I see where the makers of Evista® (raloxifene) are offering a 30-day free trial of this drug, which lowers the risk of both osteoporosis and breast cancer in women who have gone through menopause.
This gets me thinking about the options for osteoporosis treatment in postmenopausal women. Unlike many advertisements for dietary supplements, the ads for Evista are at least accurate — even though, as expected, they do not mention any of the other possible osteoporosis treatments for this group.
Before considering drug treatments, however, I must mention two less costly strategies that can help postmenopausal women fend off osteoporosis: exercising regularly and getting at least 1,200 mg of calcium and 800 International units of vitamin D a day.
Few diets provide these amounts of calcium, and especially of vitamin D, so most women need supplements of both. Tums® is the least expensive calcium supplement, but you need to remember that each 500 mg tablet of Tums contains only 200 mg of calcium, and that, for optimum absorption of this calcium, the tablets must be taken with meals.
The 3 available drug options for the prevention and treatment of osteoporosis in postmenopausal women are
- hormone replacement therapy (HRT)
- SERMs (selective estrogen-receptor modulators) such as raloxifene (Evista®)
- bisphosphonates
Hormone replacement therapy. My first choice in the period immediately after the menopause is HRT, which may consist of estrogen alone or estrogen plus a progestin. Estrogen not only reduces postmenopausal symptoms such as hot flashes, but also prevents the loss of bone mass, which defines osteoporosis and is responsible for this disorder's increased risk of fractures. Because taking estrogen just by itself increases the danger of uterine cancer, those women who have not had a hysterectomy (removal of the uterus) must also take a progestin.
A low dose of estrogen should be prescribed only for a short time, perhaps no longer than 5 years, to avoid possible adverse effects. Long-term use, for example, increases the risk of stroke. Estrogens also increase the risk of breast cancer, so women with a history of breast cancer should not take estrogen replacements.
Another possible side effect of HRT, with or without a progestin, is thromboembolism (blood clots in a leg vein that may break loose as an embolus that can then move to the lungs and block a blood vessel there).
The bisphosphonates, My second treatment choice would be one of the bisphosphonates, such as alendronate (Fosamax®), risendronate (Actonel®), and ibandronate (Boniva®). These drugs, which can be started and used at any time after the menopause, can be taken by mouth once or twice a week, or even once a month, to prevent bone loss and associated fractures.
They may also slow the progression of breast cancer that has spread (metastasized) to bone and may even prevent the development of bone metastases in women newly diagnosed with breast cancer. (Bone metastases occur in more than 80 percent of women with advanced breast cancer.)
Women must drink plenty of fluids at the time they swallow these pills, and they must remain standing for at least 30 minutes to avoid damage to the esophagus. Women who cannot stand for this period of time can be treated with Boniva administered intravenously every 3 months — or with another bisphosphonate, zoledronic acid (Reclast®), once a year.
The bisphosphonates have no effect on postmenopausal symptoms. Chronic bisphosphonate therapy, however, can cause a serious, although rare, complication: osteonecrosis (death) of the jawbone, often associated with pain, swelling, exposed bone, local infections, and fracture of the jaw.
The selective estrogen-receptor modulators. SERMs such as raloxifene (Evista®) are effective in preventing and treating osteoporosis, but these drugs would not be my first choice for women in the early years of the menopause. This is because, unlike estrogen, they increase hot flashes and can even cause them in premenopausal women. Through their actions on estrogen receptors, SERMs may enhance some of estrogen's effects, while reducing others; that is, they act like estrogen on some tissues but block its effect on other tissues.
Unlike estrogen, raloxifene has an important benefit in women with breast cancer — it may reduce the risk of invasive breast cancer. Like estrogen, raloxifene raises the danger of thromboembolism, so women who have had prior blood clots in their legs should not take raloxifene. In addition, some evidence suggests that raloxifene increases the risk of dying from a stroke in those women who are at high risk for heart disease or stroke.
Postmenopausal women are fortunate that several forms of treatment can prevent osteoporosis. Each woman should decide with her gynecologist which one is best for her.
