Q&A: osteoporosis medications; who to trust when medical opinions differ; managing thinning hair; & vaccines for older adults

An assortment of your queries!

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In this week’s reader-submitted Q&A, we’re tackling these questions:

• What are the long-term risks of osteoporosis medications?

• How do I weigh differing medical opinions?

• How can I prevent hair thinning?

• What vaccines do you recommend for older adults?

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Disclaimer: The views expressed here are entirely my own. They are not a substitute for advice from your personal physician.

Photo by Raimond Klavins on Unsplash

The following subscriber questions have been lightly edited for length and clarity.

QUESTION #1: OSTEOPOROSIS MEDICATIONS

I am 66 years old and have been on Actonel for osteoporosis for the past 2 years. I understand that you can only be on this med for 5 years. What are the options after that and what are the risks of this medication?

-Nadine

Hi Nadine,

Actonel (risedronate) is a medication that helps slow bone loss and reduce fracture risk in people with osteoporosis. You're right—this type of medication, called a bisphosphonate, is usually prescribed for about five years. After that, we take a step back to reassess whether to continue, take a break, or switch to something else based on your individual fracture risk.

Here’s what to keep in mind:

Why the five-year limit? Long-term use of bisphosphonates can, in rare cases, lead to unusual side effects like fractures in the thigh bone or jaw problems. Since these medications stay in your bones for years, taking a break (sometimes called a "drug holiday") can lower the risk of these issues while still giving you continued protection against fractures.

What happens next?

• After five years, your doctor will likely check your fracture risk with a bone density scan (DEXA) and look at other factors like your history of fractures and overall health.

• If your fracture risk is low, you might take a break from Actonel and focus on lifestyle measures like getting enough calcium, vitamin D, and weight-bearing exercise. Your bone density would still be monitored every couple of years.

• If your fracture risk is high, switching to another medication may make sense. Some options include the following: 1) Prolia (denosumab), a twice-yearly injection that prevents bone loss. Unlike bisphosphonates, it stops working quickly once you stop taking it, so a transition plan is important. 2) Forteo (teriparatide) or Tymlos (abaloparatide), daily injections that actually help build new bone rather than just slowing bone loss. These are typically used for two years. 3) Evenity (romosozumab), a newer medication that both builds bone and slows its breakdown, given as a monthly injection for one year.

Are there risks if you stay on Actonel longer? The biggest concern with long-term use is the small risk of rare fractures or jaw issues, but the key is weighing these risks against the benefits—avoiding fractures that could impact your independence and quality of life.

The best approach depends on your overall health, fracture risk, and personal preferences. Now is a great time to check in with your doctor about whether a medication switch or a break is the right next step for you.

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QUESTION #2: WHO TO TRUST WHEN MEDICAL OPINIONS DIFFER

How do you suggest patients consider differing medical opinions? I have my PCP, preventative cardiologist and gyn who feel I need to consider a GLP-1. However, my GI doctor and RDN feel that it would do more harm than good. They cite that my labs are on the fence and that the side effects for GI systems may be an issue. They also cite concerns with muscle loss for supporting my bones (I have osteopenia) and loss of cardiac muscle. I respect and have a good relationship with all of them. I run into similar scenarios as the HCP for my aging parents. Their medical team members are amazing, yet often have very different opinions. So how do you suggest one navigates this?

-B

Hi B,

Thanks for writing. It can be very challenging to hear differing medical opinions, especially when you don't know who to trust more than someone else. It can even feel overwhelming when you trust and respect each member of your care team! It’s a common challenge, particularly when managing complex health concerns that cross multiple specialties. Here are some thoughts based on my experience:

First, consider your personal risk tolerance and goals. Are you more concerned about the long-term risks of not addressing metabolic concerns, or do the potential GI side effects and muscle loss feel like deal-breakers? If osteopenia is a major concern, strategies to preserve muscle—like strength training and adequate protein intake—should be part of the discussion whether or not you start the medication.

Identify the common ground. While your doctors may have different perspectives, they are all working toward the same goal—your best health. Look for the areas of agreement. In this case, everyone is invested in optimizing your metabolic health while minimizing risks.

Weigh risks and benefits based on your personal health landscape. Every medication, including GLP-1s, comes with trade-offs. Your PCP, cardiologist, and gynecologist may see the potential for improved metabolic health, while your GI doctor and dietitian are focusing on possible side effects and long-term impacts on muscle mass. Your job is to synthesize these perspectives within the context of your own health priorities.

Ask for a team discussion. If possible, see if your doctors can align on a plan. A virtual or in-person case conference may help bridge gaps in perspective. If that’s not feasible, consider having your PCP—who often acts as the central coordinator—help synthesize the various recommendations.

