Natural Processses May Weaken Older Bones

Osteoporosis develops due to natural processes in the body. Bone is not inert—it is constantly in flux, being broken down by specialized cells called osteoclasts and rebuilt by counterpart cells called osteoblasts. This remodeling process maintains skeletal strength by replacing old bone, but as we age, bone is broken down faster than it is rebuilt. “Postmenopausal women are particularly at risk from this imbalance because menopause causes levels of the hormone estrogen to fall,” Dr. Bloom explains. “Estrogen contributes to bone strength because it stimulates osteoblasts to make new bone.”

Contributing Factors

Other factors also play a part in osteoporosis. For example, we absorb less calcium (a vital ingredient of strong bones) from food as we get older—moreover, the kidneys become less efficient at conserving the calcium we do absorb. With less calcium coming in and more being excreted in urine, the body may tap into the calcium stored in bones. Certain medical conditions (for example, celiac disease and rheumatoid arthritis) may worsen bone loss. So can some drugs, including corticosteroids like prednisone (Rayos®), the breast cancer drugs anastrozole (Arimidex®) and exemestane (Aromasin®), and some epilepsy medications. Long-term use of proton pump inhibitors (PPIs) like omeprazole (Prilosec®), which is used to reduce stomach acid in people with gastroesophageal reflux disease, may contribute to osteoporosis because PPIs impair calcium absorption.

Osteoporosis Screening

The U.S. Preventive Services Task Force recommends women ages 65 and older be screened for osteoporosis. The standard screening approach utilizes dual energy x-ray absorptiometry (DXA). DXA calculates how many grams of calcium and other bone minerals are packed into a segment of bone by measuring how much of the x-ray beam passes through the bone. The spine, hip, and wrist are screened, since these are the areas most likely to be affected by osteoporosis and osteoporotic fractures.

DXA results compare your bone density to that of a healthy 30-year-old adult and give you what is called a “T-score.” A range of –1 and above indicates normal bone density. A score between –1 and –2.5 indicates osteopenia (low bone density), and –2.5 and lower indicates osteoporosis. If your T-score is –2.5 or lower, your doctor likely will recommend osteoporosis medications to slow your bone loss.

A smaller type of bone scanner often is available for public use in pharmacies and can measure peripheral bone density in the finger, wrist, or heel. These scanners don’t provide as accurate a measure of bone density as DXA, but if you use one and get an abnormal result, ask your doctor if you should have a follow-up DXA scan.

Assessing Fracture Risk

Your doctor may input the results of your DXA scan into the FRAX tool to gauge your fracture risk. The tool also can be used to assess whether postmenopausal women younger than age 65 should be screened for osteoporosis. These younger women typically have risk factors for osteoporosis, such as lower body weight (less than 127 pounds), a family history of osteoporosis, sustaining a fracture after age 50, a long-term smoking habit, and excessive alcohol intake. FRAX can be used to determine whether people with osteopenia may benefit from taking osteoporosis medications, too. “Studies have suggested that most fragility fractures occur in people with osteopenia, as opposed to those who meet the criteria for a diagnosis of osteoporosis,” Dr. Bloom says.

FRAX results consist of two percentage scores. One indicates the probability you

will suffer a major osteoporotic fracture within the next 10 years, and the other indicates the probability you will suffer a hip fracture within that same 10-year window. Osteoporosis medications typically are considered if your risk for a major osteoporosis-related fracture is 20 percent or greater or your risk for a hip fracture is 3 percent or greater, regardless of DXA results.

Accuracy Updates

The original version of FRAX (see Resources) relies on age, body mass index (a relation of height to weight) and other well-validated risk factors. However, it doesn’t take into account dose responses for several risk factors (including glucocorticoid use, smoking, and alcohol intake), a person’s recent falls history, or how recently a person suffered a fracture. The updated version of FRAX—called FRAXplus®—which recently became available to clinicians, addresses these shortfalls. It also includes additional variables, including the presence and duration of type 2 diabetes, and your trabecular bone score (TBS), which is calculated during a DXA scan and offers clues about the quality of bone as opposed to its density.

