Midlife: What to do when bones start to thin
By Amanda Leigh MascarelliAs we age, our bones become thinner and more porous. No one disputes that.
For the first four decades of life, men and women’s bones undergo a continual renewal, shedding collagen and then rebuilding through mineralization — a process that plateaus in midlife for both men and women. But whereas men’s bone density typically declines gradually over their lifetimes, bone loss accelerates rapidly for women during menopause because of the lack of estrogen.
Severe thinning of the bones, or osteoporosis (Greek for “porous bones”), can lead to an increased risk of bone fracture. No one disputes that either.
To help determine whether a person is at risk for osteoporosis, doctors often rely heavily on a test called a T-score. That’s where the “what to do about it” complexity begins.
Whether or not one chooses to treat osteopenia (defined as lower-than-normal bone density and often considered a precursor to osteoporosis) comes down to a judgment call and a weighing of the risks of treatment versus the risks of waiting to see what happens.
A woman’s bone density is compared against “normal,” or the typical bone density of Caucasian women ages 20 to 29. If a patient’s bone density is equal to the norm, her score would be zero; if someone has extremely thin bones, her score might be -3. But because bone loss occurs naturally with age, many older women automatically fall into the negative range.
Here’s where it gets complicated. The World Health Organization defines osteoporosis as a bone-mineral density (T-score) of lower than -2.5 and osteopenia as a T-score of between -1 and -2.5. But in 2003, the National Osteoporosis Foundation and American College of Obstetrics-Gynecology changed their guidelines, recommending that women with T-scores lower than -2.0 be treated for osteoporosis, rather than the existing threshold of -2.5.
Under this new definition, 6.7 million American women were instantly “diagnosed” with osteoporosis and would be recommended for treatment — with costs of at least $28 billion, according to a 2007 study. Using the -2.0 threshold, more than half of Americans ages 65 and older are labeled as having osteoporosis.
Some experts believe that the label of osteopenia itself is overly broad and misleading. “Osteopenia is normal,” says Dr. Nortin Hadler, a rheumatologist at the University of North Carolina and author of “Worried Sick: A Prescription for Health in an Overtreated America.” “It’s like gray hair.”
“If you look at the way we define osteopenia, it’s defined very crudely with very low sensitivity,” he says. “So almost everyone who is osteopenic is not in the group who’s going to get fragility fractures. They’re just in a greater risk group.”
The drugs used to treat osteopenia and osteoporosis, called bisphosphonates (such as Boniva, promoted by Sally Field), aim to increase mineralization of the bone. But the treatments themselves can cause problems. In some women, bisphosphonates can cause ulcers in the esophagus or lead to bone necrosis, or bone death.
Dr. Alexander Fishberg, medical director at the Center for Family Medicine at Florida Hospital, acknowledges that some physicians have fallen into the trap of treating osteopenia like a disease, rather than an increased risk. “I think some women may get treated where the risk of fracture is very low,” Fishberg says.
But he says that patients shouldn’t shrug off concerns about osteopenia, and he points to evidence that many women in the osteopenia category will get fractures.
Fishberg takes T-scores into consideration but says that the decision of whether to treat osteopenia shouldn’t be based on the score alone. Fishberg relies on the World Health Organization calculator called FRAX, which patients can also use themselves. This tool takes into account a woman’s family history and other risk factors. The discussion between a patient and her doctor should involve factors such as lifestyle, exercise, calcium and vitamin D, he says.
“That’s how I make my decisions,” Fishberg says. “A good old-fashioned discussion with your patient to help form a plan so that both parties agree that the treatment is right for them.”
Ultimately, the decision of whether to be treated for osteopenia must be made by the patient and doctor, he says. “In this day and age, our treatment should be individualized. An individual score does not define the woman.”
