Should bone loss always be treated?

Even as millions of American women go undiagnosed -- and untreated -- for osteoporosis, a serious condition that can lead to devastating fractures, millions of others are trying to prevent broken bones they might never get.

Diagnosed with a milder form of bone loss called osteopenia, which is not truly a disease, they take medication that might not be necessary.

Confusion about what degree of bone loss is a red flag for future broken bones -- and what is simply a sign of normal aging -- has been rampant since the World Health Organization, in 1994, defined osteopenia and osteoporosis as certain ranges of scores on a bone density test.

Some doctors consider this range skewed, labeling too many -- 34 million -- Americans as having osteopenia, and too few -- 10 million -- at risk for the broken bones of osteoporosis. (Osteoporosis is generally considered a disease affecting women, but men can get it too.)

The problem comes from “calling osteopenia a disease when it is not,” said Dr. Robert Neer, director of the Osteoporosis Center at Massachusetts General Hospital. “We are over-treating a large number of healthy women who have a relatively minor risk of fracture and we are ignoring a sizable number of individuals at high risk of fracture,” Neer said.

The term osteopenia has “no medical meaning,” added Dr. Steven Cummings, an epidemiologist at UC San Francisco, who has led a number of large studies on osteoporosis and osteopenia. “I’ve seen patients who come in scared that they will become disabled soon because they have this ‘disease’ called osteopenia, when in fact they are normal for their age.”

Other critics such as Gillian Sanson, a women’s health educator in New Zealand and author of “The Myth of Osteoporosis,” go further. The medical establishment, she said, is “manufacturing patients” by over-emphasizing the normal bone loss that occurs with aging.

In essence, nobody quite knows what, if anything, an older woman whose only sign of potential problems is mild bone loss should do. Should a woman at 50 start taking drugs such as Fosamax, Actonel or Evista to guard against possible fractures in her 80s, when most fractures occur? Or should she wait until her bone tests get worse or there is a very real red flag, like having a fracture triggered by a minor fall?

For the record, the WHO defines osteopenia as a score of minus 1 to minus 2.4 on the DEXA test, or dual energy X-ray absorptiometry. Osteoporosis is defined as a DEXA score of minus 2.5 or worse. Osteopenia can, but does not necessarily, progress to osteoporosis.

Although osteoporosis clearly raises the risk of fractures, many fractures also occur in people without the disease. A 2003 study showed that the proportion of fractures attributable to fragile bones was “modest” -- between 10% and 44%.

“Low bone mineral density does raise the risk of hip fracture, but it’s only one of several factors like bad eyesight, bad coordination, use of Valium or similar drugs, overactive bladder and other conditions that contribute to the falls that can lead to broken bones,” said Dr. Nananda Col, an internist and women’s health expert at Rhode Island Hospital in Providence, R.I.

A finding of mild osteopenia on a bone density test is not, by itself, enough reason to take medications. If there are no other risk factors, even a bone density test score as low as minus 2 “in an otherwise healthy young person may be normal,” said Dr. Eric Orwoll, an osteoporosis specialist at Oregon Health Sciences University in Portland, Ore.

On the other hand, because osteopenia sometimes leads to osteoporosis, many doctors say it’s important to start treatment early to avoid broken bones later in life. Dr. Joel Finkelstein, an osteoporosis specialist at Massachusetts General Hospital, said he sometimes prescribed medication to post-menopausal women with bone density scores of minus 1.5 to minus 2, even if they were in their 50s.

“I do believe in treating a lot of these people to prevent the development of osteoporosis.... I may be more aggressive than some other physicians,” he said.

Dr. Suzanne Jan de Beur, director of endocrinology at the Johns Hopkins Bayview Medical Center, said she prescribed medication to women with scores of minus 1.5 to minus 2 if they had a family history of osteoporosis or other risk factors.

Dr. Joseph L. Melton III, an epidemiologist at the Mayo Clinic in Rochester, Minn., put it this way: Doctors who advise women to ignore osteopenia “are wrong, and people who advise everybody to treat it are wrong. It’s a personal decision based on family history and personal values.”

So, when should a woman be screened for potential bone loss? And how safe are the drugs for long-term use? In 2002, the U.S. Preventive Services Task Force, a panel of independent experts convened by the government’s Agency for Healthcare Research and Quality, concluded that women 65 and older should be screened routinely for osteoporosis. Screening should begin at 60 for women at increased risk, which includes a family history of hip fractures, current smoking, thinness and use of steroids such as prednisone.

As for drug safety, a study published in March 2004 in the New England Journal of Medicine showed that Fosamax (alendronate) appears to be safe for as long as 10 years. But a 1998 study showed that although Fosamax helps prevent fractures in women with osteoporosis, it does not do so in women with osteopenia and no previous fractures.

Fosamax and Actonel can cause small ulcers in the esophagus, or food tube; Evista can cause hot flashes, and in rare cases, blood clots.

There is no evidence that the widespread use of Fosamax and Actonel is causing any problems, said Col of Rhode Island Hospital. But the drugs do get incorporated into bone. “If 10 years down the line, it turns out that something is dangerous, it will be sitting in a lot of people’s bones. The benefits of treatment need to outweigh the risks.”

That applies to another drug too: Forteo, the only medication that actually increases bone growth. However, Forteo carries a special warning because, in rodents, it can trigger bone cancer.

Bottom line? Try to prevent thinning bones in the first place. Do weight-bearing exercise several times a week and walk briskly for 30 minutes a day or more. Get enough calcium -- 1,200 to 1,500 milligrams (but not more) a day, plus 800 international units of vitamin D, from food and, if necessary, supplements. Minimize use of Valium-type drugs. If problems such as an overactive bladder or poor eyesight are raising your risk of falls, get those treated.

And if one doctor recommends drugs on the basis of mild bone loss, consider getting a second opinion. Obviously, no one wants a broken hip. But no one should take any drug for decades without careful thought, either.