Dr. Bloom says that the additional information should help doctors more accurately predict a person’s risk of osteoporotic fractures within the next decade and tailor treatment decisions and fracture prevention education accordingly. “The risk of a recurrent fragility fracture is particularly high immediately following a fracture, so it is useful to know when a person’s most recent fracture occurred,” she notes. “While FRAX previously assumed a person was taking a moderate dose of oral glucocorticoids, FRAXplus enables doctors to factor in higher doses. Being able to consider type 2 diabetes also is helpful, since the original version of FRAX underestimates fracture risk in people with the condition even though it influences fracture risk.” A low TBS is associated with an increased risk of fracture independent of FRAX and hip bone density, while a history of falls is associated with increased hip and major osteoporotic fracture risk. “The original FRAX tool assumed an average exposure to falls in the last year, but doctors can now adjust this detail to be specific,” Dr. Bloom says.

Communication Gap

A new study has found that although most people with osteoporosis would like information regarding their fracture risk, only half of them receive it. For the study, researchers examined data from 332 postmenopausal women with osteoporosis. Among the participants, 48 percent had a history of fracture and 50 percent were taking osteoporosis medications. The analysis showed that even though 86 percent of the participants indicated that information about fracture risk was of the highest importance, only 56 percent had received information about their fracture risk. Almost all the participants expressed their desire to be informed about the more devastating consequences of fractures and were especially concerned about the risk of being unable to walk, loss of independence, and quality of life.

Presenting FRAX Results

When it came to the way FRAX results were presented, study participants were shown three options. One used verbal information and a number to denote the percentage risk, one used a traffic-light colored graph, and one used an array composed of smiley and sad face icons.

About 60 percent of the participants said they preferred the visual presentation of their fracture risk probability with a traffic-light colored graph, compared with the other options. This option also was most associated with motivating the initiation of medical treatment. “Hearing a number-based risk factor may not be as effective as seeing you are in the red-for-danger zone when it comes to your fracture risk, especially if English isn’t your first language or your numeric literacy isn’t the best,” Dr. Bloom says. “The traffic-light graph also may help people who have not suffered a fracture grasp the significance of their risk—after all, if you have never experienced a fracture, you may find it hard to appreciate how vulnerable you may be to these injuries.” But she adds that doctors need to keep in mind that some people may perceive red differently. “For example, in Japan, the color red is seen as a positive indicator of something good, so older Americans who are of Japanese descent may continue to benefit more from verbal information,” she explains. Another thing to consider is that people with color vision deficiency (also known as color blindness) may need a verbal/number-based explanation of their risk. The most common type of color vision deficiency is not being able to differentiate between red and green.

Shared Decision-Making

One limitation of the study is that at least some of the women who reported never having received fracture risk information from their doctors may have had such a discussion but could not remember it. Even so, previous research has suggested that poor communication between health-care providers and patients may contribute to poor adherence to osteoporosis medications. “These data may help involve people more in decisions over whether to initiate osteoporosis medication, as well as prompt discussions of other strategies that may protect their bone strength and protect against fractures,” Dr. Bloom concludes. Such strategies include consuming plenty of calcium-rich foods (aim to consume about 1,200 milligrams of calcium each day), getting sufficient resistance (strength-based) exercise and weight-bearing exercise (examples of the latter include walking and jogging), and removing tripping hazards in their home.

Resources

The original version of FRAX is available online and is free to use (http://tiny.cc/fraxUS). It is valid only for postmenopausal women ages 40 and older who are not currently taking prescribed osteoporosis medications. FRAXplus is not yet available for free

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A: Both osteopenia and osteoporosis refer to conditions related to a person’s bone mineral density (BMD) and are classified based on degree of severity. Osteopenia is a loss of BMD that often precedes a diagnosis of osteoporosis. Osteopenia is not as severe as osteoporosis, which weakens the bones and increases risks for fractures. Although there is not a true “cure” for these conditions, it is important to understand your own BMD (see Bone Density Scores) and bone health. Take steps to preserve BMD as much as possible utilizing a healthy diet, nutritional support, appropriate weight-bearing exercise, and possible medications. Work with your doctor and registered dietitian to understand your BMD and potential associated risk to ensure development of a regimen to support your bone health.

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A: If you haven’t had a bone density test recently, it’s a good place to start. Testing is recommended for women starting at age 65. This test compares your bone density to the bones of an average healthy young adult. The test result, known as a T-score, can reveal if you have osteoporosis or osteopenia, which is low bone density that’s not as severe as osteoporosis. Your doctor may also use other screening tools, including questionnaires, physical exams, and imaging, to predict your risk of having low bone density or breaking a bone.

