for you to check with your doctor about supplemental calcium intake before you start taking such pills.

Dairy discouraged for breast cancer?

Question from Elaine: Is dairy recommended for osteoporosis, yet discouraged for women with breast cancer?
Answers - Charles Shapiro Dairy is a good source of calcium but it seems like too much of one thing in most cases doesn't turn out to be good for you.
Marisa Weiss, M.D. There are a number of people who are concerned about the health of dairy products. Their concern comes from the high fat that is in cheese and ice cream and other rich foods. In general, we do believe that a low-fat diet is probably the healthiest diet. This issue is separate from the need to get calcium from the foods that you eat. Dairy products are rich in calcium. You can get fat-free dairy products, like milk, yogurt, and cottage cheese that are all rich in calcium but have no fat. (Other concerns about dairy products, like the hormones that are fed to the cows and the pesticides that may be on the grass that they eat, are also important to consider. That's why many people recommend organic sources of dairy products to avoid these potential substances.)

Natural alternatives for osteoporosis?

Question from Linda: I don't like to take pill supplements or medications, so what "natural" alternatives are there? I've recently been diagnosed with osteoporosis.
Answers - Charles Shapiro This is an excellent time to bring up exercise. Weight-bearing exercise, like walking and jogging, when your bones are bearing the weight of your body, has a positive effect in decreasing bone loss. Resistance exercise, or light weight training, which means lifting light weights, also helps to build bones.
Marisa Weiss, M.D. Avoidance of smoking and drinking is an important way to prevent bone loss. Natural sources of calcium and Vitamin D will also prove useful. If after you have taken all of these measures the osteoporosis persists, you may still need to consider taking a medication that could help build your bone strength up in addition. For women who already have osteoporosis, all of the exercise and dietary factors can help to some extent, but they may not help enough. You need to speak with your doctor about the nature of your osteoporosis and whether or not you already have fractures to get a sense of what your risk is of developing fractures in the future. The good news is that there is a whole choice of medications now available to help women build back bone strength that they may have lost.
Charles Shapiro If despite the lifestyle changes your bone density is such that your doctor has recommended treatment for osteoporosis, there are several options. There are two pills, Fosamax and Actonel, which are both oral medications. Fosamax is in a weekly dose. It used to come in a daily dose, but now it's a weekly dose. Actonel is also taken once a week. These medicines are highly effective, but some people experience upset stomachs when they take them. There's also a new medicine called Zometa that's intravenously administered. It's not widespread in use and not approved for use for postmenopausal osteoporosis, but in a recent study, with one intravenous dose of Zometa per year, women experienced less bone loss. That was in a paper published recently in the New England Journal of Medicine.
Marisa Weiss, M.D. One dose per year?
Charles Shapiro Both one and two doses per year were found to be effective. So stay tuned. You may be hearing more about this drug.
Marisa Weiss, M.D. Many women do find taking Fosamax, for example, a little bit difficult. You have to take it on an empty stomach, first thing in the morning, and you're not supposed to eat anything for half an hour afterwards and you also have to stay upright (don't lie down) for half an hour or so after taking it. It's also important not to take calcium for the first half of the day after your weekly dose of Fosamax.
Charles Shapiro Another option is Miacalcin, a hormone therapy medicine made up of calcitonin, a natural hormone that drives calcium into bone. Miacalcin is intranasal - you spray it in your nose, like allergy medicines—and has a positive effect on osteoporosis and bone loss.
Marisa Weiss, M.D. There are various options that you can consider with your doctor. You may tolerate one better than another. Sometimes women start with one medication; if it works well and you tolerate it well, then you stick with it. Other women who may have some difficulty with one medication may switch over to another. Your doctor will assess your response to any medication that you take, along with the lifestyle changes over time. A DEXA scan is usually repeated about once a year in women who are beyond menopause after breast cancer treatment.

Zometa or Aredia been approved?

