Osteoporosis

1 What is Osteoporosis?

Osteoporosis is the most common type of bone disease characterized by decreased bone strength, which leads to an increased risk of fractures due to brittle nature of bones.

The bones become so weak and fragile that even a minor stress or strain such as bending over, lifting or coughing can lead to a spontaneous fracture.

Osteoporosis occurs if the formation of new bone does not keep up with the removal of old bone. It may affect men and women of all races, but White and Asian women — particularly elderly women who have attained menopause — are at a highest risk.

Osteoporosis-related fractures most commonly occur in the bones of the hip, wrist, and spine, though any bone may be affected.

Some fractures, especially of the hip can cause permanently disability. Spine fractures are most common, and collapsed vertebrae may be diagnosed only when the person develops severe back pain, decreased height, or a stooped or hunched posture.

Most people believe that osteoporosis is an unavoidable, and occurs as a part of aging.

But medications, healthy diet and weight-bearing exercise can help prevent bone loss or strengthen already weak bones.

osteoperosis

2 Symptoms

Osteoporosis is often called a “silent disease,” because the disease progresses with no signs and symptoms until a fracture occurs. You may not be aware of your bone loss until a bump, fall or minor strain causes fracture. There will be no symptoms during the early stages of osteoporosis.

Once your bones have become weak due to osteoporosis, certain signs and symptoms occur, which include:

  • Back pain, caused by a compression fracture or collapsed vertebra
  • Gradual loss of height as much as 6 inches
  • A stooped posture
  • A bone fracture that occurs more easily than expected

When to see a doctor

You may consult your doctor if you have had early menopause, been on long-term use of corticosteroids for several months at a time, or if either of your parents had hip fractures in the past.

3 Causes

Osteoporosis has a variety of causes, and they all depend on the unique case of the individual.

Your bones are in a constant state of renewal, which means that new bone forms when the old bone is broken down.

At young age, your body has the capacity to create new bone more faster than it breaks down old bone, and your bone mass increases. Most people attain their peak bone mass in their early 20s.

Stunted bone growth during the childhood can lead to a failure in reaching optimal peak bone mass, and as age advances, bone mass is lost faster than it is created.

The likelihood of developing osteoporosis depends on the amount of bone mass you have attained during your youth. The higher your peak bone mass, the greater is your bone reserve, and the less likely you are to develop osteoporosis when bone loss occurs as a result of factors such as aging, menopause or other medical conditions that cause increased inflammation in the body.

In women, reduction in the estrogen production that occurs due to natural menopause, surgical removal of the ovaries, or chemotherapy or radiation treatments for cancer, can lead to bone loss, and eventually osteoporosis. Estrogen hormone plays an important role in building and maintaining bone.

In men, the testosterone levels start declining gradually after middle age, which contributes to bone loss.

Bone loss may also be associated with eating disorders, certain medications and treatments. Long term use of antiseizure medications and steroid medications can lead to osteoporosis.

Other causes of osteoporosis include

  • Alcoholism
  • Hyperthyroidism, kidney disease, and certain gastrointestinal disorders
  • Malabsorption of calcium from your food after gastric bypass surgery
  • Extended periods of bed rest due to prolonged illness

Sometimes, bone loss may occur without any known cause. Thin bones and increased bone loss runs in families. Often, white, elderly women are more likely to have bone loss and osteoporosis.

4 Making a Diagnosis

Your family doctor may advise bone density tests as diagnostic test for osteoporosis, which is recommended for all women by the age of 65. Guidelines also recommend screening in men by the age of 70, especially if there are health problems that are likely to cause osteoporosis.

If the results of your bone density test is abnormal or if you have other complex health disorders, such as kidney dysfunction, you will be referred to a doctor who specializes in metabolic disorders (endocrinologist) or a doctor who specializes in diseases of the joints, muscles or bones (rheumatologist). Here is some information that helps you get ready for your appointment, and what to expect from your doctor.

What you can do?

  • Write down the symptoms you have noticed, though it may be possible that you may not have any.
  • Note down your key personal information, including any major stresses or recent life changes.
  • Make a list of all regular medications, vitamins and supplements that you are taking or have taken in the past. It is very helpful if you record the type and dose of calcium and vitamin D supplements. It may be better if you carry the bottles along if you are not sure about the information your doctor might need.

