".....it also publicized osteoporosis as a terrible disease that menaces all menopausal women with debilitating fractures. "

As women near menopause, they are inundated with information on osteoporosis and everything that appears to be associated with it: risk of serious fractures, hormone replacement therapy, bone density tests, etc. Despite this wealth of information, there is still a certain confusion about osteoporosis, making it a conundrum for women approaching menopause. Is osteoporosis a menopausal disease? Should all menopausal women undergo preventive treatment for osteoporosis? What about the bone density test the doctors increasingly suggest to women 50 and over?

Osteoporosis, a condition most women had never heard of twenty years ago, was the subject of a massive public education campaign conducted in 1982 by the pharmaceutical company Ayerst - the same company that currently dominates the world market in hormone replacement therapy for menopause with its estrogen product Premarin. While 45 million Premarin prescriptions were written in medical clinics in the United States in 1995, there have been much leaner years. In the late seventies, the discovery of a link between endometrial cancer and estrogen use caused a precipitous drop in sales of Premarin and other menopausal estrogen products. Was it just coincidence that this was followed by Ayerst’s mega-campaign on osteoporosis? One thing is certain, the campaign not only restored the fortunes of estrogen use in the treatment of menopause, it also publicized osteoporosis as a terrible disease that menaces all menopausal women with debilitating fractures. 

Update on Osteoporosis
Bones, like our skin, have the ability to regenerate, which means they can continually rebuild themselves so that they remain strong and healthy. Our skeleton is "maintained" by two types of cells. Osteoclasts work the surface of the bone and create small openings to prepare the surface for the deposition of new bone material. Osteoblasts then take over and fill the holes with a material that takes a few days to harden. The body naturally carries out the process of rebuilding the skeleton and certain factors influence the quality of bone mass. Heredity, a diet rich in calcium and vitamin D (which makes it easier to absorb calcium) and physical activity all play a role in building good bone mass. Around the age of 35, bone mass peaks and although bone continues to be remodelled as the body requires, bone mass begins to decrease. The presence or absence of behaviours that strengthened bones in the years prior to age 35 now becomes more important.

Decrease in bone mass is a normal phenomenon that occurs in both men and women as they age. Everyone loses bone mass, though only a minority are affected by osteoporosis. And while men do suffer from the disease, their situation will not be specifically addressed in this article, for two main reasons: first, studies of osteoporosis focus mainly on women and little attention has been given to how the condition affects men; in addition, fewer men suffer from osteoporosis because by age 35 they have accumulated greater bone mass than women and maintain it for a longer time. Nevertheless, men’s risk of suffering a fracture due to osteoporosis is similar to that of women five years younger: for example an 85-year-old man is as likely as an 80-year-old women to suffer a fracture.

Though some bone loss is inevitable and normal with ageing, at what point does the loss become osteoporosis? Osteoporosis is defined by a fragility of the bone that results not only from a progressive decrease in the bone mass, but also from a deterioration in the “structure” of the bone. The bone becomes porous (whence the name osteoporosis) and more vulnerable to fracture. So it is the higher risk of fracture, and not the fractures themselves, that characterizes osteoporosis. The problem with the definition of this condition, however, is that it confuses “risk factor” with “disease”. A person can have below-average bone density and show no symptoms, experience no discomfort and never have a fracture - in short, be in good health. So is it legitimate to say they “have a disease?” To illustrate the extreme side of this definition, Dr. Susan Love(1) suggests that it would be like diagnosing heart disease on the basis of one’s cholesterol level being too high, rather than on a history of heart attacks. Similarly, many women are diagnosed with osteoporosis because they have low bone density, but this is a factor that only increases the risk of having a fracture. 

Osteoporosis: A Menopausal Disease?
Ads for drugs to fight osteoporosis, women’s magazines and the medical community continue to insist on the link between menopause and osteoporosis. This supposed connection has convinced many women that every fifty-year old is inevitably faced with osteoporosis. Several factors have helped establish the myth that menopause = osteoporosis. First, it was long believed that osteoporosis and the loss of bone density were affected by estrogen levels alone, a belief that rendered women powerless in the face of the disease. Dr. Louis Aviolo of Washington University in St. Louis, recalls that the idea of post-menopausal osteoporosis first appeared in the 50s: “Since women are more vulnerable to fractures after menopause, they concluded that osteoporosis was due exclusively to a decrease in the estrogen level.” In fact, studies tend to show that estrogen is not the only factor that influences bone health and loss of bone density.(2) And that is great news for women, because it is much easier for them to act on the other determining factors: especially exercise, which has great virtues for those suffering from osteoporosis.

