Dear Dr. Roach: I'm a 50-year-old post-menopausal woman, and my first bone density test (DEXA) came back showing osteoporosis in a portion of my spine and osteopenia in an area of my neck. I did a FRAX score, and it indicated my risk for a major osteoporotic fracture is 4.5 percent in 10 years. I'm reading a lot of conflicting information about the safety and efficacy of various medications, as well as whether or not lifestyle changes can improve bone density or just keep it from declining further.
I'm also at high risk of breast cancer, so my doctor is suggesting I consider raloxifene to "kill two birds with one stone." I don't take anything right now other than some vitamins.
A: Exactly when to begin medication treatment for osteoporosis remains controversial, and different experts in different countries have come to different conclusions. For example, in the U.S., cost-effectiveness analysis has shown that treatment (with generic bisphosphonates, such as alendronate) is effective when the 10-year risk for a major osteoporotic fracture exceeds 20 percent. In the U.K., pharmacologic treatment was found to be cost effective with a risk of 7 percent. In Canada, treatment is recommended if over 20 percent.
Given your preference not to take medicine and your low risk of fracture, medication for your osteoporosis wouldn't be recommended at this time. If your breast cancer risk were so high that raloxifene is recommended solely to reduce your risk of breast cancer, then I would see that making sense.
As far as what you can do to reduce risk of a fracture now, you should be doing the following: getting calcium through your diet and vitamin D (minimum 800 IU) through food and supplements, and having your vitamin D level checked; not smoking; exercising regularly (at least 30 minutes three times per week, ideally weight-bearing exercise or progressive resistance strength training); and avoiding excess alcohol.