Last week the Food and Drug Administration approved Fosamax, the first non-hormonal treatment of osteoporosis. With other medications on the horizon, an emerging issue is how to make the best use of bone mineral density testing, which can diagnose osteoporosis or even a woman's risk for it. Here, a closer look at osteoporosis.
Most women know that they should have a mammogram and Pap smear at regular intervals.
Considered mainstays of women's health care, the two tests are responsible for saving thousands of lives yearly by detecting breast and cervical cancer when the diseases are most treatable.
Very few women, however, know about a third test--one that could help ensure their physical strength and mobility even at very old ages.
Increasingly, health professionals are recommending that women have a bone mineral density test at regular intervals beginning at menopause to determine if they have osteoporosis or are at risk.
Despite the verifiable value of bone densitometry, it will be an uphill battle to convince women, health insurers and even some doctors of the test's importance, experts predict.
A recent poll of 1,000 women found that 60% were unaware that the bone-weakening disease could be detected with a test, and only 4% were aware of what kind of test was used to diagnose the disease, according to the National Osteoporosis Foundation (NOF).
This level of ignorance is alarming considering that 50% of all U.S. women will have an osteoporosis-related fracture at sometime during life.
"What is frustrating is that bone-density testing is like mammography was 15 to 18 years ago: It took the women to convince the doctors to do mammography. And it's going to take the patient to bring this to the attention of the doctor," says osteoporosis expert Dr. Allan Frankel of Century City Hospital.
Osteoporosis develops when bone mineral is lost at a faster rate than the body produces new bone to take its place. The disease is most common after menopause when women cease to produce estrogen, which helps keep bones strong. The disease also can develop in younger women and in some men.
Until recently only estrogen therapy and the hormone calcitonin were available to treat osteoporosis. But Fosamax is expected to be the first of several new medications that will not only help reduce the risk of fracture in women with the disease but may also prevent it in high-risk women.
"It's fantastic," says Dr. Glenn Braunstein, chairman of the Department of Medicine at Cedars-Sinai Medical Center and chief of a government advisory panel that recently recommended approval of Fosamax. "There has been a tremendous increase in the interest of the pharmaceutical companies, and the Food and Drug Administration is also fast-tracking these drugs."
The question is whether women and their doctors are poised to benefit from these advances, says Dr. Michael Kleerekoper, a Wayne State University bone expert, in a recent issue of the Annals of Internal Medicine. Unfortunately, the vast majority of patients learn they have osteoporosis only after they have suffered a devastating bone fracture. Once a woman fractures her hip or spine, only 20% recover fully.
"Accurate, precise, non-invasive methods of measuring bone mass have been available for almost three decades. Yet, osteoporosis is still most often diagnosed only after the first . . . fracture has occurred," Kleerekoper says.
There are several reasons both women and their doctors have ignored the risk of osteoporosis, experts say. These include:
* The myth that osteoporosis affects only very old women.
* The fear that little can be done to treat it.
* The belief that bone-density testing is too expensive, inconvenient and unlikely to be covered by insurance.
"The awareness among physicians is high but the interest is low," Frankel says. "I hate to say that it's because this is a woman's disease, but I think part of it is that doctors think it's inherently a boring illness."
Women are not much better at making osteoporosis an issue for themselves. Despite the fact that estrogen therapy is a known deterrent of osteoporosis--reducing the risk of fracture by as much as 60% in some studies--only 15% to 25% of post-menopausal women take hormone therapy for a year or longer.
Unless a woman has bone densitometry at menopause, when the decision whether or not to take estrogen is usually made, she may be unaware of her risk for osteoporosis, says Dr. Robert Rude of Orthopaedic Hospital in Los Angeles. In general, the women at highest risk for the disease are white, thin, sedentary, have had a diet low in calcium and have received little exposure to sunlight, Cedars-Sinai's Braunstein says.
Most women do not realize that after age 35 bone mass declines at a rate of about 1% a year until menopause. The bone-loss rate then increases to about 2% a year, according to the NOF. By 55, the average woman has already lost 30% of bone. Thus, the rate of bone loss--too fast or normal--can be determined at this time, long before so much bone is lost that a woman is in danger of a fracture, Rude says.
Bone-density scans, which are most often taken with a machine called dual energy X-ray absorptiometry (DEXA), provide two measurements. One measurement compares the patient to what is expected for someone her age, sex and size. The other reading compares the patient with the estimated peak bone density of a young adult of the same sex.
"Age 50 is a very reasonable time for women to get their first scan," Frankel says. "But most [bone-scanning centers] are doing only two or three a day when they could be doing 20."
Judith McCalla was eager to undergo bone-density testing. The middle-aged Studio City woman had watched her mother suffer from osteoporosis and knew she was at risk because of her small stature.
"It scared me," says McCalla of her mother's battle with the disease. "She had a curvature of the spine. . . . She couldn't even sleep in bed because it would fracture her vertebrae. She had to sleep in a chair."
McCalla's own test showed mild osteoporosis, but she has plenty of time to do something about that. And she is.
"I took calcium before having bone densitometry, but it was hit-and-miss. I wasn't as serious about taking it as I should have been. But after having bone densitometry, you had better believe I take it. I exercise more and I take better care of myself."
McCalla says she will continue to get a regular bone-density test--which is safe, painless and costs about $185--even though she says her insurance will not cover it. Until recently, insurance companies routinely refused to cover bone densitometry to ascertain the risk of osteoporosis. In California, however, legislation introduced by Assemblywoman Jackie Speier (D-Burlingame) was passed in 1993 prohibiting insurers to refuse reimbursement for scans deemed medically appropriate. Nonetheless, many health professionals report patients still have difficulty obtaining reimbursement for periodic bone scans after the initial one.
Part of the reason insurers have balked at the testing is that there's a lack of established guidelines on who should get bone-density testing, at what age and how often.
"Right now, there aren't steadfast guidelines, but we're working on them," says Audra Singer of the NOF.
But, says Cedars' Braunstein, the nation may be unprepared to provide routine screening for all menopausal women and high-risk individuals. There are only 1,500 of DEXA scanners nationwide, most of them in major academic centers, so they are not easily available to rural areas.
Research is under way to see if a digitized, computerized analysis of hand X-rays can be used to diagnose osteoporosis and the risk of fracture. This kind of test could cost as little as $25, according to one estimate. "That's probably the screening procedure of the future," Braunstein says.
* "Act Against Osteoporosis Education and Awareness Program," a free public forum, will be held Nov. 11 at the Los Angeles Biltmore Hotel. To reserve a seat, send a letter or postcard with your name, address and phone number to National Osteoporosis Foundation, Attn. L.A. Community Program, 1150 17th St. N.W., Suite 500, Washington, D.C. 20036.