Bone Death: What You Should Know About Common Bone Loss Drugs

If you want to keep dancing as you grow old take heed of a recent report from the Journal of Rheumatology. A few weeks ago it published a study that showed a connection between bone death (bone necrosis) and the class of commonly prescribed drugs known as Bisphosphonates (Fosamax, Actonel, Boniva, Skelid, and Didronel). 196 cases of bone death were discovered among 87,837 otherwise healthy men and women using these medications.

This report is the first of its kind to clearly link these drugs to an increase in serious, irreversible bone death. We’re talking here about normal individuals, who took these drugs orally for an average of only two years, not cancer patients or patients taking massive amounts of these medications intravenously (as previously reported). These medications have been in use since 1995, and we are just now beginning to see their long-term adverse effects. What is worse, these drugs stay in the bones for decades and their effects cannot be reversed.

Although such drugs create denser bone, unfortunately they also interfere with normal bone health by preventing new bone from forming. Your bones may look better (denser) on bone density testing, but this does not guarantee strong bones. Why? Because these medications don’t stimulate new bone growth- in fact, they prevent new bone growth. Only new bone is strong and resilient. Old mineralized bone is brittle. So these drugs do only half the job (processing bone breakdown) and interfere with the other very necessary half (building new bone). What you need are hormones, vitamins, minerals, protein, good digestion, and a steady exercise routine to keep your bones strong and to rebuild weak bones.

I recently updated the topic section of my website to include new topics. In the Bone Health Section I discuss how healthy bones grow and how to maintain and improve bone health naturally. Check it out to keep dancing as you age.

Estriol—The FDA Got It Wrong

In January the FDA wrote a letter to 7 compounding pharmacies warning them about making false claims about estriol and other natural forms of bio-identical estrogen. Compounding pharmacies, which are not regulated by the FDA, have been advised to stop compounding estriol. My local paper, the Boston Globe published an article about this. I have submitted the following editorial in response to ensure that women will not be confused or misled by such unfounded accusations.

A recent story regarding “custom menopause drugs” prompted me to attempt to clear up the confusion surrounding the use of estrogen. In my medical practice, I have personally prescribed estriol and compounding hormones to hundreds of women for nearly ten years. Estriol, a form of estrogen that is naturally made by all women, is the predominant form of estrogen produced during pregnancy. There have been hundreds of studies citing the safety and effectiveness of estriol. It has been shown to reduce urinary infections, and other symptoms in menopausal women with fewer side effects than other forms of estrogen. Many believe it may also help prevent breast cancer, as studies have shown that women with breast cancer tend to have deficient levels of estriol, and pregnant women with high levels of estriol have added protection against the disease.

Steven Silverman is simply wrong in suggesting that “there is no scientific evidence that compounded hormones are biologically identical to the hormones produced by the body.” Estriol in compounding creams has the identical chemical structure found naturally in women. It has been a part of the U.S. Pharmacopeia for decades and has been coursing through the veins of all women since we were created. Furthermore, the FDA has no business attempting to regulate what licensed physicians and compounding pharmacists do. This exceeds the bounds of their authority. Perhaps its not surprising that this latest FDA “concern” was prompted by Wyeth Labs, makers of the now largely discredited synthetic hormone, Prempro.

PMS

I have received many emails from women suffering from PMS. So this is for you and the countless others who suffer monthly ups and downs and inside outs. I go into greater detail in my book but here it is in a nutshell.

PMS is very treatable. I like the Chinese take on PMS. It is “stuck liver “ energy or Qi (pronounced “chee”). The liver, is where our hormones get broken down. Understand the liver and you will understand how to feel good. According to Chinese Medicine, anything that helps the liver improves PMS and anything that is bad for the liver worsens it. So, alcohol, dairy and caffeine are not good for PMS. Herbs that help the liver, like milk thistle, the herbal combination lipotropic complex and Chinese blends that move the liver, help PMS very well.

I treat PMS with liver herbs- either Chinese blends or lipotropic complex. Initially, take these herbs 2-3 times each day for the entire month, and as you improve, use them only from the midcycle onward. In addition, stop caffeine (except green tea- which does not stagnate the liver much), alcohol, and dairy. Okay, maybe you can’t stop. Occasional use is fine- but avoiding them really will help.

