Be cautious about medications offered for bone thinning

Millions of American women are being diagnosed with osteopenia, which is not truly a disease, and many are told to take medication they may not need to prevent broken bones they might never get.

At the same time, millions of others are never properly diagnosed or treated for osteoporosis, which can lead to devastating fractures.

The widespread confusion about what degree of bone loss really is a red flag for future broken bones and what is simply a sign of normal aging has been rampant since, in 1994, the World Health Organization defined ''osteopenia" and ''osteoporosis" as certain ranges of scores on a bone-density test. Some doctors consider this range skewed, labeling too many -- 34 million -- Americans as having osteopenia, and too few -- 10 million -- at risk for the broken bones of osteoporosis. (Osteoporosis is mostly a disease of women, but men can get it, too.)

Things have become even more muddled since 2002 when many older women stopped taking hormone therapy -- which can help prevent bone loss -- after a major study showed that it also raised the risk of breast cancer, heart disease and stroke. Between 2002 and 2003, worldwide sales of Fosamax, used to prevent bone loss, soared 19 percent, to $2.7 billion.

In essence, nobody knows what if anything an older woman with very mild bone loss should do. Should a woman at 50 start taking drugs like Fosamax, Actonel or Evista to guard against possible fractures in her 80s, when most fractures occur? Or should she wait until there is a very real red flag, like having a fracture triggered by a minor fall?

The problem comes from ''calling osteopenia a disease when it is not," said Dr. Robert Neer, director of the osteoporosis center at Massachusetts General Hospital. The WHO defined osteoporosis too narrowly, leading many people to think they are not at high risk, and osteopenia too broadly, encouraging too many women to take medications, he said.

''We are overtreating a large number of healthy women who have a relatively minor risk of fracture and we are ignoring a sizable number of individuals at high risk of fracture," Neer said.

The term ''osteopenia" has ''no medical meaning," said Dr. Steven Cummings, an epidemiologist at the University of California at San Francisco who has led a number of large studies on osteoporosis and osteopenia. ''I've seen patients who come in scared that they will become disabled soon because they have this disease called osteopenia, when in fact they are normal for their age."

For the record, osteopenia is defined by the WHO as a score of minus 1 to minus 2.4 on the so-called DEXA test, which stands for dual energy X-ray absorptiometry. Osteoporosis is defined as a DEXA score of minus 2.5 or worse.

Osteopenia can but does not necessarily progress to osteoporosis. Indeed, while osteoporosis raises the risk of fractures, many fractures occur in people without it.

''Low bone-mineral density does raise the risk of hip fracture, but it's only one of several factors like bad eyesight, bad coordination, use of Valium or similar drugs, overactive bladder and other conditions that contribute to the falls that can lead to broken bones," said Dr. Nananda Col, a women's health expert at Rhode Island Hospital in Providence.

In other words, a finding of mild osteopenia on a bone test is not, by itself, enough reason to take drugs, said Dr. Eric Orwoll, an osteoporosis specialist at Oregon Health Sciences University in Portland.

On the other hand, because osteopenia can, though does not always, lead to osteoporosis, many doctors believe it's important to start treatment early to avoid broken bones later in life.

Dr. Suzanne Jan de Beur, director of endocrinology at the Johns Hopkins Bayview Medical Center, said she prescribes medication to women with scores of minus 1.5 to minus 2 if there's a family history of osteoporosis or other risk factors.

Dr. Joseph L. Melton III, an epidemiologist at the Mayo Clinic in Rochester, Minn., put it this way: Doctors who advise women to ignore osteopenia ''are wrong, and people who advise everybody to treat it are wrong. It's a personal decision based on family history and personal values."

So, when should a woman be screened for bone loss? And how safe are the drugs for long-term use?

In 2002, the US Preventive Services Task Force, a panel of independent experts convened by the government's Agency for Healthcare Research and Quality, concluded that women age 65 and older should be screened routinely for osteoporosis. It said screening should begin at 60 for women at increased risk, which includes a family history of hip fractures, current smoking, thinness and use of steroid drugs.

As for drug safety, a study published in March of last year in the New England Journal of Medicine showed that Fosamax (alendronate) appears to be safe for as long as 10 years. But a 1998 study showed that, while Fosamax helps prevent fractures in women with osteoporosis, it does not do so in women with osteopenia and no previous fractures. Fosamax and Actonel can cause small ulcers in the esophagus; Evista can cause hot flashes and, rarely, blood clots.

There is no evidence yet that the widespread use of Fosamax and Actonel is causing any problems, said Col of Rhode Island Hospital. But the drugs do get incorporated into bone. ''If 10 years down the line it turns out that something is dangerous, it will be sitting in a lot of people's bones. The benefits of treatment need to outweigh the risks."

The bottom line: Try to prevent thinning bones in the first place. Do weight-bearing exercises several times a week and walk briskly for 30 minutes a day or more. Get enough calcium -- 1,200 to 1,500 milligrams (but not more) a day -- plus 800 International Units of vitamin D, from food and supplements.

And if one doctor recommends drugs to protect your bones on the basis of mild bone loss, consider getting a second opinion. Obviously, no one wants a broken hip. But no one should take any drug for decades without careful thought, either.

Judy Foreman is a freelance columnist who can be contacted at foreman@globe.com.