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Osteopenia and Osteoporosis, Part 2

Last week in Part 1 we wrote an overview of osteoporosis and osteopenia. I couldn’t help but note that most US physicians can date their knowledge of both diagnosis and treatment to the saturation marketing of Big Pharma’s variety of osteoporosis medications, most notably the bisphosphonates (Fosamax, Boniva, Reclast).

As we all get older, our bones become more porous and more susceptible to fracture. Women’s bone health is closely tied to estrogen levels, so as you cross into menopause and your estrogen levels drop, osteopenia (low bone density) can be followed by osteoporosis (brittle bones and higher fracture risk).

As noted in Part 1, smaller, lighter women are at greater risk. Ethnicity matters too. White and Asian women have the highest risk while women of color generally have lower rates of osteoporosis because their estrogen stays at higher levels over the course of their lives.

The official recommendation of the US Preventive Services Task Force is for osteoporosis screening using a DEXA (dual energy x-ray absorptiometry) scan to start at age 65. You should have one earlier if you have elevated risk, including having a family member who has osteoporosis and/or who has broken a bone because if it. Your risk is also elevated if you’ve been a long-term user of corticosteroid drugs and/or if you have a history of fractures.

Osteopenia itself is generally not treated with prescription meds. However, if you receive a diagnosis of osteopenia, regard it as a bone health call to action.

Bone-building approaches
Important factors that can change your risks considerably include calcium intake, vitamin D levels, menstrual history (irregular periods, light periods, and difficulty with fertility all point to low estrogen and increased risks), medication history, nutritional supplements, frequency of weight-bearing exercise, and whether or not you’re being treated for a condition (such as breast cancer or autoimmune disease) that includes sex hormones or cortisone as part of the treatment.

In addition, read about the new test that measures bone metabolism (click here to read more), the rate at which you’re building up and breaking down bone. This test, originally developed at the University of Chicago, is now offered through Genova Labs.

For maximum usefulness, get your sex hormone levels tested as well. These tests are not used for diagnosing either osteoporosis or osteopenia (you still need a bone density test for that), but can give you a ballpark look at the risks ahead. Health insurance often covers them.

What if I’m at high risk?
If your DEXA scan shows significant osteoporosis and a high risk for fracture over the next decade, your doctor will likely recommend that you take one of the bisphosphonate drugs. I’m not thrilled with these meds.

Before moving to drugs you can try the following:
Add nutritional supplements. See below for specifics.
Increase the amount of weight-bearing exercise you do regularly. Click here for some examples. Also consider a supervised, heavier-weight lifting program based on the results of this study.
Look into estrogen replacement. Some good studies are appearing that show low-dose estrogen can treat osteoporosis.
Eat an anti-inflammatory diet. Click here for details.

I’ve been following unenthusiastically other Big Pharma meds for osteoporosis, including teriparatide (Forteo, side effect bone cancer—Tymlos works the same way) and calcitonin nasal spray (Miacalcin, side effects headache, back pain, sores in nostrils) and am unimpressed.

More on bisphosphonates
By far the most widely used prescription meds for osteoporosis are the bisphosphonates, taken as weekly tablets (Fosamax, Actonel), monthly tablets (Boniva), or annual intravenous infusions (Reclast).

On the plus side, current studies show that you need take these for just three to five years, depending on the severity of your osteoporosis when you start. However, while the bisphosphonates made it through the FDA approval process because of a (relatively) low incidence of side effects and a measurable improvement in bone density tests, the drugs are not squeaky clean.

They work by disrupting the normal bone-building process. In the absence of these drugs, your old bone cells are cleared away (by osteoclasts) while new bone is built (by osteoblasts). Bisphosphonates turn off the osteoclasts and as a result your body manufactures a more dense but actually weaker bone.

The irony here is that while the bone is technically denser, it’s actually more prone to fracture.

Side effects can be grim. The most recently publicized is osteonecrosis of the jaw (bone breakdown and infection) to the extent that the bisphosphonates now come with an FDA black box warning.

