Women's Health: Osteoporosis, Hormones

The Women's Health Issue

We're dedicating this month's newsletter to bone, hormones, and other issues that mostly concern women. Men, you are on your own until next month. Anyone interested in women's health, read on.

Girls just want to have fun (not fractures)

Who hasn't heard of a grandma who broke her hip and ended up dying of complications — or spending the rest of her life in a wheel chair? Post-menopausal women are vulnerable to bone weakening and fractures. For this reason, physicians routinely order DEXA bone scans to test bone density. The DEXA scan is generally regarded as the most accurate measure of a woman's risk of fracture. From this test, we can tell if a woman has osteoporosis (excessively weak bones) or ostepenia (softening bones but not as bad). The DEXA scan measures, with some error, bone mineral density, but there may be better ways to determine whether a woman is really at risk for fracture.

One patient of Virginia Mason endocrinologist Farideh Eskandari, MD had been on a bisphosphonate (a bone-strengthening drug such as Fosamax) for about ten years. Despite this treatment, her DEXA scan still indicated osteopenia. One day the woman fell down a flight of stairs. She was badly shaken and ended up with bruises but no broken bones. Although she did not fracture anything, the fall worried her and she consulted Dr Eskandari.

Dr Eskandari viewed the fall down the stairs as a "bone stress test" of sorts and reasoned that because the patient had survived with no fractures, her bones were probably stronger than the DEXA scan showed. Since the patient had been on a bisphosphonate for about twice the FDA recommended length of treatment, Dr Eskandari recommended that she discontinue the drug. The patient's primary-care physician — accustomed to doling out formulaic treatment based on the DEXA — resisted. But the patient and her doc came to accept Dr Eskandari's view that DEXA results had to be interpreted in light of real world information. Instead of the drug, she advised the patient to continue taking vitamin D and calcium to keep her bones healthy and strong.

Beyond the DEXA

Since the DEXA can't tell us everything, the World Health Organization (WHO), has developed and made available a fracture risk tool called FRAX. FRAX is a risk model based on population studies. Two women may have the same DEXA score and very different likelihoods of a low-impact fracture because of age, smoking, body mass index, and other factors. The FRAX questionnaire takes this into account and gives you a percent risk of major fracture and hip fracture over the next ten years. This enables you and your physician to make the wisest decision about your bone health.

If you would like to use the FRAX tool, it is available as follows:

Vitamin D for bones

Evidence reported in the Journal of Clinical Endocrinology and Metabolism (1992, 75:176) indicates that as we age, our intestine requires more vitamin D in order to absorb calcium. Without vitamin D, our body must scavenge calcium from the bones. As outlined in our newsletter on bone formation, bone is comprised of a strong protein scaffold that is then hardened with calcium. If you don't have enough vitamin D, however, you make soft bone. We absolutely need vitamin D to get the calcium incorporated into the bone structure.

Medical authorities used to recommend women take 1,000 - 1,500 milligrams of calcium daily to maintain bones. Now they have lowered that to 500 - 700 mg, recognizing that other nutrients (such as vitamins D and K) play a major role in bone formation as well.

You're convinced you need vitamin D, but how much vitamin D is enough? That depends on how much sun and exercise you get. Vitamin D in the diet does not all end up circulating to target tissues. Recent research shows that people of normal weight and higher activity levels have more circulating and available vitamin D than people of less healthy habits. People living in northern climates require 1,000 IU a day of supplemental vitamin D. By the way, Dr Eskandari not only gives vitamin D to her patients, she measures levels while they are taking it to be certain that they are absorbing it. Both men and women need to take supplemental vitamin D, but women need it more.

Vitamin D for everything else

And as long as we are on the subject of vitamin D, surveys show that women with higher levels of vitamin D are less likely to develop endometrial (uterine), skin, and colon cancers. Women with a serum vitamin D level of 52 ng/ml developed breast cancer at half the rate of women with levels under 13.

The number one health threat to both men and women is heart disease. Optimal vitamin D helps us maintain normal blood pressure. Women with higher levels of vitamin D are less likely to die from heart disease.

Finally, women are much more likely than men to suffer from an autoimmune illness, such as hypothyroidism (which is most often due to an autoimmune process), multiple sclerosis, rheumatoid arthritis, fibromyalgia, scleroderma, lupus, and a number of others. Vitamin D helps prevent these illnesses. It regulates the immune system such that it remains alert to fight infection, but does not overreact and destroy normal tissue.