Question from Joy2: Has a yearly 15 ml infusion of Zometa or Aredia been approved? Do you know of any ongoing clinical trials for women with a previous history of early-stage breast cancer and osteopenia or osteoporosis?
Answers - Charles Shapiro Zometa is approved for elevated calcium associated with cancer and for people who have cancer involving the bones that's painful. There is an ongoing study for which I'm the principal investigator. We take women over 40 who are about to receive chemotherapy and give them intravenous Zometa either early or later. That is, half the women get early Zometa (what I mean by early is during the chemotherapy) and half get the Zometa one year after the start of chemotherapy. We're measuring two things: bone loss at one year and bone loss at three years, because it's possible that this accelerated bone loss will tail down and you might not have to start the Zometa with the chemotherapy. That's what we're trying to find out in the study. Half the women will get Zometa during their chemotherapy once every 3 months for two years and half the women will get chemotherapy and Zometa starting one year after chemotherapy for 2 years.
Marisa Weiss, M.D. For Dr. Shapiro and me as physicians, this is an exciting time because we are only now beginning to understand the impact of chemotherapy and hormonal therapy on women's general health. Also, we now have some tools, like the medications that we described to you, that we can use to help make a difference. It wasn't all that long ago that we were without effective medications to help women deal with this significant health issue.
Charles Shapiro I might add two points. We worry about osteoporosis from early menopause due to chemotherapy because most people with early-stage breast cancer will be long-term survivors, and that's a positive message. You get a lot of negative messages when first diagnosed, but this is a potential side effect that we can treat. It's important because we expect you to survive breast cancer, and we just want to make sure that as a survivor you're not breaking bones. The second point is all the things we're talking about to prevent osteoporosis—lifestyle changes, not smoking and drinking, exercising, having a good diet—are general recommendations not impacting only osteoporosis but for overall health. We're focusing on osteoporosis in this session, but these recommendations are truly ones that lead to longer and healthier lives.
Marisa Weiss, M.D. I also want to share two practical pieces of information. First, it's important for you to make your house slip proof. You really need to go through your house and make sure there are no loose carpets or things you can trip on and fall down and risk breaking a bone. I have many patients who come to see me all dressed up wearing high-heeled shoes. I usually scold them and tell them to please wear safe shoes where there's good contact between the shoe and the floor. Wear a solid heel rather than a stiletto, and try to wear rubber bottom shoes.

You should also be careful of wide-legged pants because you can trip on them when you are walking. Another thing that I talk to my patients about is maintaining good posture. These days, with all of us working so hard at the computer, reading, and doing other sedentary activities, our shoulders, heads and necks are often in a curled position. It is important to be aware of your posture, straighten your shoulders, and keep your head high and your back straight. Yoga can be very helpful in teaching you how to hold yourself and how to carry yourself and sit in a way that improves your posture. This can make a big difference over time.

Okay to take Fosamax with tamoxifen?

Question from Sue: I am currently taking tamoxifen. Is it OK for me to take weekly Fosamax concurrently? Fosamax causes me to feel ill. I get a "migraine headache." I now take my tamoxifen later in the day and it seems to help.
Answers - Charles Shapiro It's OK to take tamoxifen and Fosamax. However, if you're having side effects from the Fosamax and you really need to be on the Fosamax, then we would suggest discussing this with your doctor.
Marisa Weiss, M.D. I have patients who are on tamoxifen, calcium and Vitamin D. Over time if a DEXA scan shows that significant bone loss persists, then I may add another medication like Fosamax, Actonel, or Miacalcin. Sometimes a woman may need the combination of medications in order to get the best result. It is also true that you may not need the combination of medications indefinitely. If DEXA scans show substantial improvement, you may be able to maintain that bone strength without the full combination.

As you can see, all of these decisions take a lot of careful thought. Work closely with your physician to help guide you through these decisions. If you feel that your current doctor is unfamiliar with early onset of osteoporosis after treatment for breast cancer, try to find another physician with that area of expertise.

Swimming good for building bones?

Question from Gail: Is swimming, as an exercise, good for building bones even though it is not a weight bearing exercise?
Answers - Charles Shapiro Yes. Swimming, even though it's not weight bearing, does create resistance and is an excellent choice of exercise.
Marisa Weiss, M.D. Swimming really helps you maintain your muscle tone and your sense of balance. The stronger you are and the better your sense of balance, the less likely you will be to fall and experience an injury that could be associated with a bone fracture.

Flexion exercises cause fractures with osteoporosis?

Question from Joy2: I think when discussing exercises it's important to state that flexion exercises of the trunk and hip can cause vertebral and hip fractures if you have osteoporosis.
Answers - Charles Shapiro If you have osteoporosis and already have a fracture, then I would consult your physician about the best kind of exercise for you.
Marisa Weiss, M.D. It's important to do these things in moderation. If you're not exercising at all now and you want to start tomorrow, you need to be very careful and gentle on your body. It's also important to learn how to stretch before and after exercise so that you can take the best care of your muscles.

