Bones / OrthopedicsMenopauseOsteoporosisRheumatology

Osteoporosis: What to know

Osteoporosis results in reductions in bone density. The body is reabsorbing more bone tissue and creating less for replacement.

The bones become brittle and weaker in people with osteoporosis, raising the risk of fractures, particularly in the hip, spinal vertebrae and some peripheral joints such as wrists.

The International Osteoporosis Foundation (IOF) reports that osteoporosis actually exists in over 44 million individuals in the US.

In this post, we look at how osteoporosis is treated, what causes it and how it is diagnosed by a doctor.

Signs and symptoms

A lady on wheelchair
Breaking bones after falling lightly may be a sign of osteoporosis.

Osteoporosis progresses gradually, and a person does not know they have it until after a small accident, like a fall, they suffer a fracture or split. Even a cough or sneeze can cause the osteoporotic bones to break.

In those who have osteoporosis, breaks may also occur in the knee, hands, or spinal vertebrae.

When a split occurs in the vertebrae of the spinal cord, this may lead to changes in posture, stoop, and spine curvature. People also might notice a decrease in height or their clothes may not fit as well as they did previously.

When to see a doctor

Severe pain with osteoporotic bone damage at any of the typical locations may suggest an severe or unexplained fracture.

People should seek medical attention as soon as they feel this kind of discomfort.

Treatment

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

To achieve these goals, people at risk of osteoporosis and fractures can use preventive lifestyle steps, supplements, and some medications.

Drug therapy

Drugs that can help avoid osteoporosis and that can treat it include:

Bisphosphonates: These are antiresorptive drugs which slow down bone loss and reduce the risk of fracture in a person.

  • 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 continue to use stem cell therapy for potential treatment of osteoporosis. Researchers found in 2016 that injecting a specific form of stem cell into mice reversed osteoporosis and bone loss in a manner that could help humans, too.

Scientists say genetic factors are a heavy determinant of bone density. Researchers are researching which genes are responsible for bone formation and loss, hoping this may provide potential therapies for osteoporosis in the future.

Causes and risk factors

Doctors identified many risk factors linked to osteoporosis. Some are modifiable, but some can not be avoided.

The body is continuously removing old bone tissue and creating new bone to preserve bone density, strength, and integrity.

When an individual is in their late 20s, bone density peaks, and it starts to decline at around 35 years of age. As a person grows older, bone breaks down faster than it rebuilds. If this breakdown happens frequently, osteoporosis can develop.

It may affect both males and females but is more likely to occur in women following menopause due to the rapid decrease in estrogen. Estrogen usually protects women from osteoporosis.

The IOF advises that 1 in 3 women and 1 in 5 men will experience fractures due to osteoporosis once people reach age 50.

Unavoidable factors

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:

  • inactivity
  • immobility

Exercising weight bearing helps to avoid osteoporosis. It places regulated stress on the bones, promoting bone production.

Drugs and health conditions

Taking certain medications may increase the risk of osteoporosis.
Taking certain medications may increase the risk of osteoporosis.

Many diseases or medications cause changes in hormone levels, and other medications decrease bone mass.

Hyperthyroidism, hyperparathyroidism and Cushing ‘s syndrome are disorders that affect hormone levels.

Research reported in 2015 indicates that there could be an increased risk of osteoporosis among transgender women who undergo hormone treatment (HT). However this risk may be minimized by using anti-androgens for a year before beginning HT.

Transgender people do not appear to have an increased chance of osteoporosis. However, to validate those results, scientists need to perform further work.

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

Osteoporosis caused by glucocorticoids is the most common form of osteoporosis that occurs as a result of the use of medication.

Prevention

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.
Dairy products are a plentiful source of calcium, which can help a person reduce the risk of osteoporosis.

Calcium is essential to bones. People will see to it that they ingest enough calcium every day.

Adults aged 19 and over can eat 1,000 milligrams ( mg) of calcium a day. Women over the age of 51 and all adults over the age of 71 will get a regular intake of 1,200 mg.

Nutrition 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. 

Vitamin D also plays a vital role in osteoporosis prevention, as it helps the body absorb calcium. Sources of diet include fortified food, saltwater fish, and liver.

Some vitamin D, however, does not come from diet but from sun exposure, so doctors prescribe moderate, regular sunlight exposure.

Lifestyle factors

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

Nutrition, exercise, and fall prevention strategies play a key role in reducing the risk of fracture and the incidence of bone loss for people who already have osteoporosis.

Fall prevention

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 U.S. Preventive Services Task Force (USPSTF) recommends bone density screening for all women aged 65 and over, including younger women at high risk of fracture.

Diagnosis

A doctor must take the family background and any risk factors into account. If they suspect osteoporosis, a bone-mineral density scan (BMD) will be needed.

Bone density scanning uses an X-ray form, known as dual-energy X-ray absorptiometry (DEXA).

DEXA may indicate the risk of fractures from the osteoporotics. It can also assist in tracking a person’s reaction to treatment.

A DEXA scan can be carried out in two types of devices:

  • 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 view the test results as a DEXA T score or as a Z score.

The T-score measures a person ‘s bone mass to a younger person’s peak bone mass.

  • 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 to that of someone of a similar age and build.

Usually, a doctor will repeat the examination every 2 years as this helps them to compare outcomes.

Other tests

An ultrasound scan of the heel bone is another tool used by doctors to determine osteoporosis, which can be done in primary care. It is less common than DEXA, and the measurements can not be compared with DEXA T scores by the doctors.

Complications

As the bones get weaker, fractures occur more often, and they take longer to heal with age.

That can lead to chronic pain and loss of stature as bones begin to collapse in the spine. Some may take a long time to recover from a broken hip, and some do not live comfortably anymore.

Anyone worried that they might be at risk of osteoporosis should receive screening from their doctor.

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