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The second major thief of menopause is osteoporosis.

Margie is very good at giving care to everyone else—her laundry-toting postadolescent kids and the battered women she works with at the community center in her college town. Still blond, though aware she is white at the roots, Margie will turn fifty this year. "Oh, shit, my number's up" was her reaction. Her doctor told her ten years ago she was a sitting duck for osteoporosis. Small-boned, she remembers her statuesque mother shrinking about seven inches to a mere five feet tall before she died. "I already know I have bone thinning," she admits.

Typically she resists addressing the issue because that would mean her good-bye to youth. "I'll take hormones when I get there."

"What's there?" her girlfriend challenged her.

"You know, old."

Old is too old to start protecting bones. By the time anybody can see osteoporosis, it's too late to reverse it. As you'll recall, we begin to lose bone after the age of thirty-five; the normal rate of loss is about one percent a year. "When you hit fifty, bone loss accelerates to about a percent and a half each year for about ten years," says epidemiologist Trudy Bush, quoting the studies. "Then it levels off again at one percent a year."

Two factors determine a woman's risk of having significant bone loss during this transition. First, her genetic background, and here nature turns the tables on our Western beauty ideal. "I could look at a woman and bet her risks of osteoporosis—fair-skinned, very thin, a smoker, and an early menopause—and usually she'll be symptomatic," says Dr. Lewis Kuller of the University of Pittsburgh School of Public Health.

The second factor is: How strong are the bones a woman has built at her peak? About one third of American women of all ages are calcium-deficient. "The preoccupation of teenage girls is with thin thighs, not good bone, so they get into the habit of drinking diet soda instead of milk," laments Dr. Barrett-Connor. But generational differences here are striking. The frail women who are now immobilized in nursing homes are a different breed from baby boomers who are out there bouncing from work to gym in their nitrogen-cushioned aerobic shoes, popping calcium and snacking on veggies.

Porous bones, which lead to increased risk of fractures, are a major public health problem. One third to one half of all postmenopausal women—and nearly half of all people over age seventy-five—will be affected by this disease, maintains the National Osteoporosis Foundation in the U.S. Almost a third of women aged sixty-five and over will suffer spinal fractures. And of those who fall and fracture a hip, one in five will not survive a year (usually because of postsurgical complications).

Untreated, not only do older women die from the consequences of osteoporosis, but it often leaves older women frail, susceptible to falls and broken bones, as well as to the little tortures of hairline fractures in the bones they use for walking and bending—and this by their sixties. Later, in their seventies, osteoporosis makes it painful merely to sit on hipbones pulverized almost into powder; it keeps many women homebound, later even chairbound, and is one of the primary reasons an independent woman will finally succumb to nursing home admission.

Taking calcium supplements alone cannot undo the damage done by the loss of estrogen during the period of accelerated loss. And contrary to conventional wisdom, exercise by itself is also ineffective in preventing bone loss. These were the results of a study on prevention of postmenopausal osteoporosis reported in the New England Journal of Medicine (October 24, 1991). Two regimens were found to be effective. An exercise program plus calcium supplements slowed or stopped bone loss. The best results were obtained when estrogen was combined with exercise: Bone mass was increased, and other symptoms—hot flashes and sleepless1 ness—improved after three months.

Vitamin K has been found to inhibit the precipitous loss of calcium in postmenopausal women by up to 50 percent, in a study from the Netherlands. Dark green leafy vegetables like broccoli and brussels sprouts are sources of Vitamin K.

What kind of exercise works for osteoporosis prevention? The slogging pedaler on a stationary bike is not doing her bones much good, and swimming doesn't help, according to Dr. Richard Bockman, head of the endocrine department and co-director of the Osteoporosis Center at New York's Hospital for Special Surgery. The weight of the body has to be carried by the bones in order to stimulate bone strength. Brisk jogging requires a push-off that is much greater than one's body weight. The point is that one needs stress on that hip, and brisk walking can increase that stress in a natural way. "Everyone can walk briskly," encourages Dr. Bockman. "Or do serious walking on a treadmill at a tilt, which gives you both weight bearing and aerobic benefit."

Robert Lindsay's study group at the Helen Hayes Bone Center confirms a measurable prevention of bone loss in postmenopausal women treated with 0.625 mg of Premarin plus Provera. It is not uncommon today to see women started on estrogen at age sixty or older. It is not too late. "There is pretty good evidence that giving estrogen will slow any further bone loss at least up until the age of seventy-five," says Dr. Lindsay. Estrogen won't reverse the attrition that has already taken place, but it will stop it from getting worse, he adds.

Dr. Stanley Birge at Washington University has introduced a radical notion into the debate: "The effect of estrogen on protecting against bone fractures may be due to maintaining high mental functioning." In the OASIS Fall and Hip Fracture Study, women over seventy who were on estrogen performed better on tasks measuring mental processing speed than women of the same age and education who were not on the hormone. Dr. Birge postulates that estrogen-deprived women over seventy are more likely to suffer the dreaded hip fracture, because when they lose their balance, they don't respond fast enough to break their fall. "Whereas women of the same age who had wrist fractures—evidence they did respond and break their fall—showed twice the mental processing speed."

Technological advances in machinery now make it possible to measure precisely the weight and strength of a woman's bones. Most major American cities with a medical center or university have bone densitometer machines (although many are used only for research). Whatever regimen of calcium and exercise and/ or hormones a woman tries can be evaluated against her own base line, to show annually how much bone she is maintaining or losing. It's the same principle as having annual mammograms.

"Physicians have to get used to thinking of bone mass measurement just as they think about a blood pressure measurement," urges Dr. Lindsay. Some Blue Cross health plans will pick up part of the cost of osteoporosis testing. Medicare does not yet reimburse for bone mass measurement. With regard to bone disease in older women, we are exactly where we were with breast cancer twenty years ago: Osteoporosis prevention hasn't yet been considered worthy—another example of the scandalous politics of women's health.


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