a special program of the National Emergency Medicine Association (NEMA)

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Week: 586.7  

Guest: Dr. Diane Schneider, researcher, Univ. of California San Diego 

Topic: Estrogen/Osteoporosis 

Host/Producer: Steve Girard 

NEMA: When should a woman begin estrogen therapy to ward off osteoporosis? We find out in a few moments....  

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.  

NEMA: The loss of estrogen production after menopause seems to allow for increased osteoporosis...or loss of bone mass...late in life...which leads to fragile bones - easy to break - and potentially debilitating conditions. Estrogen therapy prevents osteoporosis, and therefore is essential in keeping a high quality of life during The 70’s and 80’s. We’re with Dr. Diane Schneider of the University of California, San Diego, who led a study aimed at gathering information on when estrogen therapy is started, and the resulting bone mass effects....  

SCHNEIDER: To give you a bit of background... this is what’s called an observational study, so we did not do anything specifically for treatment of these individuals. But instead we looked at them as far as what they had done over the past years, based on a community, outside of San Diego called Rancho Bernardo. And in this community we looked at originally about a thousand women. And out of that 1 thousand women, after we excluded them for things such as known low bones or osteoporosis, and that type of thing...we ended up with the 740 women. And then looked at what they had done over their lives since menopause, having to do with hormones. And we ended up with 5 different patterns of use. So: there were the women that never used estrogen. Then we looked at women who had used estrogen, and divided them up into two different groups...those women who are on current estrogen and those women who had, in the past, used estrogen. And then, within those groups, the past users, we looked at the individuals who had started at menopause versus the women who had started after age 60, and the same for the current users. We looked at past versus current use and then stratified by the time of onset of use, either around menopause or after age 60. So, within those 5 groups then, looking at their bone mineral density, because that was our objective... to look at the timing of use of estrogen and bone mineral density. We found that the women who had started estrogen at the time of menopause, and taken it for an average of 20 years had the highest bone mineral density, the highest bone mass - which was not a surprising feature - as well as the women who had never been on estrogen therapy had the lowest bone mineral density.  

NEMA: So, what part of the results gave us something to think, and talk about?  

SCHNEIDER: What the surprising finding was looking at the women who had started estrogen after age 60 - taking it for an average of 9 years - had nearly the same bone density as women who had taken it more then double the amount of time. In addition, that women who had used it in the past for an average of 10 years, starting at menopause, and then stopping it - which had been through the usual recommendation when these women who now average age is in the 70’s, when they have gone through menopause some 20 years ago. They had bone mineral density, or bone mass, that was not significantly different from women who had never taken estrogen. So the main sort of take away points are that for the best bone density, was to take estrogen starting at menopause and continuing until late life. The second point was that it may never be too late to start an estrogen, and that the women who started later had very good bone density. And the third point being that women who started estrogen that stopped it , discontinued it...that it did not convey any long term benefits.  

NEMA: So, it seems that the point of discussion is when women may need to begin estrogen therapy with the purpose of preventing osteoporosis in mind. There is an elevated risk of breast cancer that reportedly goes along with increased estrogen levels....and so, if the bone mineral density of those who started taking estrogen at or after age 60 is virtually the same as those who began taking therapy at menopause and are still taking it, there may be some benefit in starting the therapy later, when the risk of bone fractures increase...and with less breast cancer risk...?  

SCHNEIDER: That’s certainly what the study suggests that that perhaps may be a beneficial thing but based on this study alone it certainly would not be a recommendation. But it’s something that definitely needs to be looked at and studied before that type of recommendation could be made.  

NEMA: And that there is no lingering effect on bone mineral density, after taking estrogen for several years, was also interesting....  

SCHNEIDER: Right, because if you stop it, you lose its , benefit . It doesn’t hold over.  

NEMA: In talking about the next step for research in this area...is that something you’re interested in...or will you move to another area...?  

SCHNEIDER: No, in my own particular research, it is geared to bone and metabolism - having to do with primarily osteoporosis. In order to undertake, the type of study would be, quite actually, a long term study and with some major funding. So hopefully, if not us , someone else will be able to get some research funding to do that particular type of project.  

NEMA: What about the group of folks at the elderly community...will that pool of people be used for more study?  

SCHNEIDER: Now, at Rancho Bernardo we do have this study of osteoporosis, and we are hoping that we get additional funding through the National Institute on Aging, to do a thorough look at these individuals who are now getting quite old - theIr average age now being the 70’s... to look at the rates of bone loss in older individuals and for things that haven’t been looked at in the older , elderly population.  

NEMA: I’ve kind of gotten a crash course, the last couple of years, when my mom fell twice and broke both of her upper legs...that really kind of changed everything. It was amazing...and it’s amazing how it takes a personal interest in something that you really heighten your, education and awareness about things.  

SCHNEIDER: Unfortunately, that osteoporosis has been pretty much a silent disease that’s been ignored. Unlike other problems, like high blood pressure and hyperlipidemia, we don’t wait until someone has a heart attack or stroke before they treat their high blood pressure or high cholesterol. But what’s happened in osteoporosis, because there’s not that easy measurement in the office...like a blood pressure cuff or a blood test, sort of the ravages of osteoporosis occur without anybody , recognizing that the individual had low bone mass until a fracture occurs. So, it’s like one of the few silent diseases - we’ve been waiting for things to happen before we try to fix it. Hopefully, the future will change with education like you’re doing and not only the public, but physicians, so we can recognize this illness much earlier because people are surprised that they may have low bone mass, although they look totally normal...and that’s the whole point.  

NEMA: Just as aside here what what if someone says, well my mom suffered broken bones when she was older...I want to get myself checked out. Are there other tests, and how hard or easy are they to obtain to figure out if you are losing bone mass.  

SCHNEIDER: There’s something called bone densitometry, which is usually done through something called a deximachine which is short for dual energy x-ray absorbtiometry. Simple , tests usually done in radiology. There’s a very little amount of radiation, and usually an individual’s hip and spine is imaged, a very short test , takes less than 15 minutes. The average cost across the country is probably about 150 dollars and, for instance, in the state of California where I practice, Medicare reimburses 124-dollars.  

NEMA: The subjects’ bone density was tested in four places: the hip, the lumbar area of the spine, the end of the forearm bone near the wrist, and the mid part of the forearm. The study was documented in a recent article which appeared in the Journal of the American Medical Association . Again, the conclusions of this study seem to indicate the same benefits from starting estrogen therapy later, rather than continue them right after menopause. The side benefits include lowering the risk of breast cancer associated with taking estrogen, and the cost of getting therapy for several years. Our thanks to Dr. Diane Schneider of the University of California, San Diego.  

SPOT: 15 years in the prevention of heart disease, stroke and trauma - The National Emergency Medicine Association. This show is just part of what NEMA does. We send out millions of pieces of prevention information to people around the country, give grants to organizations in research, public information and emergency services, and have been instrumental in the creation and expansion of the Chest Pain Emergency Room movement. To play a role, call 800-332-6362.  

NEMA: Thanks for joining us for today’s program. If you have any comments or suggestions, contact this station. Or visit our home page at: www.nemahealth.org

...for a look at transcripts of this or past programs, or to find out more about the National Emergency Medicine Association. I’m Steve Girard at The Heart of the Matter.