There are several preventive measures that may reduce the risk of osteoporosis and its complications. Calcium is essential for maintaining healthy bones. Dairy products, leafy green vegetables, fish with soft bones (like salmon and sardines), and fortified foods are good calcium sources. Vitamin D helps the body absorb calcium. Fatty fish, egg yolks, and fortified foods are good choices. Sunlight also helps the skin produce vitamin D, but the amount produced varies based on geographic location, skin type, and time of year. Weight-bearing exercises like walking, playing pickleball, and dancing, and resistance exercises such as weightlifting with dumbbells or using elastic bands can help maintain bone density, too. As for medications, the choice depends on various factors, including the severity of bone loss, risk of fracture, and potential side effects. The drugs are effective, and some can reduce the risk of fractures by 50% or more. They fall into two basic types: Antiresorptive medications prevent bones from breaking down, and anabolic drugs help build new bone. Most people start with bisphosphonates, which are antiresorptive. Estrogen is also a type of antiresorptive drug, and it can be effective at preventing bone loss in certain conditions, but risks and benefits should be weighed. Anabolic drugs are generally for people who are at the highest risk for fractures. Some of these agents can be taken orally, while others are given as an injection or infusion. Review safety precautions and side effect profiles of different medications before starting treatment. Regular monitoring, including bone density tests and bloodwork, may be needed to assess the effectiveness and tolerance of the medications and to make any needed adjustments.

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Undergoing a dual-energy X-ray absorptiometry—more commonly known as a DXA scan—is the first step to identifying if you are at risk of fracture. “A DXA scan measures bone density of specific areas that are the most common sites of fracture, such as the first four lumbar vertebrae, the femurs (bones that run from your knees to your hips), and the nondominant forearm,” says Dr. Serota.

What Do the Results Mean?

A DXA scan’s result is given as a T-score. “A T-score compares your bone density to a normative database of healthy adult females at peak or ideal bone mass, measured in units of standard deviations,” explains Dr. Serota. A T-score of -1.0 or above is normal bone density. You have low bone density (formerly called osteopenia) if your T-score is between -1.0 and -2.5. Osteoporosis is defined as a T-score of -2.5 or lower. “Severe or established osteoporosis is a T-score of -2.5 or lower accompanied by a history of a low-trauma fracture, which is defined as a fracture caused by a fall from standing height or less,” explains Dr. Serota.

A trabecular bone score (TBS) is a another—newer—parameter that is an indirect indicator of bone microarchitecture. The TBS is generated from a software application that is installed on DXA machines. The program takes the DXA image of the lumbar spine (low back) and creates a grayscale pixel image of the vertebral trabecular bone microstructure. Dr. Serota explains, “Broadly speaking, a TBS is suggestive of bone quality, not simply bone quantity.” TBS is important because about one-half of people who break bones do not have a bone density that is classified as osteoporosis. TBS can help recognize these people and allow for more personalized care to prevent broken bones.

If you think a DXA scan is less important than a mammogram or a colonoscopy, consider this advice from Dr. Serota: “Osteoporosis is a silent thief; it does not cause symptoms or pain until you break a bone. Our skeletal ‘bank account’ is nearly full by age 20, with some consolidation into the early to mid-30s. Everything in life— menopause, illness, lifestyle choices, a nutrient-poor diet—withdraws from this ‘fund.’ The objective is to prevent the first fracture, and a DXA scan helps by showing us how much is in your ‘bank account.’”

Risk Factors

Several underlying medical conditions are associated with low bone density and/or increased fracture risk. Those commonly seen include celiac disease, inflammatory bowel disease, rheumatoid arthritis, anorexia, and hyperparathyroidism.

Lifestyle-related risk factors include smoking and alcohol intake. Dr. Serota notes that drinking cola and caffeinated beverages to excess also may be problematic, as is a diet deficient in protein. Exercise is important, but, Dr. Serota cautions, excessive exercise in the absence of appropriate calories can be harmful to bones.

Who Needs a DXA Scan

A DXA scan is recommended for all women ages 65 and older, but age is not the only factor to consider. “The International Society for Clinical Densitometry also advises DXAs for postmenopausal women younger than age 65 who have risk factors for low bone mass, such as low body weight, prior fracture, high-risk medication use, or a disease or condition associated with bone loss. “If we are expecting a rapid rate of change in bone density, such as in early postmenopause or in the first few years after starting treatment for osteoporosis, we check bone density every year,” says Dr. Serota. Any change in health status, including a new medical condition, weight loss of more than 10 pounds, new medications, and, of course, falls and fractures, may prompt testing at shorter intervals.

