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Mon, March 18

Dr. Roach: All medications have potential side effects

DEAR DR. ROACH: Would you please discuss the use of Evista for treatment of osteoporosis as an alternative to bisphosphonates? The decision of which medication to take is very confusing, since every one of them has serious side effects. I am trying to choose the lesser of the evils. – S.K.

ANSWER: Raloxifene (Evista) has some properties similar to estrogen and some properties opposite to it. It has two major benefits: It acts like estrogen in bones, increasing bone density and reducing fracture risk, and it acts as an anti-estrogen in normal breast tissue and breast cancer, reducing the risk of developing breast cancer. Raloxifene is not as effective as bisphosphonates (such as alendronate), so normally it is used in women who can’t or shouldn’t take bisphosphonates, or in women who have both an increased risk for breast cancer and osteoporotic fractures.

You are quite right that all medications have the potential for side effects, sometimes serious. For raloxifene, the most concerning is a risk for blood clots, similar to that of estrogen, with an increased risk for about 1 in 1,000 women taking the medication for a year. This needs to be balanced against the benefits of 1 fewer case of vertebral fractures and also 1 fewer case of invasive breast cancer per thousand women per year. A particular woman at very high risk for breast cancer or fracture would be expected to have more benefit, but those at higher risk for blood clots would likely have a higher increase in risk.

Not all women need medication treatment for osteoporosis, and I get many letters from women who are not appropriate candidates for medication but are still prescribed powerful drugs with significant side-effect risks. Medication treatment should be reserved only for women at high risk for fracture, based on a very low bone mineral density, previous fracture or

high risk of fracture based on their FRAX score (http://www.shef.ac.uk/FRAX/).

It’s always important to weigh the risks of a medication against the risks of not taking it.

DEAR DR. ROACH: You recently wrote about a surgically placed implant for erectile dysfunction. What gets implanted? And where? Thanks for your attention to my ignorance. – K.V.N.

ANSWER: Implants are reserved for men who have not had results from oral medications, and those who cannot use or who have failed injections and vacuum devices. An appropriate medical evaluation is appropriate for all men with erectile dysfunction.

There are several different types of implants, but the most commonly used is a three-component implant, which consists of two plastic inflatable cylinder prostheses placed surgically in the penis, with a fluid reservoir placed in the abdomen, and a small manual pump in the scrotum. The implants are inflated by the pump moving the fluid from the reservoir into the cylinders. All the components are internal.

With newer devices and surgical techniques, complication rates are lower (but still not zero), and patient satisfaction rates are well over 90 percent.

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