Moreover, when you take a tablet version, you need to be upright for a half an hour to avoid ulcers on your esophagus, and yes, chronic esophageal irritation does cause a higher risk of esophageal cancer among bisphosphonate users.

The third serious side effect involves your heart. The abnormal heart rhythm atrial fibrillation has been a known side effect of the bisphosphonates for the past ten years, but Big Pharma researchers keep reassuring doctors not to stop the med, that a hip fracture is more dangerous than an abnormal heart rhythm. Since undiagnosed atrial fibrillation is a leading cause of stroke, and most people who have atrial fib are unaware of it, I’m inclined to disagree with Big Pharma here.

So, you might ask if I prescribe bisphosphonates. The answer is yes, but only to a carefully selected group of patients, namely those with definite osteoporosis on a DEXA scan to which I’ve added an assessment of other factors listed here (nutritional supplements, exercise routine, vitamin D levels, and bone turnover rate).

Next steps
The bone supplement I’ve been recommending for years is OsteoPrime Forte (by Integrative Therapeutics), two capsules twice daily.

This product was formulated by Alan Gaby, MD, author of Preventing and Reversing Osteoporosis. Dr. Gaby spent years researching osteoporosis and bone health and found there was a lot more to healthy bones than just taking calcium.

However, it’s important to recognize that food sources of calcium (dark green veggies, bony fish, click here for a complete list) are better absorbed than tablets. Build your meals around these foods.

Get your vitamin D level measured and aim for 50-70 by adding daily D if needed. While sunshine is helpful in boosting vitamin D levels, most of the year we don’t have any sun, so you’ll probably need to take additional D.

Also consider collagen. Although bone broth is quite low in calcium, it’s does contain some collagen.  Click here for more foods involved in collagen production.

Be well,
David Edelberg, MD

Leave a Comment


  1. Joan Levin says:

    Please warn people that if their osteoporosis advances to the point where they wish to try the more heavy duty drugs, and if they decide on Prolia (Amgen’s monoclonal antibody) to retard bone breakdown, that under no circumstances should they DELAY their regular 6 month shot without a backup plan. There is newer literature suggesting that even a relatively short delay in receiving these injections can lead to painful, debilitating vertebral compression fractures. Both Amgen and the FDA have been informed of this, and there is published literature pointing to this as well, but to date nothing has been done to add the words “delay” or “brief delay” to the professional labeling or patient information.

    I was horribly affected by this and have met others — mainly postmenopausal women on Prolia, who had no idea about this so since neither the manufacturer (Amgen) nor the FDA seem to be doing so, I am doing my best to get the word out.

    Briefly it is an account about how, after many years of doing the very things you recommend, my normally active life ended because of something that could most likely have been avoided with adequate labeling of Prolia. It has been six months and I still have not been able to resume many normal activities and I am in pain much of the time.

    I would like to help others avoid similar unnecessary disasters!

  2. Joan Levin says:

    I should add relative to the above, that in my case the DELAY in receiving my shot on time was due to the DOCTOR’S inability to keep the scheduled appointment! But neither the doctor nor the medical center where the doctor worked indicated that I should come in anyway even if the doctor was not there to receive the injection on time. This suggests that even the medical community is not aware of the dangers of a delay!

  3. Dr E says:

    Hi Joan
    Thanks for this. I had not read about this and it;s quite frightening

  4. Lynnie says:

    Thank you so much for these rich, resourceful articles about osteopenia and osteoporosis. I am 63 years old, and have osteoporosis in my hips and osteopenia in my spine. A question: what are your thoughts about taking strontium citrate? I am currently taking 500 mg of this first thing in the morning, and waiting at least an hour before eating, and 2 hours before taking 750 mg of calcium hydroxyapatite and my other supplements. Do you recommend a particular brand of DHEA 5 mg supplement, as well? Thank you!

  5. Dr E says:

    This sounds like a good addition for healthy bones! We use Integrative Therapeutics DHEA

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