Chinese medicine also connects emotions to our organs. Guess what emotion is associated with our liver ? The Chinese call it “smoldering anger.” I love that they distinguish between various forms of anger. We women are prone to the smoldering type (men on the other hand are prone to the explosive type). So, in addition to herbs and diet, look at what you hate about your life and try to change it. If you can’t or won’t, try the Chinese herbal formulas, “End Witchiness” (for irritability) or “End Monthly Blues” (for depressive symptoms) . They work well and I think all women should have a bottle of these on hand.

In addition, I divide PMS into 2 parts: Young PMS, and Older PMS.

Young PMS affects women under 35. Most have OK levels of progesterone. So PMS in their case is usually due primarily to “stuck liver.” Sometime there is stress so that their ovulation is off and they may not produce enough progesterone. Sometimes there is a thyroid issue so that progesterone is not being made or not working well. But, because most young PMS is a liver issue, it usually improves with liver herbs, improved diet (less dairy, alcohol and caffeine) and regular exercise (another way to improve liver “flow” according to Chinese sages). So if you are under 35, take herbs, lay low on caffeine and dairy, and exercise. If this isn’t doing it ask your doctor to check a progesterone level and your thyroid function.

Older PMS, affects women over 35. They are most likely in need of better progesterone and estrogen balance. You can have your doctor measure a progesterone level when it is peaking, on days 19 to 21 in your cycle. Your level should be greater than 6ng/ml (your level needs to around 11 to get pregnant). If progesterone is low ask to use bioidentical natural progesterone (on days 15 to 25) or you can try using Vitex, a herb that improves progesterone levels. Liver herbs, diet changes and exercise also help.

If you are having PMS 24/7, before and after your cycle, you are probably low in progesterone and estradiol. So check an estradiol level- it should be greater than 60 pcg/ml. If progesterone and /or estradiol are low- support them with bioidentical hormones. Use Estradiol on days 1 to 25 and add in progesterone on days 15 to 25.

Good luck!

Vitamin D: More Than Bone Heath

Recent studies have established the importance of vitamin D for cancer prevention. It is now clear that all women should have their vitamin D levels monitored for bone health and for cancer prevention. This is especially important for premenopausal women to prevent breast cancer. Here is why:A study of 1180 women (older than 55 years) showed that calcium and 1100 IU/day of vitamin D resulted in higher vitamin D levels and half as many cancers over a 4 year period, compared with women who used placebo (pills without any vitamin D or calcium). (Am J Clin Nut 2007. 85:1586-1591)

A second study was published from data derived from the Women’s Health Initiative. This study showed that vitamin D and calcium supplementation lowered the incidence of breast cancer in premenopausal women. No change was found for the 20,000 postmenopausal women; however, the vitamin D dose was small, only 400 U/day, and these older women were likely deficient at the start of the study. Unfortunately, vitamin D levels were not followed (as they were in the earlier mentioned study) so there is no way to determine if vitamin D deficiency was improved in both groups. (Arch Intern Med, 2007. 167: 1050-1059).

Less than ten years ago vitamin D used to be considered a potentially dangerous vitamin supplement, and recommendations were to use no more than 400 U/day. Research has since shown that an estimated 60% of all women in the United States, regardless of where they live, are deficient in vitamin D, and it can be supplemented safely in 1000- 2000 U/day (many doctors are using much higher doses). Vitamin D is vital to build strong bones and is also important for immune function and cancer prevention.

Ask your doctor for a blood test of your 25 OH D level, and aim for a level of 50 nmol/L. How much vitamin D you take depends on how low your level is. Taking 1,000 U/day will raise your level by 15-25 nmol/L. The best form to take is cholecalciferol, D3 (preferred to ergocalciferol D2). Always take vitamin D with food to improve absorption. If you are taking it and your level is not improving consider taking a pancreatic enzyme (that contains lipase) with your meals. Also remember vitamin D is made from sunlight on our skin- so get 20 to 30 minutes of outdoor sunlight every day if possible.

