There is no one answer appropriate for all to this question. Each person needs to be evaluated individually to determine what her specific circumstances, desires, and concerns are. These need to be taken into consideration. Based upon these a thoughtful plan is developed specifically addressing her needs with the aim of achieving the best outcomes.

What I can share with you is my opinion about how to manage osteopenia in low risk osteopenic women and share several composite cases that represent situations I encounter regularly that illustrate different approaches to this situation. My purpose is to provide you with some ideas to consider and discuss with your doctor.

The first question I always ask myself when seeing a patient in consultation for osteoporosis is what is their risk for fracture now and in the future. In my opinion this is the key question because if sets the stage for everything that follows. The fracture risk determines the type of therapeutic approach, the urgency of treatment, and the patient’s prognosis. How is this done? I rely on the FRAX fracture risk assessment tool to calculate a patient’s 10-year probability of hip and other osteoporotic fractures.  Dr. John Kanis and his colleagues and the World Health Organization (WHO) developed the FRAX and customized it for every major country and ethnic group worldwide. The FRAX uses your femoral neck bone density, race, gender, age, and country to calculate fracture risk and is proven to be extremely accurate. I also use all the information provided by your medical history, family history, medication history, and the lab test results to make my determination.

Case #1
Mary is a 57 y/o white female referred for evaluation after being found to be osteopenic on a screening DXA bone density test. She past postmenopause uneventfully 5 years ago and has never taken estrogen or any medication to treat or prevent osteoporosis. She takes calcium and a multiple vitamin, eats well, and exercises twice weekly playing tennis and walks twice weekly. She is not on any medications that cause osteoporosis nor does she have any disease that cause osteoporosis. Her lowest T-score is –1.8 in the spine and –1.6 at the femoral neck. Her FRAX is low risk predicting a 0.75% chance of a hip and 3% chance of a major osteoporosis fracture over the next decade. Her blood and urine tests are normal. Her family history is positive for osteoporosis in her mother who fractured her hip at 75 and her maternal grandmother who she remembers had a Dowagers hump but no one ever diagnosed her formally back then with osteoporosis. She and her doctorr want advice what to do. He offered her Fosamax but after reading about it on the Internet she is afraid to take it or frankly any of the drugs she read about.

Discussion
I see a dozen Mary’s every month! She probably has the inherited form of osteoporosis that affects white people whose ancient ancestors hail from Northern Europe. This is suggested by her being osteopenic at 57 and her family history. So she is likely to develop osteoporosis in the coming years. When white women enter menopause, half are osteopenic already on DXA testing. Out of that group only a third will progress to osteoporosis. It is this data and the discovery of rare but serious side effects of some of the drugs used for prevention of osteoporosis that has fueled the movement away from using drugs for prevention of osteoporosis. I support this position. The FRAX is very useful here because it clearly predicts her current fracture risk based upon everything remaining the same is low. This means there is no treatment urgency. She is not fragile. She can ski, sky dive, bungee jump, whatever!

Things never stay the same. Since she is likely to have the osteoporosis genetic complex, her postmenopausal bone loss rate is going to be accelerated greater than other women like her but without the OGC. On no treatment, her DXA bone density will probably decrease 2%+ per year on average.

Mary’s Treatment Options
Diet is fundamental to any osteoporosis prevention strategy and Mary scored well in both regards. Her intact parathyroid hormone was 32; the vitamin D was within the ideal range at 42 ng/ml, serum calcium 9.9 mg/dl, 24-hour calcium 200 mg/gm Cr, serum magnesium 2.2 mg/dl, and 24-hour magnesium 96 mg/gm Cr. Take my word for it, all these tests are normal and indicate her intake, absorption and excretion of the key nutrients affecting bone and mineral metabolism are balanced. Her exercise history is great, she looks fit on exam, her resting heart rate was 64, and her BMI was 23. She does not need to do better than that and trying to do so is too much to ask. So exercising more, taking more calcium or a different type of calcium, eating better, and so on won’t work for her because her lifestyle inputs are already good enough. Are they perfect? No, but they do not need to be perfect. Perfect in not sustainable but good enough is. It is important to be realistic and practical. Asking for perfection is setting yourself up for failure while accepting good enough is the secret to success in most things.

That settled, what next? Here are the options all assume she continue with the current good enough lifestyle choices that she has made:

  • No drug treatment with DXA monitoring annually or biannually
  • Begin hormone replacement therapy with DXA monitoring annually or biannually
  • Begin Fosamax, Reclast, Evista, or Actonel and monitor with DXA annually or biannually

These are all reasonable options for Mary to choose and none is too risky. Among the options there are, in my opinion better and worse choices and it is my practice to share my view with my patient because I think that is my responsibility to do so. If this situation sounds similar to yours, then my advice to you is speak to your doctor and discuss these options with him or her. One of the reasons that observation without drug treatment is a perfectly acceptable and safe choice is because you are going to have regular DXA monitoring. If the DXA test shows that your bone density crosses over into osteoporosis, treatment with one of the drugs US FDA indicated for treatment is a must. Otherwise you are almost certainly going to experience fractures. You could still fracture with treatment but all the studies show treatment reduces fracture risk by at least 50% compared with no treatment. That is an important benefit.