More information on vitamin D

Our previous newsletters on vitamin D are February 2004 and March 2004

Hormone update

There is a long history of misinformation about female hormones. Here are a few updates to set the record straight.

Hormone overload: the Wiley Protocol

In the May Medicine for People!, we did an exposé of alternative medical treatments that are long on hype and short on logic. Recently I became aware of another bone-headed idea that directly affects women.

I learned about the Wiley Protocol when women started coming in for treatment after bad results from trying out this hormone regimen.

T. S. Wiley promotes herself as a "scientist and researcher" in the field of estrogen replacement therapy. She advises estrogen replacement at doses high enough to cause women to begin having menses again. Because so many patients were asking about this, I reviewed her book, Sex, Lies and Menopause. In my opinion, she does not completely understand human endocrine physiology. She uses scientific references in a fraudulent way that misleads the non-scientific reader. She purports to prove that taking high doses of estrogen is safe because she uses "identical-to-natural" estrogen. While "identical-to-natural" estrogen is almost certainly safer than the standard medicine made from horse estrogen, any estrogen, especially at high doses, can lead to blood clots, cancer, heart disease, and other problems.

Wiley is one heck of a convincing writer. However, every one of the women I've seen who followed her protocol said that after a few months she gained weight or fluid or developed malaise and that the claimed benefits did not occur.

So, if you see T.S Wiley coming, run the other way.

Hormone levels

While we are on the subject of hormones, let's talk about testing hormone levels in saliva and blood. Many books and websites recommend such tests, but there are two reasons not to take them. First, the labs available to you may not adhere to the standards you'd expect. See our February 2008 newsletter. Second, the range of hormones in a group of healthy women is pretty wide. Estradiol runs from a peri-ovulatory low of 107 picograms per milliliter to a high of 281. Other forms of estrogen have similarly wide ranges. A woman may, therefore, have a serum level of 120 (considered normal) but be up half the night with sweats. Most likely she was used to having higher levels — but still in the normal range — when she was younger. She will sleep better with estrogen replacement and gain nothing from the lab test but a drop in her checking account balance.

You may have heard of "estrogen receptors". These vary from woman to woman and estrogen secretion varies as well. Cells that are more sensitive to estrogen are going to respond to less of it, so the woman will make less estrogen and have lower levels. Cells that are relatively insensitive to estrogen are not going to respond unless her ovaries make a greater amount of estrogen, and so they will; she will have higher levels. People are different, but the net estrogen effect is similar.

The best barometer of estrogen status is how your body feels. Having hot flashes and night sweats? Chances are you are low. Do your ankles swell and your breasts hurt? Chances are you are high.

We have further information on female hormones on this website — see our hormone replacement article and our July 2002 newsletter.

Will natural hormones be outlawed?

Wyeth Pharmaceuticals, the manufacturer of Premarin, is lobbying the FDA to prevent compounding pharmacists from providing identical-to-natural, non-patented estrogen to their patients. They claim that certain natural hormones, such as estriol, are "unapproved new drugs" and should be prohibited. Wyeth itself actually sells estriol in Europe! The FDA, however, accepts Wyeth's argument and is working to remove these compounded estrogens from the marketplace.

If you would like to express your views to the FDA, you can learn how at HOMECoalition.org.

Cervical cancer can be prevented — free vaccine

Cervical cancer occurs mainly in women who carry the human papilloma virus (HPV), a virus that is spread by sexual intercourse. Not every woman with HPV develops cervical cancer, but infection with high-risk strains of HPV imposes a stress on cells of the cervix. Sometimes this results in cancer. HPV can cause warts in the genital area but more often does not. Most women who carry it do not know they have it, nor do their male partners. A vaccine reduces a woman's risk of catching HPV. The Jefferson County Health Department provides free vaccinations to qualifying women aged 19 to 26, and discounted vaccinations to girls aged 9 to 18. They tell me they would rather administer the vaccine than be overly picky about who qualifies. Call 385-9400 to learn more.

Previous newsletters on women's health issues

Incontinence Prevention: November 2005
Mammograms: April 2005
Estrogen: January 2004
Estrogen: July 2002
Menopause: June 2003