04 May The Role of Hormones in Osteoporosis
Hormones and Osteoporosis
The thing with bone loss is we tend to only worry about it or address it after the diagnosis is already made. Reality check, we start losing bone mass and strength well before our first DEXA scan. “But Dr. Winter, it seems like a pretty benign diagnosis, right?” Another reality check, it’s far from.
What is Osteoporosis?
Osteoporosis is a systemic skeletal disorder characterized by low bone mass and microarchitectural deterioration of bone tissue, with a consequential increase in bone fragility and susceptibility of fracture. Woah, that’s a harsh definition! Beyond the definition of osteoporosis, it is more important to understand the mortality associated with the increased fracture rate, especially hip fractures. According to The Aging Male: Clinics of Geriatric Medicine (1) and American Journal of Medical Science (2) one-half of men who fall and break a hip die within a year.
Yes, you heard me right, ONE YEAR! Then, to add insult to injury, the rate of hip fracture is projected to increase by 310% in men and 240% in women by 2050.
If those statistic weren’t nerve racking enough here are some more:
- By the age of 60, almost one-half of the women in the U.S. will have osteoporosis.
- One in five women will break a hip in her lifetime.
- One-half of the women who fall and break a hip never walk again.
I’ll admit, I was shook up reading those numbers as well, but I’m not one to sit passively by, it’s time to take action. Hopefully we all know the basics of osteoporosis prevention. We should be getting adequate minerals and vitamins through diet and supplementation, regular weight bearing exercise as well as decreasing if not eliminating alcohol and cigarettes.
What are the risk factors for developing Osteoporosis?
Prevention is key my friends. What can we start doing today that can make a drastic difference? Whether you are 20 or 90, male or female, everyone should look at this list and have a heart to heart about daily life choices you are making for your bone health.
- Vitamin D deficiency
- Calcium deficiency
- Alcohol abuse
- Genetic predisposition
- Excessive caffeine
- Sedentary lifestyle
- Eating disorders
- Long term use of steroid medications like prednisone
Hormone Replacement Therapy May Be Effective in Treating Osteoporosis.
Osteoporosis is generally an age related disease, as you can see from the list above it is strongly associated with menopause and andropause, a time in our lives that we lose sex hormones. Our main sex hormones estrogen, progesterone, and testosterone all decline during menopause and andropause. We mostly think of these hormones in regard to symptoms commonly associated with menopause/andropause like hot flashes, night sweats, fatigue, brain fog, and low libido, irritability, and loss of muscle mass. Turns out these hormones contribute to our health in even more ways, including bone health. These powerhouse hormones contribute significantly to the cycle of bone breakdown and building. Remember osteoporosis occurs when the creation of new bone doesn’t keep up with the loss of old bone.
In a nutshell:
Estrogen maintains bone.
Progesterone builds bone.
Testosterone builds bone makes and the bones strong.
On a deeper level, without proper hormone balance the intestines lose their ability to even absorb calcium, the main bone building mineral, from foods or supplements and the kidneys become less efficient at maintaining calcium homeostasis in the body. The inadequate calcium absorption from the gut and increased loss into the urine accelerated bone loss dramatically. The bright side is the intestinal and renal changes that occur at menopause/andropause are reversible with hormone replacement. (3)(4)(5)(6)(7)
How does Hormone Replacement Therapy Compare with Bisphosphonates?
The first line therapy of osteoporosis tends to be anti-resorptive agents such as bisphosphonates. The goal of these medication are to stop bone loss but possible side effect from bisphosphonates include increase in hip fracture after 5 years of use, osteonecrosis of jaw bone, atrial fibrillation, hypocalcemia, GI symptoms, adn musculoskeletal pain. YIKES!
In two medical trials, estrogen has been shown to be equal to oral bisphosphonates in controlling bone turnover and increasing bone density in postmenopausal women.
Both estrogen and testosterone have receptors on osteocytes, osteoblasts, and osteoclasts (these are the cells responsible for the breakdown and building of bone). Interestingly estrogen with androgen therapy increases BMD to a higher degree than estrogen therapy alone. In 1995, Davis et al.72 concluded that in postmenopausal women, treatment with both testosterone and estradiol pellet implants was more effective in increasing bone mineral density (BMD) in the hip and lumbar spine than estradiol implants alone. In fact, the largest annual increases in BMD using HRT have been seen with testosterone in post-menopausal females. (8) (9) (10) (11) (12) (13) (14)
What Types of Hormone Replacement Therapy Are There?
As a naturopath that specializes in hormone replacement therapy, I will always prefer bio-identical hormone replacement therapy over synthetic versions. Bio-identicals have been shown to be safe, effective, and mimic nature as closely as we can. It’s also imperative that we be able to customize your treatment to you, your dose is probably a lot different than your neighbors!
Types of bio-identical hormone replacement therapy available include topical creams, troches, oral capsules, and pellets. They all have their pros and cons that should be discussed with your healthcare provider.
Your Next Steps:
- Take a look at your risk factors and change what you can.
- Get a DEXA scan no later than 65 years old, sooner if you have significant risk factors.
- Test your hormones to see if hormone support or replacement would be right for you.
Take care of your bones and they’ll take care of you!
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(1)Ducharme, N., “Male osteoporosis,” in Morley, J., (Ed.) The Aging Male: Clinics of Geriatric Medicine. 2010; 26(2):301-09
(2)Gruntmanis, U., “Male osteoporosis: deadly, but ignored,” Amer Jour Med Sci 2007; 333:85-92.
(3)The combination of aging and estrogen loss results in a 20% to 25% decline in absorptive function from age 40-60 years.
(4)Menopause is associated with a decline in intestinal calcium absorption and an increase in urinary calcium excretion which leads to a lower calcium levels and consequently the patient has bone loss.
(5)Heaney R., et al., “Menopausal changes in calcium balance performance,” Jour Lab Clin Med 1978; 92:953-63.
(6)Arjandi, B., et al., “Evidence for estrogen receptor-linked calcium transport in the intestine,” Bone Miner 1993; 21:63-74.
(7)Dick, I., et al., “Estrogen and androgen regulation of plasma membrane calcium pump activity in immortalized distal tubule kidney cells,” Mol Cell Endocrinol 2003; 212:11-8.
8)Bone, H., et al., “Alendronate and estrogen effects on postmenopausal women with low bone mineral density,” Alendronate/Estrogen Study Group,” Jour Clin Endocrinol Metab 2000; 85(2):720-26.
(9)Greenspan, S., et al., “Combination therapy with hormone replacement and alendronate for prevention of one loss in elderly women: a randomized controlled trial,” JAMA 2003; 289(19):2525-33.
(10)The anti-fracture rate reported from the Women’s Health Initiative Study revealed that estrogen was equal to anti-resorptive agents.
Rossouw, J., et al., “Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial,” JAMA 2002; 88(3):321-33.
(11) Canderelli, R., et al., “Benefits of hormone replacement therapy in postmenopausal women,” Jour Amer AcadNurse Pract 2007; 119(12):635-41.
(12)Davis SR, McCloud P, Strauss BJ, Burger H. Testosterone enhances estradiol’s effects on postmenopausal bone density and sexuality. Maturitas. 1995 Apr;21(3):227-36.
(13)Barrett-Connor E. Menopause, atherosclerosis, and coronary artery disease. Curr Opin Pharmacol. 2013 Apr;13(2):186-91. doi: 10.1016/j.coph.2013.01.005. Epub 2013 Jan 23.
(14)van Staa TP, Sprafka JM. Study of adverse outcomes in women using testosterone therapy. Maturitas. 2009 Jan 20;62(1):76-80. Epub 2008 Dec