Case #2
Joan is a 58 y/o Hispanic female whose doctor did a bone density test and found her to have a T-score of 1.75 in the spine and –2.0 in the femoral neck. Her FRAX was low risk for a hip and major osteoporotic fracture being 1.2% and 4% respectively. She is a teacher and on her feet all day. Her diet is “OK”, she does not follow anything special. Both she and her husband work so they eat out about 3 nights each week “but at the good places like Zaxby’s and Crate and Barrel almost never fast foods”. “Milk gives me gas” so she avoids all dairy except for occasional frozen yogurt. She takes medication for blood pressure and cholesterol and she has pre-diabetes. She does not use vitamins of calcium supplements. She uses Milk of Magnesia as a laxative. She is overweight with a BMI of 29. “I know I need to loose a few pounds but I am too tired to exercise when I get home from work and then I have so much to do for my husband and son”.

Her physical exam revealed an attractive olive skinned middle-aged Hispanic women with no abnormal findings. The patient’s lab tests showed a low vitamin D level at 14 ng/ml with low normal serum calcium at 8.8 mg/dl and normal serum magnesium at 2.3 mg/dl. The intact parathyroid hormone was high normal at 63. The 24-hour urine was low at 65 mg/gm Cr with magnesium high at 254 mg/gm Cr. Her family is from Chile; there is no history of osteoporosis or fractures of the hip.

Discussion
Joan is vitamin D deficient because of her skin tone that naturally blocks UV rays preventing production of vitamin D in the skin and because modern people in the developed world live and work inside most of the time. The second reason has to do with Joan being overweight. She has an increased amount of body fat and vitamin D is a fat-soluble vitamin. What vitamin D her skin makes or what little she gets from fortified bread and dairy products is stored in the body fat. The more fat tissue you have, the greater your need for vitamin D because if becomes diluted in the fat. All people found to have a low vitamin D level should have it corrected to the ideal range whether they have bone health issues or not. The reason is because vitamin D regulates the immune system as well as playing a major role in bone and mineral metabolism. Immune health is an important way to ward of infectious disease, autoimmune disease, and cancer.

Since Joan is Hispanic, she cannot have the osteoporosis genetic complex that affects white women exclusively. Bone density studies of Hispanic women show that their bone density is on average 5% lower than white women’s bone density. Epidemiology studies of postmenopausal Hispanic women who have moved to the US and those who have remained in their home country find their hip fracture rates are 250% lower than white women of the same age. Similarly fractures of the spine and other sites associated with osteoporosis occur at only 40% the rate seen in similarly aged white women. This means that even though she is osteopenic on DXA, her prognosis is

Joan’s Treatment Options
A normal woman Joan’s 5’ 3” height weighs about 130lbs and her BMI would be about 23. For that person a daily intake of 2,000 IU of vitamin D3 is usually adequate for her to reach a vitamin D level in the ideal range of between 40 and 60 ng/ml. Because Joan is overweight at 160 lbs, she will need more vitamin D3. I would start her on 3,000 IU daily and recheck the level every 3 months after making adjustments to get her in the ideal range. Once there, she should stay on that dose for the rest of her life unless she looses weight or moves to a nudist colony in the Caribbean. Too much vitamin D is not good. For more on that, see Vitamin D in this section of the website. So at a minimum Joan needs to get her vitamin D up. Her diet is not in balance with her caloric burn as demonstrated by her heath problems and weight. We don’t have a diet history to go by but lets assume she could eat much better than she does now. She does not exercise so obviously there is an area ripe for intervention. Both these lifestyle enhancements will require Joan to make a significant commitment for change and that begins with the intention to do so. Does she have that motivation because if she does not, then well you know, nothing happens.

From the bone perspective only though it probably makes no difference because Joan is unlikely to ever become osteoporotic. She is at risk for age related osteoporosis and that condition is fueled by chronic calcium and vitamin D deficiency that we have taken measures to correct and therefore prevent. What she is not likely to develop is postmenopausal osteoporosis of the premature type seen in white women and their descendents almost exclusively.

Here are Joan’s treatment options assuming that her vitamin D nutrition will be normalized and her calcium nutrition will be too with dietary improvement:

  • No drug treatment with DXA monitoring annually or biannually
  • Begin hormone replacement therapy with DXA monitoring annually or biannually
  • Begin Fosamax, Reclast, Evista, or Actonel and monitor with DXA annually or biannually

The above choices are all sensible options for the patient to make but some are better than others and the patient may have a lot to say about what she does. Today most women take an active role in their healthcare choices unlike their mothers who were more likely as not to adapt a passive role in the patient doctor relationship. While it is a much greater challenge providing care to women today, I hardily prefer it and commend and greatly respect women who desire to understand what is happening to them, why, and what their options are for managing it.

If your situation resembles Joan’s then now would be a good time to discuss it with your doctor and look at your options. Someone like her has so much to gain from adopting better lifestyle choices. She feels tire and rundown all the time because of those poor choices. I know for a fact if she improved her diet by cutting the carbohydrates and began moderate regular exercise she would loose 10 lbs quick as a wink and feel and look 5 years younger. If she kept it up, she could prevent the diabetes from every developing and probably be able to come off her BP and cholesterol medication. But first comes the intention. Without the intention, nothing will follow.