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Recent research underlines the fact that older cancer survivors may need to be particularly vigilant about preserving their bone health and avoiding fractures. The findings are important given that the number of cancer survivors living in the United States is increasing. “Quality of life is particularly important for mental well-being if you have overcome cancer,” says Mount Sinai geriatrician Patricia Bloom, MD. “Not only do broken bones impact quality of life—they also are serious injuries that raise an older adult’s risk of disability and death.”

Greater Fracture Risk

For the study (JAMA Oncology, January 2023), researchers analyzed data from 92,431 people, mean age 69. The group included both cancer survivors and older adults without a history of cancer. Just under 13,000 study participants experienced a fragility fracture. “These are defined as fractures that result from low-level trauma, such as a fall from standing height or less,” Dr. Bloom explains. “Fragility fractures typically indicate that some underlying health condition—such as osteoporosis—has weakened the bones.” Compared with people who did not have a history of cancer, cancer survivors who were more recently diagnosed (within five years) with an advanced-stage cancer that had metastasized (spread) to distant sites had the greatest risk of fracture. Cancer survivors who received chemotherapy were more likely to suffer a fracture than survivors who did not—however, people who receive chemotherapy differ from those who don’t, so it’s hard to pin down the role of chemotherapy in increasing fractures.

Bone Renewal vs. Breakdown

Bones undergo a constant process of renewal known as remodeling. In this process, old bone is broken down by specialized cells called osteoclasts and new bone is formed by cells called osteoblasts. “In our younger years, the body maintains an equal balance between bone breakdown and formation, but in older age more old bone is broken down and less new bone is created,” Dr. Bloom says. “It’s this lack of balance that can lead to osteoporosis. Older women are especially vulnerable to osteoporosis because after menopause levels of the hormone estrogen—which inhibits bone breakdown—fall. Older men also experience an increased risk of osteoporosis, but not until their 70s.”

Cancer and Bone Health

Cancer survivors face additional risks for poor bone health because cancer is associated with inflammation that may inhibit the activity of osteoblasts. Cancer treatments also are a factor. “Calcium is important for bone health, but chemotherapy drugs reduce calcium levels,” Dr. Bloom says. “Some cancer drugs also affect estrogen levels.” The steroids some people take to help manage nausea due to chemotherapy may impede calcium absorption from food, while radiation therapy harms the cells that produce bone. “People who have cancer also may get less of the physical activity that strengthens bones,” Dr. Bloom adds.

Exercise Helps

Previous studies also have suggested that cancer survivors are vulnerable to fractures, but the specific factors that may heighten or reduce the risk have been unclear. These findings, along with a previous study by the same research team, provide useful clarification as to what bone-strengthening strategies may be most effective for people with a history of cancer. “The earlier study found a lower risk of fragility fractures in long-term cancer survivors who met recommended physical activity guidelines for moderate- to vigorous- intensity aerobic physical activity— defined as brisk walking in the study— and weight training,” Dr. Bloom notes. The data also emphasized the importance of smoking cessation for cancer survivors.

Calcium-Rich Foods Are Vital

All older adults can help protect their bones by consuming a diet that includes calcium and vitamin D (see What You Should Know). Women ages 51 and older should get 1,200 milligrams (mg) of calcium per day (1,000 mg for men ages 51 to 70, increasing to 1,200 mg at age 70). It is better to get your calcium from food sources rather than supplements.

We get most of our vitamin D from sun exposure, which synthesizes vitamin D in the skin. If you’re boosting your intake through diet, aim to get 600 international units (IUs) per day up to age 70 and 800 IUs thereafter. “If you live in an area that does not get much sunlight in the winter months, ask your doctor if you should take a vitamin D supplement,” Dr. Bloom adds. “Take steps to reduce your risk of falling, too, since falls are the main cause of fractures in older adults. Eradicate tripping hazards from your home, and see if your local senior center offers tai chi classes, which can boost your balance.”

Osteoporosis Screening

Older women are advised to get screened for osteoporosis at age 65 (there is an ongoing debate about whether older men should get screened). If you’re younger and a cancer survivor, ask your doctor whether you should get screened before you reach the recommended age. “If screening reveals that you have osteoporosis, your doctor may prescribe medications to help slow your rate of bone loss,” Dr. Bloom says. “If screening indicates that you have osteopenia—a milder form of bone loss—you still should be proactive when it comes to bone-protecting strategies, since these may prevent you from progressing to osteoporosis.”

