All women with HCV especially postmenopausal women, and women with cirrhosis should undergo bone-mineral-density testing in order to determine whether they have osteoporosis. Blood tests, by themselves, are an insufficient means of measuring bone density and calcium requirements.

There are some steps that can be taken to reduce the likelihood of osteoporosis. Women should supplement their diets with calcium (1,000 to 2,000 milligrams per day) and vitamin D (400 to 800 IU per day). Also, an exercise routine, including weight-bearing exercises, must be incorporated into one’s lifestyle. Weight-bearing exercises not only increase muscle size, but they increase underlying bone mass, thus decreasing the likelihood of osteoporosis. Smoking, alcohol, and excessive caffeine should be avoided as these factors may worsen osteoporosis

Estrogen-hormonal therapy has been demonstrated to increase bone mass. However, oral estrogen replacement should generally be avoided in women with HCV, as it may cause additional liver problems, such as worsening of cholestasis. Furthermore, estrogen supplementation may cause certain benign liver tumors, such as hemangiomas and/or hepatic adenomas, which are more common in women to enlarge. Estrogen patches are generally a safer choice. Implantable estrogen, a recent development, is probably safe, but long-term studies as to its effect on liver disease have not been done. Soy estrogen, originally thought to be a safe alternative, should be avoided, as recent reports have suggested that it may cause drug-induced hepatitis.

Biphosphonates are phosphate derivatives that bind to the surface of the bone, thereby blocking bone removal and decreasing bone loss. Currently, there are three biphosphonates - alendronate [Fosamax], etidronate [Didronal]) and risedronate [Actonel], that have been approved by the FDA for the prevention and treatment of osteoporosis. These medications have been shown to increase bone mass, prevent bone loss, and to decrease the incidence of bone fractures.

Fosamax and Actonal have the advantage of a once-a-week administration, as opposed to the alternative of daily administration.

Biphosphonates should be taken on an empty stomach, along with at least 8 ounces of water. The patient should swallow the tablet while in an upright position and not lie down for 30 minutes after taking this drug. Calcium should not be taken at the same time. Women at high risk for osteoporosis with HCV with may benefit from starting biphosphonate therapy before they develop osteoporosis.

Any woman who already has osteoporosis should begin biphosphonate therapy promptly. However, women with esophageal varices should probably avoid these medications because of the drugs capability to cause ulcers in the esophagus, which may precipitate esophageal variceal hemorrhage. Calcitonin (Miacalcin) is a hormone produced by the thyroid gland that decreases the release of calcium from the bones. Calcitonin has been shown to reduce the incidence of bone fractures and bone loss in postmenopausal women with osteoporosis.

Synthetic calcitonin, known as miacalcin, is FDA approved for the treatment of osteoporosis. When sprayed into the nose, miacalcin is quickly absorbed into the blood stream. It may be also be taken as a subcutaneous injection.

Miacalcin has also been shown to decrease bone pain associated with bone fractures caused by osteoporosis. In addition, it appears to be quite beneficial in preventing bone loss after liver transplantation. Thus, miacalcin can be an effective alternative for women who do not wish to take, or are unable to take, bisphosphonates.

Menstrual Cycles

Women with HCV on antiviral therapy treatment often report a variety of menstrual irregularities. And, menstrual irregularities are more common in women with cirrhosis than in women with less advanced disease Some menstrual changes that have been noted include: premature or delayed menses, decreased and prolonged menses, clotting and spotting during menstruation, and an increased incidence and intensity of premenstrual syndrome (PMS) symptoms. Menstruation typically returns to normal within 6 month of discontinuation of antiviral therapy.

It is also important to mention that since HCV can be present in menstrual blood, sanitary napkins or tampons should be placed in a leak-proof sealed bag and promptly disposed of. Also extra precautions (the use of dental dams and condoms) should be considered during and just after menstruation to decrease the chance of transmission, particularly if the sexual partner has open cuts or wounds.

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