What age for bone loss? Does Evista help?

Question from Suzanne: At what age does a woman usually start losing bone, and does it ever return, say with the help of Evista?
Answers - Charles Shapiro After age 35 when the peak bone mass is reached, all persons, women or men, lose bone, but women have a heightened loss right around the time of menopause because in menopause the estrogen levels are decreasing and estrogen has a protective effect on bone. Raloxifene or Evista is approved for use in postmenopausal osteoporosis, so it's one drug option; however, Evista isn't as effective as Fosamax or some of the other drugs of that class called bisphosphonates.

Urine tests good measure for calcium loss?

Question from Lucy: Are urine tests a good measure for calcium loss?
Answers - Charles Shapiro Urine tests are a good measure for bone turnover. They're very sensitive for bone turnover, but I don't think I mean calcium per se. I'm not aware of the test that measures calcium loss in the urine.
Marisa Weiss, M.D. Some physicians like to get the urine test, which is called the N-Telopeptide. This test looks at the balance of the bone turnover. If the DEXA scan that you get is not giving your doctor a good enough idea of whether the medication is working or not, your doctor may order a urine test to help figure it out. It is an easier and less expensive test to get than the DEXA scan. Some doctors may want to get both the DEXA scan and the urine test. The DEXA scan is usually done once a year. The urine test could be done at the 6-month interval just to get a sense of whether the bone turnover is in proper balance or not in response to the medication and lifestyle regimen that you are pursuing.

Who is best trained to read DEXA scans?

Question from Ann: There are many places to get DEXA scans. In some places the scans are read by radiologists, other places by gynecologists and interns. Who is best trained to read your DEXA scan? There seems to be a lot of competition for our dollars.
Answers - Marisa Weiss, M.D. In general DEXA scans are done within the radiology department. The quick scan of a hand, foot or ankle is the type of test that is often done in a gynecologist's office. In my experience, radiologists and a computerized program that they work with usually interpret and issue a report on the DEXA scan result. Then your doctor takes that information and compares it to the prior DEXA scan result and pulls in other information that may be useful.
Charles Shapiro In each community there's a doctor more experienced with DEXA scans who may serve as the local expert, and women should ask their doctors if they know who the experts are in their area.

Wheelchair exercises for osteoporosis?

Question from April: I am confined to a wheelchair and have advanced osteoporosis, so how can I exercise?
Answers - Charles Shapiro It depends on the impairment. If your legs are impaired, you can exercise your arms. If that's not possible and you can't exercise, then you have to go through treatment other ways, which most commonly would be medication.
Marisa Weiss, M.D. You may need to be creative and your doctor may refer you to a physical therapist who can help you develop an exercise plan that is compatible with the specific reason why you're limited to a wheelchair. I have a number of patients who have been able to do this, to figure out a way to stay in the best condition possible just by being in a wheelchair. One in fact goes to a physical therapist and does exercises on a table several times a week, out of the wheelchair. When you are in bed at night, there may be some physical exercises that may be safe to do with careful medical advice.

Blood pressure medicines cause bone loss?

Question from Betty: Do certain blood pressure medicines contribute to bone density loss?
Answers - Charles Shapiro Thiazide diuretics or certain water pills contribute to bone loss.
Marisa Weiss, M.D. Steroids like Prednisone or Decadron can certainly increase your risk for osteoporosis. If you need to take these medications over a long period of time, osteoporosis is a real issue.
Charles Shapiro Most commonly, severe asthmatics or people with chronic emphysema who are on long-term steroids may have a problem with bone loss.
Marisa Weiss, M.D. Or rheumatoid arthritis.
Charles Shapiro There are other medical conditions that are associated with bone loss, such as a hyperactive thyroid gland.

Can chemotherapy itself cause bone loss?

Question from Binney1: Can chemotherapy itself cause bone loss?
Answers - Charles Shapiro That's a good question. We don't know the answer to that, except to say that women in my study who retained their periods had no significant loss of bone. They had a transient loss of bone related to decreasing estrogen levels, but at one year, they had no significant change in their bone density. However, the women who became postmenopausal experienced a lot of bone loss and it was related to lowered levels of estrogen. So that's a question that remains to be answered. Our study suggested that it was the estrogen and not the chemotherapy itself that was responsible for the bone loss.
Marisa Weiss, M.D. I know that everyone wants to thank you for your original research on this very important question.
Charles Shapiro Thank you.
Marisa Weiss, M.D. You're welcome.