Write down questions to ask your doctor

Preparing a list of questions can save a lot of time to discuss about other issues. For osteoporosis, some basic questions to ask your doctor include:

  • Do I need to be screened for osteoporosis?
  • What type of tests will be needed to confirm the diagnosis?
  • What kind of treatments are available, and which one do you recommend?
  • Do any side effects occur from treatment?
  • Is there any generic alternative to the medicine you have prescribed to me?
  • Are there any alternatives to the primary approach that you have suggested?
  • How can I best manage my other health conditions together?
  • Should I follow any activity restrictions?
  • Will dietary changes help?
  • Do I need to take supplements?
  • Will a physical therapy program be beneficial to me?
  • How do I prevent falls?

What to expect from your doctor

Your doctor may ask you a number of questions. Be ready to answer them so that you will have enough time to go over any points that need more time to be spent on. Your doctor may ask:

  • Have you experienced any fractures or broken bones?
  • Have you noticed a decrease in your height?
  • How is your diet, especially dairy intake?
  • Do you take adequate amount of calcium and vitamin D?
  • Do you take any vitamins or supplements?
  • Do you exercise regularly?
  • Did you exercise more or less in the past?
  • Do either of your parents have osteoporosis?
  • Has anyone in your family had bone fractures, especially hip fractures?
  • Have you ever had stomach or intestinal surgery?
  • Are you suffering from chronic diarrhea?
  • Were you on long-term corticosteroid medications (prednisone, cortisone) such as pills, injections, suppositories or creams?

Your bone mineral density is measured through DEXA scan that uses a low radiation X-ray to determine the proportion of minerals in your bones. This is a painless procedure, and in most cases, it measures the density in the hip, wrist, and spine bones. This test is used to:

  • Diagnose bone loss and osteoporosis
  • Predict your risk of future bone fractures
  • Check the efficacy of your osteoporosis medicine

A newer technique of low-radiation spine X-ray called a vertebral fracture assessment (VFA) is often done along with a DEXA to identify fractures that occur without any symptoms.

Certain blood and urine tests will be ordered in case the cause of your osteoporosis is suspected to be a medical condition, rather than the gradual bone loss that results with aging.

5 Treatment

The treatment plan for osteoporosis is based on an estimate of your risk of having a broken bone in the next 10 years with information obtained from bone density test. If your risk is not very high, treatment involves lifestyle changes such as dietary and risk factor modifications, regular exercise routine, and taking vitamin D and calcium supplements.

In both men and women at increased risk of fracture, the main drugs prescribed to prevent and treat osteoporosis are bisphosphonates. These medications block the activity of cells causing bone loss. Examples include:

Side effects of these drugs include nausea, pain in the abdomen, difficulty in swallowing, and an increased risk of an esophageal inflammation or ulcers. These occur rarely if the medicine is taken in a proper way.

Intravenous forms of bisphosphonates do not cause stomach upset. It may be more convenient to schedule either a quarterly or yearly injection than to remember a weekly or monthly pill. Bisphosphonate therapy for more than five years has been associated with a rare problem in which the middle of the thighbone cracks or even breaks down completely.

Bisphosphonates may also affect the jawbone leading to osteonecrosis of the jaw, a rare condition that usually occurs after a tooth extraction, which involves deteorioration of a section of the jawbone.

Hormone-related therapy

Estrogen and combined estrogen and progestin (hormone therapy) is helpful in prevention of postmenopausal osteoporosis, especially when started soon after menopause, it can help maintain bone density. However, estrogen therapy can increase a woman's risk of blood clots, endometrial cancer, breast cancer, and possibly heart disease.

Therefore, estrogen is typically used for bone health only if menopausal symptoms also require treatment. Raloxifene (Evista) mimics estrogen's beneficial effects on bone density in postmenopausal women, without some of the risks associated with estrogen. Taking this drug may also reduce the risk of some types of breast cancer. Hot flashes are a common side effect. Raloxifene also may increase your risk of blood clots.

Estrogen without progestin is advised in women who have undergone hysterectomy (surgical removal of uterus), because estrogen increases the risk of developing cancer of the uterine lining and progestin reduces that risk.
In men, osteoporosis may be linked with a gradual age-related decline in testosterone levels. Testosterone replacement therapy increases bone density, but osteoporosis medications are also recommended.

Calcitonin:

A man-made form of this hormone is approved for the treatment of osteoporosis in women who are at least 5 years beyond menopause, and to treat sudden pain experienced during a spine fracture. Calcitonin is a hormone responsible for calcium regulation and bone metabolism.

Parathyroid hormone:

A type of human parathyroid hormone (PTH) is approved for treatment in postmenopausal women and men with osteoporosis who are at high risk for having a fracture. But, the use of this therapy for more than 2 years is not advisable.