Minerals and Bones—More Than Just Calcium

Bone is made up of collagen, with minerals to give it strength. If you lack minerals, your bones are more prone to breaking as you age. Now, most everyone knows about the importance of calcium for bone health, but there are many other minerals that should be part of your bone health program. Don’t rely on calcium alone. Here is a list of minerals needed to maintain and restore bone:

  • Calcium needs to be balanced with phosphorous (2:1), so the more phosphorous you eat, the greater your need for calcium. Protein and soda raises your phosphorous, so don’t go overboard with either of these. To improve your bones you will need 1200-1500 mg of calcium each day. The best forms (most easily absorbed by your body) are: calcium citrate, malate, gluconate, lactate, ascorbate, and hydroxy apatite. (Try to avoid carbonate, it is the hardest form to absorb and requires normal stomach acid.) Most people think dairy is the best food source but many other foods have even higher amounts. In addition to cheeses, good food sources are: kelp, kale, turnip greens, dulse, collard greens and almonds.
  • Magnesium is needed to activate vitamin D to build cartilage. Magnesium deficiency is the most common mineral deficiency that I see in my patients; and studies have shown that, if it is low, bones are more prone to break. You lose magnesium with excessive sweating and stress, and deficiency is common in perimenopause and menopause. You should take 300 mg/day. Take more if your RBC (red blood cell) magnesium level is below 4.8 mg/dL. Best forms are glycinate, taurate, and aspartate (citrate is good if you are prone to constipation, it will cause your stool to be looser). Good food sources are kelp (the best food source), whole grains (wheat bran and wheat germ), tofu, legumes, seeds and nuts.
  • Boron prevents calcium wasting, is needed for vitamin D to work, and it improves estrogen and testosterone levels. You need 2 to 3 mg/day. Good food sources are fruits and vegetables. Unfortunately, many soils are boron deficient which may explain why many Americans are boron deficient, despite eating these foods regularly.
  • Zinc enhances the actions of vitamin D and is also needed to make bone. Most American diets are low in zinc. It is best taken in the Zinc picolinate form. You need 15 to 30 mg/day. The absolute best food source is oysters, but other shell fish, pumpkin seeds and ginger root are also good. Although it is in many legumes, nuts and seeds, zinc is not easily absorbed from these plant foods (it binds to fiber compounds).
  • Manganese is needed for bones to incorporate other minerals and to make collagen. You need 15 to 20 mg/day. Good food sources are nuts (especially pecans, almonds, and brazil nuts), whole grains (especially barley, rye, whole wheat, split peas and buckwheat), dried fruits, and green leafy vegetables.
  • Copper prevents bone breakdown. You need 1 to 2 mg/day. (Beware, however, that too much copper can lower your zinc and vice versa). Good food sources are shellfish- particularly oysters, and legumes.
  • Strontium improves bone density. Over time our food has become low in strontium. The recommended dose is 500 mcg/day, but I sometimes use higher doses in patients suffering bone loss who are resistant to treatment.
  • Silicon is the second most abundant element on earth, second to oxygen, but it is not easily absorbed into our bodies. It is needed for healthy skin, ligaments, tendons and bones. Most people need 20 to 40 mg/day. Good food sources are unrefined grains such as brown rice and oatmeal.

Bone Health and Digestion

Over 26 million women have osteopenia, or bone thinning. Another 24 million are estimated to have osteoporosis (a more severe form of bone loss). Most women don’t discover that they have a problem until their bone loss is advanced, and unfortunately most women with osteopenia are simply told “take some calcium” and “do some push-ups”. Now, calcium is great and so are push-ups, but there is so much more that you can do to prevent and reverse bone loss.

Let’s start with your digestion. Your gut, where digestion takes place, is key to good bone health. How? Well, good bones require the right amount of protein and minerals. Protein and minerals come from the foods we eat, so building bone requires a good diet and healthy digestion. You need enough stomach acid (Hydrochloric acid, HCl) and digestive enzymes to digest and absorb your food. In particular, you need protease and HCl to digest protein, and enough lipase to digest and absorb fats. If you have had your gallbladder removed you may even need a bile supplement.

