By Glenn S. Rothfeld, MD 

The question of estrogen replacement therapy (ERT) is hotly debated among women nearing menopause, their physicians, and the press. Many complex issues make this debate a lively one, but osteoporosis is perhaps the most complex and important one. And for good reason. Osteoporosis affects over 20 million Americans, and is expected to cost over $30 billion dollars annually by the end of the decade. These costs include fractures that currently number 1.5 million per year. The elderly, who account for most of these fractures, frequently require extensive rehabilitation, surgery, long-term care, and treatment of secondary problems like infection. Between 12 and 20% of elderly who fracture their hip die soon after.

So osteoporosis is not merely another nuisance of aging, but a severe and growing medical problem in the U.S. Unfortunately, much is not understood about this disease, and the present medical treatment is largely limited to TUMS, synthetic estrogens, and (in a growing number of women) strong drugs that prevent further damage to already diseased bones. To understand a natural approach to osteoporosis, we must appreciate how the many systems of the body work together to foster health.

Osteoporosis is defined as a loss of bone mass, and therefore, bone strength. This is very different from osteoarthritis, which is a wearing away of cartilage and bone at joints, and from diseases such as rickets and osteomalacia, which involve abnormal bone formation. Osteoporosis is not painful, in fact, it causes no symptoms until it is bad enough so that a fracture occurs, usually after many years of losing bone mass. Bone is constantly being broken down (reabsorbed) and formed again in a process called remodeling, which allows our bones to stay strong and to adapt to different situations. After age 40, bone is slowly lost in both sexes, and after menopause, women lose additional bone for about a decade. Thus the best strategy of preventing osteoporosis is to reach age 40-50 with as dense a bone as possible, so that the age-related loss will not be as serious.

Bone turnover is affected by diet, by nutrients, by many different bodyhormones, by physical activity, by stress and sleep, and by genetics. There clearly are environmental factors: women in Surinam in South America were found to have less osteoporosis than their North American counterparts despite having less calcium in their diet. Skeletons from 200 years ago show much less bone loss than today. Toxins that interfere with bone formation, fewer micronutrients in the diet, and modern-day stresses are all implicated.

A diet that supports bone health should be low in sugar and table salt, both of which promote loss of calcium in the urine. It should avoid soft drinks for the same reason, and because of calcium-wasting phosphates that are added to sodas. Non-starchy vegetables and fruits should be emphasized, and some protein as well. Grains, when eaten, should not be processed or refined. And as for dairy (the food most people and their doctors associate with calcium), it’s unclear. Dairy is certainly rich in calcium but that calcium is not as usable due to high phosphorus content in dairy, and other problems like lactose intolerance, allergy to milk protein and toxins in milk make it a mixed blessing.

The key nutrient of bone health is, of course, calcium, and calcium supplementation has been shown to benefit bones in a variety of ways, especially before and during menopause. All calcium is not the same, however, and the calcium in TUMS and similar products is calcium carbonate, one of the least absorbable sources. Calcium lactate, citrate, gluconate and aspartate are all well absorbed, and several studies have shown their increased availability over calcium carbonate. Of recent interest is some products containing something called microcrystalline hydroxyapatite concentrate (MCHC), which contains calcium in the form that it exists in bone, along with the other factors occurring in bone. This substance has shown superiority in several studies of bone density and fractures.

Contrary to popular ideas, the story of bone health doesn’t stop with calcium, however. Wherever calcium goes in the body, magnesium goes as well, and it comes as no surprise that over half the body’s magnesium is in the bones, and that magnesium deficiency leads to abnormal mineralization of bone. What causes magnesium deficiency? Just about any stress we are exposed to, including many medications, emotional stresses, prolonged illness or activity, and even loud noises! The best magnesium sources are the same as for calcium, and frequently these minerals are combined. The preferred ratio of calcium to magnesium is 1:1.5 or even 1:1, which usually means adding more magnesium.

Vitamin D is essential in calcium metabolism and, fortunately, we’ve been given a regular source of vitamin D, sunlight. Outdoor activity has many advantages, and vitamin D supplementation is one. Vitamin K, usually ignored except in bleeding situations, is essential in the forming of bone proteins, and prevents calcium loss in the urine. Boron, a trace mineral, also seems to have a regulating effect on calcium and bone metabolism, as well as the sex hormones estradiol and testosterone.

Which brings up the role of sex hormones in bone activity. Estrogen, contrary to popular understanding, does not treat osteoporosis. It prevents further breakdown of bone, and has been shown to prevent fractures after taking it for years post-menopausally. The body of evidence supporting estrogen usage in post-menopausal women is growing, and most physicians would agree that significant osteoporosis on bone density testing is a reason for hormone replacement, if otherwise appropriate. However, the timing and type of estrogen is still very much in question.

