I am 74 years old and have never taken hormone therapy. My doctor put me on Fosamax last year, and since I can’t actually see any results, I would like to know your opinion of the effectiveness of this drug for strengthening bones. My doctor feels it is safe and effective. I am not currently taking any other medications. I would value your opinion, because no one else seems to have heard of Fosamax.
Osteoporosis is notoriously difficult to treat as it generally produces no symptoms until fractures of bones occur. Likewise, effective treatment isn’t always detectable, because strengthening the bones through treatment does not make someone necessarily feel better. It is a silent disease, not unlike hypertension in that respect. Because of this, it is often difficult to diagnose, and difficult to convince someone that they should take expensive medicine that often has side effects.
To begin to understand osteoporosis, it is important to be aware of a few facts about bone metabolism. The bone in the body is constantly undergoing remodeling — that is, being absorbed and reformed. Both of these processes are influenced by complex factors including race, family history, age, sex, nutritional factors (primarily calcium and vitamin D intake), hormonal factors, smoking and alcohol intake, level of weight-bearing exercise, and other diseases that a person may have.
Osteoporosis is generally assumed to be a disease only of women, but actually about 20 percent of people with the condition are men. Men tend to get it at a later age, perhaps because they do not suffer the abrupt loss of sex hormones that women have during menopause, and because men generally enter old age with a larger bone mass than women. However, everyone loses osteoblasts (the cells responsible for building up bone during the remodeling process) as they age, and therefore the condition eventually catches up with men.
The nutritional and hormonal factors that contribute to osteoporosis have received a lot af attention in recent years, since they can be modified to prevent or at least moderate the condition. Loss of estrogen in women and testosterone in men definitely accelerates bone loss. Inadequate calcium intake with vitamin D will prevent the bones from reforming strongly during the remodeling process. An excess of thyroid hormone, occurring either because of hyperthyroidism or because of excessive thyroid replacement, as well as an excess of cortisone, will hasten osteoporosis.
If osteoporosis doesn’t cause pain or other symptoms, why are we worried about it and urging women after menopause to take hormone replacement, and drugs like alendronate (Fosamax) with the potential for serious side-effects? Thirty years ago it was considered normal that elderly women lost several inches in height and developed a curvature of the spine. My mother lost at least four inches of height during the final 35 years of her life because no one was aware of the causes of osteoporosis, or of any treatments. During the 1960s and ’70s it was not common to offer women hormone replacement unless they suffered from severe hot flashes, which my mother did not have.
Now we realize that the bone loss of osteoporosis causes the vertebrae of the back to collapse, often causing severe back pain, and that it makes someone very susceptible to fractures from falling — particularly wrist and hip fractures. Even with modern orthopedic treatment, the disability and death that can follow a hip fracture are terrible, and prevention of these complications is the reason we have become much more aggressive about treating osteoporosis.
For women around menopause, it is now recommended that treatment to prevent osteoporosis be started with at least 1500 milligrams (mg) of calcium per day along with 800 units of vitamin D, together with estrogen replacement. (Estrogen and progesterone must be given if the woman has not had a hysterectomy.) Raloxiphene, a new estrogen-like drug, can be used if someone is unwilling to take estrogen, although it may not be as effective in preventing osteoporosis. Smoking and excessive alcohol intake must be stopped, and weight-bearing exercise encouraged. If one is taking thyroid hormone, the dose must be carefully watched. Fosamax, which inhibits the osteoclasts which absorb bone during the remodeling process, should be considered if a woman has osteoporosis and is unwilling or unable to take estrogen, or if the disease is progressing despite other treatments.
The only way to determine if treatment is helping the bones is to measure the bone density. Most experts would certainly advise doing this before starting Fosamax and would monitor the effectiveness of the drug by repeating the density measurement periodically. We don’t know if that is being done for today’s writer. It also is unclear if she is taking calcium and vitamin D. If she is not, she should be. The use of estrogen in someone 75 years old who has never taken it is more controversial. The studies showing a beneficial effect of estrogen involved mostly younger women. I would probably not push her to take estrogen, although I would be quite tempted to suggest that she take raloxiphene, admittedly without good evidence for its effectiveness at her age. I certainly would urge her not to simply stop the Fosamax without discussing her questions, and ways to monitor her bone density, with her doctor.