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A pulmonary embolism (PE) is a blood clot that blocks blood flow to an artery in the lungs. The portion of the lung that is blocked is unable to get oxygen; if that lung tissue is destroyed, it is called a pulmonary infarction. PEs often form in a vein in the leg, and then break off and travel to the heart.

Possible causes of PE include the pooling of blood during extended periods of inactivity. Sometimes, the cause of a PE cannot be determined.

You are at increased risk of a PE if you’ve had surgery that requires bed rest while you recuperate, or if you have heart disease or cancer. PE risk is also higher for women who have a personal or family history of breast cancer and take the medications tamoxifen or raloxifene, or who take hormone therapy following menopause. Long periods of inactivity, such as may occur during lengthy plane trips, also raise the risk of PE; this is why you’re advised to stand and walk around the cabin during a long flight if possible, or to move your feet and legs periodically if you remain seated.

Symptoms of a PE include sudden shortness of breath, dizziness or feeling faint, rapid heartbeat, pale, clammy skin, excessive sweating, and wheezing. A PE can also cause sharp pain in the chest, shoulder, arm, neck, or jaw. If you experience these symptoms, get emergency medical care as soon as possible; if a PE goes undiagnosed and untreated, it can be fatal.

To prevent PE and blood clots in general, many people with cardiovascular disease and/or those undergoing surgery are given anticoagulant medications. Elevating your legs and wearing compression stockings can also lower the risk, as can getting regular physical activity most days of the week.

I have pain in the bottom of my foot by my heel. Could it be caused by plantar fasciitis?

Yes, it’s possible. Plantar fasciitis is characterized by pain in the morning when you take your first step, followed by slight improvement, and then an increase in pain later in the day. The condition also can cause pain when you’ve been sitting for a while and then get up to walk. With plantar fasciitis, the pain originates in the plantar fascia, a band of tissue that extends lengthwise from your heel to the ball of your foot. If the tension on this tissue is too great, the fascia can develop small tears and become inflamed, which is what causes the pain. Usually, plantar fasciitis is diagnosed based on your description of symptoms and a physical exam; testing or scans usually aren’t necessary.

You’re more likely to develop plantar fasciitis if you’re overweight and/or you have diabetes, high arches or flat feet, or spend a lot of time on your feet. It also can occur if you don’t warm up before exercise and then overstretch the plantar fascia. Treatments you can try at home include stretching, icing your heel and ankle, and taking nonsteroidal anti-inflammatory drugs (ibuprofen, naproxen) to reduce the pain. Also wear shoes that provide adequate cushioning and good support, and avoid going barefoot, especially on hard surfaces such as tile or cement floors.

Heel pain also can come from a stress fracture to the calcaneus (heel bone). This pain tends to occur after you’ve walked for a while. It’s fairly common among people who overtrain or run on hard surfaces, or in older adults with low bone mass (osteopenia) or osteoporosis.

If you have a calcaneal stress fracture, treat it with rest, ice, a heel pad, and over-the-counter pain relievers. If the pain continues or worsens, or it is severe enough to interfere with daily activities or exercise, see your doctor; you may want to get a referral to a podiatrist, who specializes in foot care.

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“Osteoporosis is a potentially debilitating condition that can be treated, but it is underdiagnosed because many women are not screened for it,” says Alana Serota, MD, an osteoporosis expert at the Weill Cornell-affiliated Hospital for Special Surgery. “In fact, the number of women who have osteoporotic fractures each year in the United States is higher than the number that are diagnosed with breast cancer, have a heart attack, or have a stroke combined.”

Testing for Bone Strength

Undergoing a dual-energy X-ray absorptiometry, or DXA, scan is the first step in learning if you are at risk of fracture.

“A DXA scan provides the aerial bone density of specific areas that are the most common sites of fracture, such as the first four lumbar vertebrae (in the lower back), the femurs (bones that run from your knees to your hips), and the nondominant forearm,” says Dr. Serota. The DXA scanner measures the amount of X-rays that pass through the bone from a high-energy and a low-energy beam; the difference in the two measurements indicates your bone density.

She notes that “DXA” is the correct medical abbreviation for the test, but you also may see it referred to as a “DEXA” scan.

Interpreting the Results

A DXA scan’s result is a “T score.”