Many vitamins important for bone health are fat-soluble, that is, they require adequate fat digestive enzymes (lipase) to be absorbed by your body. The fat-soluble vitamins are vitamins A, D, E, and K, all important to make bone. Without adequate fat digestion and absorption you can take all the vitamins in the world, but they won’t do you any good, since you may not be able to absorb them.

If you have bone loss that is not improving with optimal hormone support (estrogen, progesterone, testosterone, DHEA, and growth hormone- too much to explain here, see my book) ask your doctor to have your digestion evaluated to make sure you are absorbing fats optimally in your stool. If you are not, then use a digestive enzyme. If you don’t want to be tested, try adding a good pancreatic enzyme that contains lipase and protease and see how that works.

Women and Heart Disease: What’s New?

We women are most likely to die from heart disease. Using natural bioidentical hormones (transdermal estradiol and natural progesterone) in the first 10 years of menopause can reduce that risk.

First some interesting facts, then the updates.

  1. Heart disease is the leading cause of death in women in our country (that’s about 500,000 deaths each year). Every year since 1984 heart disease has claimed the lives of more women than men.
  2. Women are more likely to die from their heart attack than men.
  3. Women tend to have different symptoms of heart attack than men (more jaw pain, neck pain, back pain, fatigue, shortness of breath, anxiety and nausea). In fact 25% of women have no chest pain.
  4. Heart research studies predominantly men.
  5. High LDL (bad cholesterol) levels have never been shown to correlate well with heart disease in normal women. in other words, having a lot of cholesterol doesn’t necessarily indicate that you are at greater risk for heart disease. (Your LDL level is important if you have a history of diabetes, hypertension or prior heart disease).
  6. Important risk factors for women are low HDL (good cholesterol), low estradiol (the active form of estrogen made by our ovaries), and high CRP (cardio- reactive protein, a blood marker of inflammation).

So What’s New?

Still think that hormones are bad for the heart? That’s what the WHI study showed right? Wrong. The WHI study showed that using synthetic hormones in women over the age of 60 did not improve their risks of heart disease and maybe even put them at higher risk for a heart attack. But the story appears to be different for younger women.

Recently there have been some really interesting articles published about the younger women in the WHI study (women 59 years and younger). The take home message is: Hormones used in the first 10 years of menopause appear to reduce heart disease, stroke, bone fractures, and diabetes.

Here are some interesting snippets from recent journal articles:

  1. JAMA reported that women in the WHI study who used estrogen close to menopause (within the first 10 years) had less risk of heart disease than women who didn’t use hormones. This was not shown for stroke, (because hormones used orally cause an increase in clotting which predisposes to stroke, see below).
  2. The New England Journal of Medicine reported that women from the WHI study aged 50 to 59, who used estrogen had less plaque (hardening of the arteries) compared with women of the same age who did not use estrogen.
  3. Circulation published an editorial discussing the very well done French study, (the ESTHER study), which showed that using transdermal bioidentical natural estrogen (estradiol) did not increase clotting, but oral estradiol did. In addition, using natural bioidentical progesterone did not increase clotting but some forms of synthetic progesterone did.

The New England Journal of Medicine recently summarized many new findings from the WHI showing that women under the age of 60 using synthetic estrogen have a lower incidence of death, heart disease, stroke, bone fractures, breast cancer, and new onset of diabetes.

References

  1. Rossouw, JE, et al. Postmenopausal hormone therapy and Risk of Cardiovascular Disease by Age and years since menopause. JAMA 2007;297:1465-1477
  2. Manson, JE, et al., Estrogen Therapy and coronary Artery Calcification. NEJM 356:2591-2602
  3. Manson, JE, et al., Invited commentary: Hormone Therapy and risk of coronary Heart Disease-Why Renew the Focus on the Early Years of Menopause. American J Epidemiology Advance 2007;166: 511-517
  4. Brouwer, MA, et al., Estrogen Therapy and Coronary Artery calcification. NEJM 357:1252-1254.