What to know about osteoporosis
In people with osteoporosis, the bones become porous and weaker, increasing the risk of fractures, especially in the hip, spinal vertebrae, and some peripheral joints, such as the wrists.
The International Osteoporosis Foundation (IOF) estimate that over 44 million people in the United States currently have osteoporosis.
In this article, we look at how to treat osteoporosis, what causes it, and how a doctor diagnoses it.
Signs and symptoms
Breaking bones after falling lightly may be a sign of osteoporosis.
Osteoporosis develops slowly, and a person may not know they have it until they experience a fracture or break after a minor incident, such as a fall. Even a cough or sneeze can cause a break in osteoporotic bones.
Breaks will often occur in the hip, wrists, or the spinal vertebrae for people who have osteoporosis.
If a break occurs in the spinal vertebrae, it can lead to changes in posture, a stoop, and curvature of the spine. People might also notice a decrease in height or their clothes may not fit as well as they did previously.
When to see a doctor
Severe discomfort in any of the common locations for osteoporotic bone damage could indicate an unexpected or unidentified fracture.
People should seek medical evaluation as soon as they notice this type of pain.
Treatment aims to:
- slow or prevent the development of osteoporosis
- maintain healthy bone mineral density and bone mass
- prevent fractures
- reduce pain
- maximize the person's ability to continue with their daily life
People at risk of osteoporosis and fractures can use preventive lifestyle measures, supplements, and certain medications to achieve these goals.
Drugs that can help prevent and treat osteoporosis include:
Bisphosphonates: These are antiresorptive drugs that slow bone loss and reduce a person's fracture risk.
- Estrogen agonists or antagonists: Doctors also call these selective estrogen-receptor modulators, SERMS. Raloxifene (Evista) is one example. These can reduce the risk of spine fractures in women following menopause.
- Calcitonin (Calcimar, Miacalcin): This helps prevent spinal fracture in postmenopausal women and can help manage pain after a fracture.
- Parathyroid hormone, such as teriparatide (Forteo): The U.S. Food and Drug Administration (FDA) has approved this hormone for treating people with a high risk of fracture as it stimulates bone formation.
- Monoclonal antibodies (denosumab, romosozumab): These are immune therapies that some people with osteoporosis take after menopause. Romosuzumab carries an FDA black box warning due to possible adverse effects. Other types of estrogen and hormone therapy may help.
The future of osteoporosis treatment
Doctors may use stem cell therapy to treat osteoporosis in the future. In 2016, researchers found that injecting a particular kind of stem cell into mice reversed osteoporosis and bone loss in a way that could also benefit humans.
Scientists believe that genetic factors strongly determine bone density. Researchers are investigating which genes are responsible for bone formation and loss in the hope that this might offer new osteoporosis treatment in the future.
Causes and risk factors
Doctors have identified several risk factors for osteoporosis. Some are modifiable, but it is not possible to avoid others.
The body continually absorbs old bone tissue and generates new bone to maintain bone density, strength, and structural integrity.
Bone density peaks when a person is in their late 20s, and it starts to weaken at around 35 years of age, As a person grows older, bone breaks down faster than it rebuilds. Osteoporosis may develop if this breakdown occurs excessively.
It can affect both males and females, but it is most likely to occur in women after menopause because of the sudden decrease in estrogen. Estrogen normally protects women against osteoporosis.
The IOF advises that once people reach 50 years of age, 1 in 3 women and 1 in 5 men will experience fractures due to osteoporosis.
According to the American College of rheumatology, nonmodifiable risk factors include:
- Age: Risk increases after the mid-30s and especially after menopause.
- Reduced sex hormones: Lower estrogen levels appear to make it harder for bone to regenerate.
- Ethnicity: White people and Asian people have a higher risk than other ethnic groups.
- Height and weight: Being over 5 feet 7 inches tall or weighing under 125 pounds increases the risk.
- Genetic factors: Having a close family member with a diagnosis of hip fracture or osteoporosis makes osteoporosis more likely.
- Fracture history: A person over 50 years of age with previous fractures after a low-level injury is more likely to receive a diagnosis of osteoporosis.
Diet and lifestyle choices
Modifiable risk factors include:
Weight bearing exercise helps prevent osteoporosis. It places controlled stress on the bones, which encourages bone growth.
Drugs and health conditions
Taking certain medications may increase the risk of osteoporosis.
Some diseases or medications cause changes in hormone levels, and some drugs reduce bone mass.
Diseases that affect hormone levels include hyperthyroidism, hyperparathyroidism, and Cushing's syndrome.
Research published in 2015 suggests that transgender women who receive hormone treatment (HT) may have an increased risk of osteoporosis. However, using anti-androgens for a year before starting HT may reduce this risk.
Transgender men do not appear to have a high risk of osteoporosis. However, scientists need to carry out more research to confirm these findings.