“A T-score compares your bone density to a normative database of healthy adult females at peak or ideal bone mass, measured in units of standard deviations (SD),” explains Dr. Serota.

A T-score of -1.0 or above is normal bone density. You have low bone density (formerly called osteopenia) if your T-score is between -1.0 and -2.5. Osteoporosis is defined as a T-score of -2.5 or lower.

“Severe or established osteoporosis is a T-score of -2.5 or lower accompanied by a history of a low-trauma fracture, which is defined as a fracture caused by a fall from standing height or less,” explains Dr. Serota.

Who Needs a DXA Scan

All women ages 65 and older are advised to have a DXA scan. DXAs are also recommended for postmenopausal women younger than age 65 who have risk factors for low bone mass.

“These factors include low body weight, prior fracture, high-risk medication use, or a disease or condition associated with bone loss,” says Dr. Serota.

If you think a DXA scan is less important than a mammogram, consider this information from Dr. Serota: “Osteoporosis is a silent thief; it does not cause symptoms or pain until you break a bone. Our skeletal ‘bank account’ is nearly full by age 20, with some consolidation into the early to mid-30s. Everything in life—menopause, illness, lifestyle choices, a nutrient-poor diet—withdraws from this account. The objective is to prevent the first fracture, and a DXA scan helps by showing us how much is in your bank account.”

Risk Factors

Certain lifestyle-related factors increase the risk of osteoporosis, such as smoking and consuming more alcohol than is recommended (generally, a maximum of one drink per day for women).

Dietary patterns that may weaken bones include a high intake of cola and caffeinated beverages and consuming inadequate amounts of protein.

Weight-bearing exercise helps keep bones strong, but Dr. Serota cautions that excessive exercise in the absence of appropriate calories can harm bones.

Medical conditions that are associated with low bone density include celiac disease, inflammatory bowel disease, rheumatoid arthritis, anorexia, and hyperparathyroidism.

In addition, a number of medications are linked with bone loss.

Improve Your Bone Health

Regardless of a DXA scan result, every woman can take steps to optimize bone health and reduce your fracture risk.

“Adequate dietary calcium is important. People who don’t get enough calcium from their diets will need to supplement. Nearly everyone living in the Northeast needs to supplement vitamin D to some degree, especially during winter months when the sun’s UVB rays are unable to activate vitamin D production in your skin,” says Dr. Serota.

Exercise helps to slow the rate of bone loss and decreases the risk of falls and fractures, but exercise alone is not a treatment for osteoporosis. An exercise regimen that is appropriate for postmenopausal women includes aerobics, strength training, and improving balance and flexibility.

“Finally, if medical intervention is needed, we have medications that maintain or even increase bone density,” Dr. Serota concludes.

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If any of these are common occurrences in your life, it may be time to discuss the possibility of hormone therapy with your doctor.

If you thought, “It’s too risky” when you read that last sentence, what you believe about hormone therapy, or “HT,” might be out of date. Here’s what researchers have discovered about the risks of HT in recent years.

The History of HT

“In the 1990s, many women were being treated with hormone therapy (HT). The Women’s Health Initiative study, which began in the late 1990s and assessed potential health risks of HT in postmenopausal women, was stopped in 2002 because increases in the risks of heart disease and breast cancer were linked with taking HT. However, those findings were based on study participants with an average age of 63—older than the typical age of women in their most symptomatic years, which usually occur right after menopause is complete (the average age of menopause is 51.5),” explains Susan Loeb-Zeitlin, MD, a gynecologist at the Iris Cantor Women’s Health Center at Weill Cornell Medicine.

“The study data has since been reanalyzed, with health risks calculated for women according to different sets of criteria. For women who used HT within the first 10 years of menopause and who were younger than 60, the reanalysis revealed a very different risk profile; in fact, it showed they do not have an increased risk of breast cancer, heart disease, or stroke. For most women in this age bracket, it is safe to use HT.”

When HT May Not Be an Option

For women with certain risk factors, HT is not recommended. According to Dr. Loeb-Zeitlin, these risk factors include:

• a personal history of breast cancer
• a known estrogen-sensitive type of cancer, such as endometrial cancer
• heart disease
• liver disease
• unexplained vaginal bleeding.