Complete recovery from osteoporosis possible?

Question from Nikole: Has there ever been a case in history where someone was diagnosed with osteoporosis and then had a complete recovery to where the disease was completely gone?
Answers - Charles Shapiro I would think not. The disease can be improved with lifestyle and medication changes, but I would say return to the normal bone density when you've had osteoporosis, severe bone loss, would be unusual.

Soy, isoflavones harmful for ER+?

Question from Ann: We are told to eat soy and isoflavones for our bones. But if you are estrogen-receptor-positive, it is not clear if you should use isoflavones. What are we to do?
Answers - Charles Shapiro That's a good question and one that's very confusing. The bottom line is we don't know whether soy products and isoflavones are harmful when you've had a breast cancer history. So I would say that in the absence of definitive information one way or the other, if you have an osteoporosis problem, I wouldn't choose to treat it with soy products.
Marisa Weiss, M.D. Even for women without breast cancer, it's not clear how effective soy isoflavones are at minimizing bone loss or increasing bone strength. This is an area under study.

Still annual DEXA after normal scan, tamoxifen?

Question from Debi33: If you had a normal DEXA scan and are currently taking tamoxifen, do you still need a yearly DEXA scan?
Answers - Charles Shapiro I would continue to monitor it because it's possible that with age bone loss may increase. So continue to follow the recommendation that's generally applied of yearly bone density scans of postmenopausal women.
Marisa Weiss, M.D. Dr. Shapiro's earlier point is very important to bring up again. That is, that the bone is a very active organ. The strength of your bones is a dynamic state that can change over time, so a one-time test result reflects what's happening only at the particular time that the test is given. Over time, things can stay the same, improve, or worsen. And that is why we do serial tests over time. It's also important to be aware that the recommendation to do annual DEXA scans is one that is made for women with breast cancer who are beyond menopause. This is different from the recommendations that are usually given to postmenopausal women without any history of breast cancer. So, don't be surprised if your primary care doctor says that the general recommendation is to only do a DEXA scan every few years. You then need to say to your doctor that your circumstances require extra attention, in view of your breast cancer history.

Why does smoking affect bone loss?

Question from PatriciaS: We all know that smoking is hazardous to your health. However, why does it tend to make a person more susceptible to osteoporosis? Does it rob the body of calcium?
Answers - Marisa Weiss, M.D. Smoking can affect many ways in which the body functions. Smoking brings no benefit to any organ system. It can affect all the small blood vessels that go into each organ including the bones. Significant smoking has a definite and significant bad effect on bone health. If you are smoking still, try to work closely with your doctor on a smoking cessation program. This could be one of the healthiest changes you can make in your life. Doing it on your own is so difficult. Take advantage of support groups. There are nicotine patches or gum that can help. Some people benefit from medications like Wellbutrin. We cannot overestimate how important this is.

Editor's Note: Wellbutrin (chemical name: bupropion) is known to reduce the effectiveness of tamoxifen. If you are taking tamoxifen, talk to your doctor about alternatives to Wellbutrin. For more information, please visit the Breastcancer.org Tamoxifen page.

Men at risk for osteoporosis? Percentage?

Question from Micky: Are men at risk for osteoporosis? All I ever hear about is women. If so, what percentage of men are at risk?
Answers - Charles Shapiro Men are at risk of osteoporosis because there's age-related bone loss, as opposed to estrogen-related bone loss. The hormonal treatments for prostate cancer are also associated with bone loss. Osteoporosis is a concern particularly for men with prostate cancer, who have emphysema, are on steroids, or have other health-related problems. So men are not spared.

I think that bone loss and osteoporosis are preventable and highly treatable conditions if they're recognized. We have good tools in terms of DEXA scans that can identify those at risk of developing fractures, and we have pretty good medications. Beyond medications, lifestyle changes not only impact on reducing the risk of osteoporosis, but if adopted—I'm talking about exercising, not smoking, not drinking or drinking less—will improve overall health and increase longevity. This is something in every person's control, and we really have to take control of our own health and health maintenance. So when you treat and prevent osteoporosis, many times you're doing things that not only affect the osteoporosis, but affect overall health.
Marisa Weiss, M.D. It's important to work closely with your doctor to coordinate all these efforts and also to learn about new advances as they develop. breastcancer.org features important information like this in our monthly Research News. Stay tuned!
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