?Fight bone loss now? was a mantra in the ?90s. But osteoporosis knowledge… (Pete Saloutos / Corbis )
Just A few years back, it was heresy to suggest that, when it comes to protecting bones, early treatment may not be the answer.
Part of the rite of passage through menopause a decade ago became bone-density screening. Around age 50, many women would position their skeletons under the X-ray eye of new machines that could calibrate the alarming rate at which their bones were being eaten away. On top of that, they began to hear commercials featuring women, often much younger than they, praising a pill for saving them from nursing homes, physical deterioration and crumbling spines.
For The Record
Los Angeles Times Tuesday, September 23, 2008 Home Edition Main News Part A Page 2 National Desk 1 inches; 64 words Type of Material: Correction
Osteoporosis: In Monday's Health section, an article on osteoporosis and drugs known as bisphosphonates incorrectly said that the original treatments required patients to eat before taking the drugs. In fact, originally -- as now -- the daily form of the drugs should be taken on an empty stomach first thing in the morning with a full glass of water -- not juice or coffee.
For The Record
Los Angeles Times Monday, September 29, 2008 Home Edition Health Part F Page 4 Features Desk 2 inches; 68 words Type of Material: Correction
Osteoporosis: A Sept. 22 article on osteoporosis and drugs known as bisphosphonates incorrectly described how the pills should be taken. The article said that, originally, patients had to eat before taking the drugs. In fact, originally -- as now -- the daily form of the drugs should be taken on an empty stomach first thing in the morning with a full glass of water, not juice or coffee.
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."