When to Consider HT

“U.S. Food and Drug Administration (FDA)-approved indications for HT are vasomotor symptoms (hot flashes and night sweats) and genitourinary symptoms like vaginal dryness,” says Dr. Loeb-Zeitlin. “HT is also approved for the prevention (but not treatment) of osteoporosis for women at high risk, due to risk factors such as osteopenia (loss of bone mass), a family history of osteoporosis, and/or a personal history of smoking, long-term moderate to heavy alcohol use, or steroid use.”

How do you know whether your symptoms are severe enough for HT?

“This is a decision based on how symptoms are affecting each individual woman. For many women, vasomotor symptoms have a significant impact on sleep and overall quality of life. It’s also important to consider your medical history. You need to discuss all of these factors with your doctor so you can determine what is best for you,” explains Dr. Loeb-Zeitlin.

Try Lifestyle Strategies

First Some women get symptom relief by making changes to their lifestyles.

“Before trying HT, my patients and I discuss lifestyle modifications that can help with vasomotor symptoms. Some dietary strategies that can help lessen the frequency and/or severity of symptoms include consuming less caffeine and less alcohol (especially red wine), and avoiding spicy foods and late-night eating. Some women find that practicing techniques for stress management, such as mindfulness meditation, deep breathing, or yoga, helps relieve symptoms. And for some women, weight loss is helpful,” says Dr. Loeb-Zeitlin.

Alternative medications are available for women who won‘t or can’t take HT.

“The FDA has approved the drug paroxetine (Brisdelle) for vasomotor symptoms. Another medication that is used off-label is gabapentin (Neurontin), which may improve hot flashes and sleep,” explains Dr. Loeb-Zeitlin.

Vaginal Estrogen

Vaginal estrogen—estrogen that is inserted directly into the vagina in the form of a cream, tablet, or vaginal ring—is used primarily to treat vaginal dryness, another symptom that’s common among postmenopausal women.

“Vaginal estrogen is very safe, minimally absorbed, and does not increase the risk of breast cancer or any other diseases,” notes Dr. Loeb-Zeitlin. “Over time, most symptoms like hot flashes improve—but vaginal dryness gets worse as you get older. If left untreated, it can impact vaginal and bladder health and sexual health, as well as causing persistent general discomfort.”

For women who choose not to use estrogen in any form, over-the-counter (OTC) vaginal moisturizers can help.

“If you’re going to use an OTC product, you may wish to select one that contains hyaluronic acid,” suggests Dr. Loeb-Zeitlin.

See Your Gynecologist

Even if you’re not experiencing problematic postmenopausal symptoms, it’s important to see your gynecologist.

“All women, regardless of age, should have a general checkup with their gynecologist every year or two. A checkup includes more than a PAP smear: You’ll also have a breast exam and a pelvic exam, and you can discuss any problems you are having that might need further evaluation,” advises Dr. Loeb-Zeitlin.

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Older Women Especially Vulnerable

Your bones are subject to a great deal of mechanical stress to which they respond with a continuous process of remodeling that helps them maintain their strength. The remodeling process is performed by specialized cells called osteoclasts and osteoblasts. Osteoclasts resorb (break down) old, damaged bone, and osteoblasts form new bone.

In younger adults, bone formation keeps up with bone resorption. But the hormonal changes that accompany older age interfere with this balance, particularly in women. “Estrogen plays an important role in bone remodeling, but estrogen levels fall sharply after menopause,” Dr. Bloom explains. “Lower estrogen levels increase the number of osteoclasts and decrease the number of osteoblasts. The result is that bone formation is unable to keep up with bone resorption. This can cause osteopenia: low bone density that may lead to osteoporosis.”

Older men are somewhat protected from unbalanced bone turnover because they tend to have larger skeletons and more bone mass to begin with. But as they age, lower testosterone levels affect their bone turnover, and once they reach around age 70 they lose bone mass at the same rate as women. “Research has suggested that up to one-quarter of osteoporosis-related fractures occur in older men,” Dr. Bloom notes. Keep in mind that it isn’t just age that makes you susceptible to osteoporosis—see What You Should Know for other risk factors.

Getting Screened for Osteoporosis

The United States Preventive Services Task Force (USPSTF) recommends screening women ages 65 years and older for osteoporosis. Screening also may be recommended for younger women who are at risk of osteoporosis as determined by a formal clinical risk assessment tool.

