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After she fell and broke her hand in 1996, Ann Richards, the former governor of Texas, had a bone mineral density test. Although her scores were low, Ms. Richards did not have osteoporosis. Instead, she learned she had an enigmatic and controversial condition known as "osteopenia," which meant that even though she was at risk for osteoporotic fractures of the hand, forearm, spine, or hips, her scores were not low enough for her to have osteoporosis.

Ann Richards is not alone. A new study by CUMC researchers found that women with osteopenia make up the majority of women who actually fracture, because they make up the majority of women. The study, led by Dr. Ethel Siris, the Madeline C. Stabile Professor of Clinical Medicine and director of the Toni Stabile Osteoporosis Center, found that 82 percent of women who had suffered a fracture within 1 year of a bone density test, had osteopenia, not osteoporosis.

Treating women with osteopenia, however, has been controversial. Many physicians feel osteopenia is a misleading label that causes a large number of women to receive unnecessary medications.

Other physicians argue that because these women constitute the majority of fracture patients, at least some of them require bone-preserving drugs. Bone fractures often have severe financial and health consequences; for example, 25 percent of older men and women who have hip and vertebral fractures live only one year after the fracture. Another 25 percent of patients are admitted to nursing homes.

"The decision to treat osteopenia has been highly controversial because we haven't had much data to support one path or the other," says Dr. Siris. "Now we have data that will begin to resolve these differences in opinion."

In a second paper, a team of researchers led by Dr. Siris found that some women with osteopenia have the same fracture risk as women with full-fledged osteoporosis and that by taking a few, easy-to-obtain factors into consideration along with bone density scores, physicians can identify these high-risk women. The researchers based their findings on data obtained from nearly 150,000 postmenopausal white women one year after they had taken a bone mineral density test. A density score less than –2.5 indicates osteoporosis; a score between –1.0 and –2.5 is labeled osteopenia. All of Dr. Siris's findings were published in two papers in the May 24 Archives of Internal Medicine.

The factors identified as the most important predictors of future fractures in postmenopausal women with osteopenia are previous fracture; bone density score of –1.8 or less; poor health; and poor mobility.

Osteopenic women who had sustained a fracture after age 45, regardless of the current bone density score, had a 4 percent risk of fracture in one year, equal to the risk of women with osteoporosis. Women with a bone density score of less than –1.8, poor mobility or poor health, had a one-year, 2 percent risk. And women with none of those factors had the same fracture risk, about 1 percent, as women with normal bone density scores. An algorithm based on the results correctly identified 74 percent of the osteopenic women in the study who sustained a fracture.

"Treatment of only the 18 percent of women with scores indicative of osteoporosis would have limited effect on reducing the number of women who sustain fractures," Dr. Siris says, adding that the high-risk osteopenic women identified by the algorithm may be good candidates for treatment. However, she warns, it's still unclear that giving bone-preserving drugs to women with osteopenia lowers fracture risk, because studies looking at fracture outcomes have not previously been done in osteopenic women.

"Because half of all menopausal women and one-quarter of older men experience fractures related to low bone mass, a lot of people think that broken bones are simply a fact of life in the elderly," Dr. Siris says. "People often end up in nursing homes and go through a lot of pain and suffering, but factures are not inevitable and osteoporosis can be prevented. A major research goal is to find ways to reduce this terrible burden."

Data from the studies come from the National Osteoporosis Risk Assessment, supported by Merck & Co., in collaboration with the International Society for Clinical Densitometry.

—Susan Conova


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