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Osteoporosis
Fosamax
Raloxifene		 UK Conference
(Consensus) clinical practice guidelines
against the tide
 personal posts
Going against the tide
Current generally held views about osteoporosis tend to be presented (particularly in drug advertisements) as though they are immutable facts. Here are some differing views about

Is Osteoporosis a Menopausal Disease? (soapbox)
The meno-myth of osteoporosis (soapbox)
endogenous estrogen and fracture risk
mass screening for osteoporosis
risk factors for hip fracture
efficacy of fosamax
low dose estrogen study
http://www.nejm.org/content/1998/0339/0011/0733.html
The New England Journal of Medicine -- September 10, 1998 -- Volume 339, Number 11
Endogenous Hormones and the Risk of Hip and Vertebral Fractures among Older Women
Steven R. Cummings, Warren S. Browner, Douglas Bauer, Katie Stone, Kristine Ensrud, Sophie Jamal, Bruce Ettinger, for the Study of Osteoporotic Fractures Research Group 
In postmenopausal women, the serum concentrations of endogenous sex hormones and vitamin D might influence the risk of hip and vertebral fractures. In a study of a cohort of women 65 years of age or older, we compared the serum hormone concentrations at base line in 133 women who subsequently had hip fractures and 138 women who subsequently had vertebral fractures with those in randomly selected control women from the same cohort. Women who were taking estrogen were excluded. The results were adjusted for age and weight. 
From highly recommended editorial at http://www.nejm.org/content/1998/0339/0011/0767.asp
Surprisingly, there was no effect of increasing serum estradiol concentrations on the risk of fracture among women who had detectable concentrations (>5 pg per milliliter [18 pmol per liter]) at base line, all of whom had relative risks of fracture of 0.3 to 0.5 as compared with women with undetectable concentrations. [press reports of this study used it to suggest that lower doses of estrogen might be adequate. My question is why *any* dose? Tishy] On the other hand, there was a linear relation between serum concentrations of sex hormone-binding globulin and the risk of fracture, which was three times as high for women in the highest quintile as for those in the lowest. Serum sex hormone-binding globulin binds both androgens and estrogens, and higher levels would presumably decrease the bioavailability of both hormones to skeletal tissues. 
<snip> 
Do the low, but detectable, concentrations in postmenopausal women have an effect on bone metabolism, or are the undetectable concentrations simply a marker of some other metabolic difference in this group of postmenopausal women? A study of the effects of low doses of estradiol on bone turnover in postmenopausal women who have undetectable serum estradiol concentrations at base line would help to resolve these questions. 
Extracts from a review at http://www.jr2.ox.ac.uk/bandolier/band3/b3-4.html of the 
Effectiveness Bulletin Review: Osteoporosis

The first Effectiveness Bulletin from the University of Leeds concerned screening for osteoporosis to prevent fractures. It examined the question whether population based screening programmes should be established to prevent fractures in elderly women. It assumed a model of identifying a high-risk group by screening the whole  population at the time of the menopause. 

Can high-risk patients be identified?

      The standard test is for bone density. The sensitivity and specificity of bone density measurements in identifying  those women who will go on to have fractures later in life is not established. 

      If the 20% of women with lowest bone density measurements are taken as the high risk group, then only 28% of  those would have gone on to suffer fractures later in life in the absence of therapy. Women with bone densities above this cut-off will suffer 63% of all fractures. 

      It is possible that biochemical measures to identify rapid bone losers would be more effective, and some new  assays are becoming available, but have yet to be fully evaluated. 

 Will women come for screening?
 It expected that even with a lot of effort only 70% of women will take up screening opportunities. 

 Will women accept long-term HRT?
Long-term compliance with HRT is as low as 30%. 

 What is the overall impact?
      It is likely that a screening programme using bone density measurement and long-term HRT in the high risk group will prevent fewer than 3% of fractures in elderly women. 

Implications for Health Authorities & GPFHs
      This is a detailed and well reasoned review, as well as being a good read. It has assembled a solid body of  evidence, and is a paradigm for anyone considering and screening programme.
Extracts from http://jfp.msu.edu/jclub/jc0895b.htmwhich is a review of 
Risk Factors for Hip Fracture in White Women. 
Cummings SR, Nevitt MC, Browner WS, Stone K, Fox KM. Ensrud KE, CauleyJ, Black D, and Vogt TM for the Study of Osteoporotic Fractures Research Group.  N Engl JMed 1995; 32:767-73. 

Reviewed by: Kendra Schwartz, M.D., M.S.P.H. 

Clinical question: 
Which risk factors are associated with hip fractures in white women 65 years and older? 

<snip>(prospective study of 9516 white women at least 65 years of age, 4 parts country over 3 years by mail. 192 hip fractures.) 

Results
Sixteen independent risk factors for hip fracture were identified. Those with a RR of 1.5 or greater included 

  • increased age 
  • history of maternal hip fracture 
  • self-rated poor health 
  • previous hyperthyroidism 
  • current use of long-acting benzodiazepines 
  • current use of anticonvulsant drugs 
  • on feet less than 4 hours per day
  • inability to rise from chair without using arms
  • poor depth perception
  • resting pulse rate greater than 80
  • and decreased calcaneal bone density. 
Factors which seemed protective (RR  significantly less than 1.0) included 
  • increase in weight since age 25 
  • walking for exercise. 
The incidence of hip fractures was directly related to the number of risk factors present. Adjusting for bone density did not affect the above outcomes. Some commonly believed risk factors were not significant, such as fair hair color, northern European ancestry, and earlier natural  menopause. Current smoking was not an independent risk factor as it was related to several other risk factors including gaining less weight since age 25, poorer self-rated health, difficulty rising from a chair, and fewer hours spent on feet. Estrogen therapy  seemed to be protective in those women without a history of osteoporosis or fracture, but the 95% CI was wide (RR = 0.3,  95% CI = 0.1-1.1). Calcium intake was not related to hip fracture, although intake was assessed only once by questionnaire during the study. 
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