Medical conditions that increase the risk include:
- some autoimmune diseases, such as rheumatoid arthritis and ankylosing spondylitis
- Cushing's syndrome, an adrenal gland disorder
- pituitary gland disorders
- hyperthyroidism and hyperparathyroidism
- a shortage of estrogen or testosterone
- problems with mineral absorption, such as celiac disease
Medications that raise the risk include:
- glucocorticoids and corticosteroids, including prednisone and prednisolone
- thyroid hormone
- anticoagulants and blood-thinners, including heparin and warfarin
- protein-pump inhibitors (PPIs) and other antacids that adversely affect mineral status
- some antidepressant medications
- some vitamin A (retinoid) medications
- thiazide diuretics (https://www.uptodate.com/contents/drugs-that-affect-bone-metabolism)
- thiazolidinediones, used to treat type 2 diabetes, as these decrease bone formation
- some immunosuppressant agents, such as cyclosporine, which increase both bone resorption and formation
- aromatase inhibitors and other treatments that deplete sex hormones, such as anastrozole, or Arimidex
- some chemotherapeutic agents, including letrozole (Femara), used to treat breast cancer and leuprorelin (Lupron) for prostate cancer and other conditions
Glucocorticoid-induced osteoporosis is the most common type osteoporosis that develops due to medication use.
Certain alterations to lifestyle can reduce the risk of osteoporosis.
Calcium and vitamin D intake
Dairy products are a plentiful source of calcium, which can help a person reduce the risk of osteoporosis.
Calcium is essential for bones. People should make sure they consume enough calcium daily.
Adults aged 19 years and above should consume 1,000 milligrams (mg) of calcium a day. Women who are over 51 years of age and all adults from 71 years onward should have a daily intake of 1,200 mg.
Dietary sources include:
- dairy foods, such as milk, cheese, and yogurt
- green leafy vegetables, such as kale and broccoli
- fish with soft bones, such as tinned salmon and tuna
- fortified breakfast cereals
If a person's calcium intake is inadequate, supplements are an option. Calcium supplements are available for purchase online.
Vitamin D also plays a key role in preventing osteoporosis as it helps the body absorb calcium. Dietary sources include fortified foods, saltwater fish, and liver.
However, most vitamin D does not come from food but from sun exposure, so doctors recommend moderate, regular exposure to sunlight.
Other ways to minimize the risk are:
- avoiding smoking, as this can reduce the growth of new bone and decrease estrogen levels in women
- limiting alcohol intake to encourage healthy bones and prevent falls
- getting regular weight bearing exercise, such as walking, as this promotes healthy bones and strengthens their support from muscles
- exercises to promote flexibility and balance, such as yoga, which can reduce the risk of falls and fractures
Tips for fall prevention include:
- removing trip hazards, such as throw rugs and clutter
- having regular vision screenings and keeping eyewear up to date
- installing grab bars, for example, in the bathroom
- ensuring there is plenty of light in the home
- practicing exercise that helps with balance, such as tai chi
- asking the doctor to review medications, to reduce the risk of dizziness
The United States Preventive Services Task Force (USPSTF) recommend bone density screening for all women aged 65 years and over and younger women who are at high risk of experiencing a fracture.
A doctor will consider family history and any risk factors. If they suspect osteoporosis, they will request a bone mineral density scan (BMD).
Bone density scanning uses a type of X-ray known as dual-energy X-ray absorptiometry (DEXA).
DEXA can indicate the risk of osteoporotic fractures. It can also help monitor a person's response to treatment.
Two types of devices can carry out a DEXA scan:
- A central device: This is a hospital-based scan that measures hip and spine bone mineral density while the individual lies on a table.
- A peripheral device: This is a mobile machine that tests bone in the wrist, heel, or finger.
DEXA test results
Doctors give the results of the test as a DEXA T score or a Z score.
The T score compares an individual's bone mass with the peak bone mass of a younger person.
- -1.0 or above shows good bone strength
- from -1.1 to -2.4 suggests mild bone loss (osteopenia)
- -2.5 or below indicates osteoporosis
The Z score compares the bone mass with that of other people of a similar build and age.
A doctor will typically repeat the test every 2 years as this allows them to compare results.
An ultrasound scan of the heel bone is another method that doctors use for assessing osteoporosis, and they can carry it out in the primary care setting. It is less common than DEXA, and the doctors cannot compare the measurements against DEXA T scores.
As bones become weaker, fractures occur more frequently, and, with age, they take longer to heal.
This can lead to ongoing pain and loss of stature as bones in the spine begin to collapse. Some people take a long time to recover from a broken hip, and others may no longer be able to live independently.
Anyone concerned that they may be at risk of osteoporosis should ask their doctor about screening.
Does low bone density always lead to osteoporosis?
Osteopenia and osteoporosis can exist for some time before a person receives a diagnosis. Age plays a significant role in the onset of osteopenia and the risk of osteoporosis. Bone density peaks in the late 20s and starts to weaken as a person ages.
With aging, bone breaks down faster than it rebuilds, and this is what will determine the onset of osteoporosis.Brenda B. Spriggs, M.D. FACP Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.
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