Some physicians prefer to control menopausal symptoms naturally (herbs, diet, acupuncture have all been effective) and to wait until age 60-65 to begin estrogen, since the main risk of estrogen therapy, breast cancer, is related to the total amount of exposure to estrogen. Others begin hormones at the time of menopause, trying to eliminate the larger bone loss around menopause. The studies have mostly used Premarin or other conjugated estradiols, one type of estrogen that is made in the ovary. Physicians interested in natural therapy frequently use estriol or a combination of different estrogens. Estriol, another natural estrogen, seems to be cancer-preventive, but it’s not clear whether it has the same effect on bone as estradiol. Finally, there are choices between oral and “patch” forms of estrogens.

Phytoestrogens, or plant-source estrogens, raise interesting possibilities. Soybeans, for instance, contain a substance called daidzein (similar to a medication in Europe used to treat osteoporosis). This and another isoflavone (the name for the estrogen-like substances) called genistein have been shown to stop bone loss in animals, to slow down calcium loss in urine, and to relieve menopausal symptoms.

Other hormones besides estrogen seem critical to bone health. There is a wealth of information suggesting that progesterone is important, not just to balance estrogen, but to promote bone growth. For instance, marathon runners who have maintained estrogen levels develop osteoporosis from progesterone loss. Progesterone is a tissue-building hormone, and thus it seems to promote bone formation, not prevent its loss. Most women are given Pro-Vera or similar medications, which is not progesterone but a synthetic imitation called a progestin. Progesterone itself can be given in a special oral preparation. It also can be given in a skin cream which is then absorbed. However, it is very hard to regulate the dose with skin creams, since progesterone accumulates in the fat tissue and may be released in bursts. Also, although yams are used to produce progesterone (and the other steroid hormones like DHEA) in the laboratory, the body cannot convert the yam substance to hormones, and therefore yam creams must have a hormone added to them to be effective.

Other hormones that are important in bone health are DHEA and testosterone, which are male (androgen) hormones and therefore tissue-building. Both hormones have been shown to be lower in women with osteoporosis, and to improve bone density and calcium balance. These hormones should generally be measured at menopause, and can be supplemented if low. Contrary to estrogen and progesterone, testosterone production does not decrease after menopause. DHEA may decrease, but if it does, it is associated with higher chronic disease and stress levels.

Recent chemicals have been developed to more aggressively prevent bone loss. These drugs (Fosamax, Didronel) do not grow bone once it’s been lost, and they have not been used long enough to establish long-term safety records. However, they are useful in cases of severe osteoporosis.

Exercise plays a major role in maintaining bone health. There is clear evidence that weight-bearing exercise helps to reach and to maintain bone density, at whatever age it is begun. Since the best strategy for preventing osteoporosis begins well before menopause (many women lose half their vertebral bone before the estrogen levels go down), an exercise program should begin when younger. However, even someone already showing signs of bone loss will benefit from exercise. This may be careful weight training, walking, movement sports and dancing. Also, yoga and qigong are exercise systems well-suited to older people anxious to maintain strength and mobility.

Finally, one can’t say enough about the importance of stress management. As odd as it sounds that stress causes bone loss, some estimates of the effect of chronic stress on bones are as high as 50% of the total effect. This is because stress raises the adrenal hormone cortisol, which has a strong demineralizing effect on bones. Lack of restful sleep has also been shown to affect the formation of new bone the following day. Since an adrenal gland overproducing cortisol and other stress hormones will tend to underproduce estrogen, DHEA and other hormones essential to bone health, the effect is cumulative. . Recently, salivary assays have been developed to measure the stress hormones and sexual hormones over the course of a day and throughout a month€™s cycle.

Osteoporosis is certainly one of the ravages of age, but it doesn’t have to be. The prevention and treatment of this illness can demonstrate a good Integrative Medicine approach, combining the best of nutrition, lifestyle modification, stress management, herbal therapies, and the wise use of medication in cases where it is necessary.

To implement a program based on Dr. Rothfeld’s recommendations, you may order the following supplements:

OsteoPrime Forte (a nutritional formula designed to match the nutrients that have been shown to combat osteoporosis) 2 capsules after each meal

We don’t recommend taking hormonal substances like DHEA and progesterone except under a doctor’s care. In our office, we test the hormone levels in saliva assays before prescribing any hormone therapy, even progesterone creams and melatonin.

If you wish to have more information about salivary hormone testing, click here.

Other supplements that may be helpful for stress relief and sleep difficulties are:

Valsed (an herbal formula containing relaxing herbs and nutrients) 2 after each meal, 4 at night

SpectraChrome (a nutritional formula for low blood sugar) 2 after breakfast and lunch

We recommend the book by Dr. Alan Gaby, who designed the OsteoPrime Forte supplement. The book is called: Preventing and Reversing Osteoporosis. To order this book, click here.

[Please notify your doctor that you are planning on taking these supplements. This program is not a substitute for regular medical care, and does not purport to treat specific medical illnesses.]