Since all the blame was pinned on the drop in estrogen levels, it was a simple step to link the decline in women’s bone density (and thus osteoporosis) to the onset of menopause.(3) Yet it has been shown that loss of bone density can begin several years before menopause. What’s more, the rate of this loss varies from woman to woman: accelerated bone loss for some women starts at age 50, spares others until they turn 80, while still others suffer only a very gradual loss as they age. Menopause does not necessarily result in drastic bone loss, as was long believed. The U.S. Congressional Office of Technology Assessment looked at all the studies on the subject and concluded that “acceleration of bone loss in the shoulder and hip areas after the onset of menopause is low.”(4) 

Many Treatments For a Poorly Defined Pathology
The power of the insidious association between menopause and osteoporosis has led directly to the perception of menopause as a disease. It is no wonder that this then provides the pharmaceutical companies with such fertile ground for the promotion of hormonal medications and treatments among all newly menopausal women, whether they are healthy or not. Pharmaceutical companies thus describe hormone replacement therapy to prevent osteoporosis as a sure treatment, one which all women should take, as soon as menopause begins. The authors of a Web site funded by the American Pharmaceutical Association, called Pharmacists Caring for Osteoporosis, give the following answer to the question When Should I Start Hormone Replacement Therapy?:

“It’s never too late to start. Beginning HRT during early menopause, when estrogen levels are rapidly declining, is certainly a wise decision. However, waiting until age 60 to start HRT will slow further bone loss. (...) Thus, no matter when a woman starts HRT, she and her doctor may decide to continue it for life.”(5) 

When a treatment may prevent a disease, studies can sometimes tell us how many people have to receive the treatment in order to prevent one case of the disease. A broad scientific study(7) on hormone replacement therapy and its ability to prevent fractures showed that 250 women would have to be treated with estrogen over a 10-year period in order to prevent one hip fracture. In other words, 249 women would have to take a medication every day for ten years, assume the cost of the drugs for that period of time, and subject themselves to the higher risk of other diseases, without deriving any benefit from the treatment. What’s more, the treatment is intended to prevent a disease that most of these women would never develop.

Since no study has yet examined the long-term consequences of hormone replacement therapy, it seems essential that we question the legitimacy of a preventive treatment that targets all women approaching menopause. It is important to remember that not all menopausal women will suffer from osteoporosis. Research is already underway to find a better way to identify women who are at high risk for developing osteoporosis. Hopefully these women will be offered means of prevention that rely on safer, more natural approaches.

References
1. Love, S. & Lindsey, K. (1997). Dr. Susan Love’s Hormone Book: Making Informed Choices About Menopause. New York: Random House.
2. Martin, M.C., Block, J.E., Sanchez, S.D., Arnaud, C.D. & Beyene, Y. (1993). Menopause without symptoms: The endocrinology of menopause among rural Mayan Indians.American Journal of Obstetrics and Gynecology. 168(6), 1838-1845.
3.Prior, J.C., Vigna, Y.M., Barr, S.I., Kennedy, S., Schultzer, M., & Li, D.K.B. (1996). Ovulatory premenopausal women lose cancellous spinal bone: A Five Year Prospective Study. Bone; 18, 261-268.
4.Centre for Health Services and Policy Research. (1997). Bone Mineral Density Testing: Does the Evidence Support its Selective Use in Well Women? The University of British Colombia; p. 23.
5.Pharmacists Caring for Osteoporosis. (1998). Web site created by the students and pharmacists of the University of Pacific School of Pharmacy and funded by the American Pharmaceutical Association.
6.Kiel, D.P., Felson, D.T., Anderson, J.J., Wilson, P.W.F., Moskowitz, M.A.. (1987). Hip fracture and the use of estrogens in postmenopausal women: The Framingham Study. New Eng. J Med. 317, 1169-74.
7. Therapeutic Initiatives. (1996). Therapeutic Letter 14, May/June/July, University of British Colomba, quoted by Barbara Mintzes. (1998). Blurring the Boundaries: New Trends in Drug Promotion, Health Action International, p.16.