The National Endocrine Society and National Osteoporosis Foundation recommend that men ages 70 and older be screened, but the USPSTF has concluded that current evidence is insufficient to assess the balance of benefits and harms of screening in men. Research has suggested that older men may be slipping through the cracks when it comes to managing osteoporosis. In one study, less than 3 percent of older men who sustained a fracture due to osteoporosis had been diagnosed with the condition and treated. If you are an older man, get clued into your risk factors (see What You Should Know), and discuss with your doctor whether you should be screened.

Bone density is measured at the spine, hip and wrist, since these areas are most likely to be affected by osteoporosis. Screening is carried out using dual-energy x-ray absorptiometry (DXA), a special type of x-ray that compares your bone density to that of a healthy 30-year-old adult, and provides a “T” score. A score of –1 or greater indicates normal bone density, between –1 and –2.5 indicates osteopenia, and –2.5 and lower indicates osteoporosis.

Maintaining Your Bone Strength

The North American Menopause Society recently released updated guidelines for preventing and managing osteoporosis in postmenopausal women. The primary goal of treatment is to prevent fractures. “This is best accomplished through a combination of lifestyle measures, drugs to increase bone density and improve bone strength, and fall reduction strategies,” Dr. Bloom advises.

• Your diet should include plenty of calcium-rich foods to ensure you get the recommended daily intake of 1,200 milligrams (mg) for women ages 51 and older, and 1,000 mg for men (men should boost this to 1,200 mg when they reach age 70). Calcium-rich foods include low-fat, fortified cereals and fruit juices, leafy green vegetables, canned fish, and tofu prepared with calcium sulfate. Also be sure to get enough vitamin D, which helps the body absorb calcium from food. “Vitamin D is synthesized by the skin with exposure to sunlight, so if you don’t get year-round sunshine where you live your levels may be low,” Dr. Bloom says. “This can be confirmed with a blood test.” You can boost your vitamin D levels by eating foods that contain vitamin D (fatty fish, such as salmon, trout, mackerel, sardines and tuna; fortified milk, cereals and fruit juices; and eggs). “You also might want to discuss with your doctor whether you should supplement calcium and vitamin D,” Dr. Bloom adds.

• Weight-bearing exercises are activities in which you work against gravity. “Examples include walking, running, and lifting weights,” Dr. Bloom says. “Keep in mind that swimming and cycling are not considered to be weight-bearing exercises.”

• Drug treatment Your doctor likely will recommend osteoporosis medications to boost your bone density and reduce your risk of fracture if your T-score is -2.5 or less. Called bisphosphonates, the drugs have been shown to prevent osteoporosis-related fractures in women. “There is no evidence the drugs reduce the risk of initial fractures in older men, but they do reduce the risk of subsequent fractures and improve bone density in older men,” Dr. Bloom observes. “Since osteoporosis medications accumulate in the bones, most people are advised to take a break after about five years of use.”

• Reduce your fall risk Remove tripping hazards in your home (rugs, awkwardly positioned furniture, power cords running across areas where you frequently walk), install grab bars in the shower and next to the toilet, and make sure that your home is adequately lit at night. See Ask the Experts, in our September 2021 issue, for information on fall risk assessments that can help you gauge whether you are at risk of falling in your home.

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For most women, your diet is your best source of calcium. Standard, one-cup (8-ounce) servings of milk and yogurt provide an average of 300 to 400 mg of calcium, and many varieties of cheese provide between 200 and 300 mg per 1-ounce serving.

If you don’t eat dairy foods, there are other sources of calcium. Canned salmon with bones and sardines are good sources of calcium, and many species of finfish and shellfish provide smaller amounts—about 7 to 10 percent of your daily requirement per 3-ounce serving. Some vegetables, such as spinach, collard and turnip greens, kale, soybeans, black-eyed peas, and acorn squash, also contain calcium, and many foods, including orange juice, almond, soy, and other plant-based milks, and cereals are fortified with calcium.

Many of my patients ask how best to supplement their calcium intake because they are not getting adequate amounts from their diets. This has become a more difficult question to answer in recent years because of some surprising research findings that suggest calcium buildup in coronary arteries may occur more frequently in women taking calcium supplements.

Until additional research provides a more definitive answer to the question of whether or not calcium supplements may contribute to a higher risk of heart disease, I advise patients to get their calcium from foods as much as possible. Vitamin D, which is needed for proper absorption of calcium and is found in many calcium supplements, seems fine to continue in supplement form, though.

Until more information becomes available, I advise choosing foods and beverages that will help you meet your calcium needs naturally, and asking your doctor how much calcium, if any, you need to be taking in supplement form.

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