What are my choices at menopause?

Strategies for women in their 50s

About 15% of postmenopausal women will eventually break their hip, and about 20% will develop fractures of the spine. These fractures usually start to occur about age 70. Ideally, we would like to prevent all these osteoporotic fractures. However, there are problems with all of the medications that are currently available, so prescription medications should be reserved for those women with the highest risk. All women should follow basic prevention recommendations: stop smoking, exercise, eat 1200 to 1500 mg of calcium a day, take vitamin D, and don't diet too much.

How can you tell if you are a woman at high risk? Bone density is one important risk factor. Because bone density naturally decreases with aging, 45% of white women aged 55 have "osteopenia" - but this does not mean they all need drug therapy. Physicians have not reached consensus about when to medicate women, but I think it is reasonable to treat those in the lowest 20% (at age 50, this is a hip T-score of -1.6). At that point, the risk of a future hip fracture is about twice that of a woman with average bone density.

Other risk factors include hip fractures in a close relative, low weight, and smoking. Women who have other medical problems or who take certain medicines may also be at higher risk. If you have had a fragility fracture since age 50 (not caused by a severe accident), you are in a different category and need treatment, not prevention, so the following comments do not apply.

For women who have not had a fracture but who are at high risk, the best choice of medication is not really clear! Recent studies have found problems with hormone replacement, and the other osteoporosis medications are too new to know effects after 20 years. Therefore, the choice must be made on an individual basis. This list gives the current pro's and con's of available treatments, roughly in the order I personally favor. Sometimes the choice will be no prescription medications, just basic prevention and wait until age 65 or later to start medications.

• Estrogens
  Bones are really sensitive to estrogen deficiency. Estrogen clearly improves bone density and bone strength and prevents fractures. Estrogen replacement is also the most effective treatment of menopausal symptoms such as hot flashes, sleep disorders and vaginal dryness. Estrogens cause increased risk of blood clots and strokes. When taken with daily or monthly progestins, there is also increased risk of breast cancer and heart disease. The progestins do not improve the bone strength and are not recommended for women who have had a hysterectomy. If you still have a uterus, progestins are needed to protect against uterine cancer. More studies are needed to know the best way to give progestins, but currently we suggest a progesterone IUD. Alternatively, progestins could be given for a week every 4 months.

  Currently many physicians do not recommend estrogen for anything except menopausal symptoms. I no longer start estrogens in women older than 60, but in younger women I think they are a good choice to prevent osteoporosis. Lower doses have fewer side effects and still partly protect the skeleton.

• Raloxifene.
  This medication has been studied for 8 years. It prevents vertebral fractures in women and stabilizes bone density, but has not been shown to improve hip fractures. Women taking raloxifene have 1/2 as many cases of breast cancer, which is a strong advantage to this drug. There is no risk for heart disease. Raloxifene increases the risk of blood clots, similar to estrogen; in rare cases these blood clots can cause strokes. Unfortunately for women in their 50's, this medication makes hot flashes and vaginal dryness worse. If breast cancer is your primary concern, one possible strategy would be to use the estrogens without progestins for about 5 years and then switch to raloxifene.

• Calcitonin nasal spray.
  This is the safest medicine that has benefits to the bones. Studies show some reduction in vertebral fractures (not as much as with the other treatments above). This might be a good choice for somebody with only moderate risk or somebody who has side effects with the other medications. There are no known serious side effects.

• Bisphosphonates such as alendronate, risedronate or ibandronate.
  These medications are heavily promoted by drug companies for prevention of osteoporosis, and many physicians prescribe them. They improve the bone density of women in their 50's (not better than estrogen, however) and prevent fractures in women who already have osteoporosis. They have not been studied for long-term prevention. The drugs deposit in the skeleton for many years, depressing the bone resorption rate as well as the bone formation rate. The bisphosphonates seem safe enough for the first 10 years, but there are theoretical reasons why these drugs might not prevent fractures 20 years into the future: the bones could become brittle with long-term accumulation. I generally do not use bisphosphonates in women unless they have osteoporosis or serious risk factors.

• Thiazide diuretics.
  These have been ignored by most physicians who make recommendations about osteoporosis prevention, even though observational studies show a significant reduction in hip fractures, clinical trials show a significant (although small) stabilization of bone density compared to placebo, and millions of people have taken this drug with relatively minor side effects. It certainly is inexpensive at less than a penny a day - this is precisely why pharmaceutical companies are not interested in conducting expensive clinical trials that are needed before general recommendations can be made.

• No prescription medication.
  This will avoid all side effects from medications, but calcium, exercise, and vitamins are not enough to stop the relentless bone loss that occurs at the time of menopause. Microscopic bone structure is damaged when estrogen levels decrease. Women with plenty of bone to spare can wait until they are older before they need any treatment. We really need more research studies to find out the best ways to prevent bone loss, especially for women with bone density in the lowest 20%.

Susan Ott, M.D.
2/7/07