Trial and reassess. If you’re open to trying a GLP-1, you might decide on a trial period with careful monitoring of muscle mass, bone health, and side effects. If concerns arise, you can pivot.

This same framework applies when helping aging parents navigate their own medical decisions. Medicine is nuanced, and differing opinions don’t mean one doctor is right and another is wrong. They simply reflect different vantage points. Your role is to gather information, weigh it against your personal health goals, and make the most informed decision possible. I hope this helps!

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QUESTION #3: MANAGING THINNING HAIR

I am a 62 year old woman who never got on hormone therapy and am losing my hair... it is thinning and I can see my part and it is so distressing. Is this just how it is going to be? Or is there something I can do? Also how much of this is hormone related? Thank you.

-Colleen

Hi Colleen,

Hair thinning can be incredibly distressing—especially when it feels like it's happening all of a sudden. You are not alone in this, and the good news is that there are things we can do to address it.

First, let’s talk about the role of hormones. Estrogen and progesterone play a protective role in hair growth, helping to keep strands in their growth phase longer. When these hormones decline after menopause, hair can become finer, grow more slowly, and shed more easily. Androgenic alopecia—commonly called female pattern hair loss—is often triggered by this hormonal shift. Genetics also play a big role, as does overall health, stress, and nutritional status.

But thinning hair is not an inevitable sentence. Here are some steps to consider:

• Over-the-counter treatments – The most effective topical treatment for female pattern hair loss is minoxidil (Rogaine). It’s available without a prescription and can help stimulate hair growth and slow further loss. It requires consistency—results can take months—but it’s a well-studied, safe option.

• Prescription options – Some women benefit from medications that block the effects of androgens on hair follicles, like spironolactone. This is particularly helpful for those who notice hair thinning along with increased facial hair growth.

• Nutritional support – Protein, iron, vitamin D, and biotin all play key roles in hair health. If you have any underlying deficiencies, addressing them can make a difference.

• Scalp health – Think of your scalp as the soil in which your hair grows. Avoid excessive heat styling, harsh chemical treatments, and tight hairstyles that cause mechanical stress.

• Hormone therapy? – If you are within 10 years of menopause and experiencing other symptoms like hot flashes, sleep disturbances, or bone loss, menopausal hormone therapy (MHT) could be worth discussing with your doctor. While it’s not a first-line treatment for hair loss, some women find that it improves hair quality when started earlier in menopause.

• Stress management – Chronic stress and inflammation can accelerate hair thinning. Strategies like mindfulness, exercise, and prioritizing sleep can support hair health in indirect but meaningful ways.

The upshot: I don't think you have to accept this as the "new normal." There are real, evidence-based interventions to help slow hair loss and support regrowth. Last, I do suggest a conversation with your doctor or a dermatologist. Hopefully you can get more nuanced advice there :)

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QUESTION #4: VACCINES FOR OLDER ADULTS

I read recently that childhood diseases are coming back. It was recommended that older people update some vaccinations- whooping cough, polio for example. I’m 75 and I don’t want whooping cough! What do you recommend?

-Tamara

Tamara, you’re absolutely right—some childhood diseases, like whooping cough (pertussis) and measles, are making a comeback in certain areas, often due to declining vaccination rates. As we age, our immunity can wane, which is why staying up to date on vaccines is an important part of protecting your health.

Here’s what I’d recommend for someone in your situation:

• Tdap (Tetanus, Diphtheria, Pertussis): This is the vaccine that protects against whooping cough. If you haven’t had a Tdap booster as an adult, you should get one. If you’ve already had one, you only need a Td (tetanus and diphtheria) booster every 10 years.

• Polio: While the risk of polio is low in the U.S., it has re-emerged in some areas. If you were fully vaccinated as a child, you likely don’t need a booster. However, if you’re unsure of your status or were never vaccinated, a one-time booster may be recommended.

• Shingles: At 75, you should make sure you’ve had the two-dose Shingrix vaccine to protect against shingles and its complications, like postherpetic neuralgia.

• Pneumonia: The CDC recommends pneumonia vaccines (Prevnar 20 or Pneumovax 23) for adults over 65 to prevent serious lung infections.

• Flu and COVID-19: Annual flu shots and staying up to date on COVID-19 boosters help protect against severe illness, especially as respiratory viruses circulate more in colder months.

• RSV (Respiratory Syncytial Virus): A newer vaccine is now available for adults over 60, particularly those with chronic conditions like lung disease or heart disease. It’s worth discussing with your doctor.

Since vaccine recommendations can vary based on your personal health history, the best approach is to check in with your doctor to review what you may need. It’s great that you’re thinking ahead—vaccines are one of the easiest and most effective ways to stay healthy and avoid preventable illnesses.