Estrogen agonists/antagonists:

An estrogen agonist/antagonist, also called a selective estrogen receptor modulator or SERM is approved for the prevention and treatment of osteoporosis in postmenopausal women. SERMs are not estrogens, but they only have estrogen-like effects on certain tissues and estrogen-blocking effects on other tissues.

Other osteoporosis medications

If you are not able to tolerate the more common treatments for osteoporosis or if they are ineffective, your doctor might suggest these medications:

Denosumab (Prolia):

Compared with bisphosphonates, denosumab reduces bone loss and increases bone density, thereby reduces the chance of all types of fractures. This medication is delivered through an injection under the skin, which is given every six months. The most common side effects are back and muscle pain.

Teriparatide (Forteo):

This drug is a man-made form of hormone, similar to parathyroid hormone that stimulates new bone growth. It is given through an injection under the skin. Treatment with teriparatide is given for two years, after which, another osteoporosis medication is prescribed to maintain the new bone growth. This drug is only for patients with severe osteoporosis.

Exercise helps in preserving bone density in older adults. Some exercises that can reduce your chances of a fracture include:

  • Weight-bearing exercises such as walking, jogging, and dancing
  • Balance exercises such as tai chi and Yoga

Avoid performing any activity or exercise that involves a risk of falls. Avoid high-impact exercises that may cause fractures in older adults.

6 Prevention

In order to prevent osteoporosis, you need to build and keep your bones healthy throughout your life. Ensure that you get enough amounts of calcium and vitamin D by following a healthy and well-balanced diet.

Calcium

Men and women between the ages of 18 and 50 require 1,000 milligrams of calcium every day. This daily need increases to 1,200 milligrams in women above the age of 50 and men above 70 years. Good dietary sources of calcium include:

  • Low-fat milk and milk products (200 to 300 milligrams per serving)
  • Dark green leafy vegetables
  • Canned salmon or sardines with bones
  • Soy products, such as tofu
  • Calcium-fortified cereals

You can also take calcium supplements if you do not get enough calcium from your diet alone. However, avoid excessive intake of calcium as it can lead to heart problems and kidney stones. The Institute of Medicine has recommended that total calcium intake, from supplements and diet together, should be not exceed 2,000 milligrams a day for people above 50 years of age.

Vitamin D

Vitamin D is important as it improves your body's ability to absorb calcium. Most people derive adequate amounts of vitamin D from sunlight, but this may not be possible if you stay at high latitudes, if you are housebound, or if you apply sunscreens regularly or avoid the sun completely because of the risk of skin cancer.

The optimal daily dose of vitamin D is not yet known clearly. A good starting dose for adults is 600-800 international units (IU) per day, through food or supplements. If your blood levels of vitamin D are very low, your doctor may suggest higher doses of vitamin D supplements. Teenagers and adults can safely take up to 4,000 international units (IU) per day.

Regular exercise

Regular exercises are helpful to your bones no matter from when you start doing, but it will be most beneficial if you start exercising every day right from an young age, and continue to exercise throughout your life. Exercise helps in building strong bones and slowing down bone loss.

Combine strength training exercises with weight-bearing exercises. Strength training exercises strengthen your muscles and bones in your arms and upper part of your spine, and weight-bearing exercises — such as walking, jogging, running, stair climbing, skipping rope, skiing, and impact-producing sports are helpful to the bones in your legs, hips, and lower spine.

Other tips for prevention of osteoporosis include:

Do not smoke or drink large amounts of alcohol
Taking medicines that treat osteoporosis and prevent fractures. Ask your doctor to suggest the right medication for you.

7 Alternative and Homeopathic Remedies

A few alternative remedies exist to protect from osteoporosis.

Isoflavones that are naturally found in soybeans are similar to the female hormone – estrogen in structure.

Research has shown that they can be used as an alternative to estrogen therapy in postmenopausal women to protect from osteoporosis.

Several studies have been conducted to check the effects of soy isoflavones on bone health, but the mixed effects have been detected, which ranges from a modest impact to no effect.

The benefits of these compounds on bone health is yet to be fully evaluated.

8 Lifestyle and Coping

Here are some lifestyle measures you can take to reduce your risk of having broken bones due to osteoporosis:

  • Quit smoking: Smoking further increases the rate of bone loss and your chance of experiencing a fracture.
  • Avoid drinking excess amounts of alcohol: Consumption of more than two drinks per day may hinder bone formation. In addition, being under the influence of alcohol can also increase your risk of falling.
  • Follow safety measures at home to prevent falls: Always wear footwear with low-heels and non-slip soles. Keep away unnecessary clutter, loose electrical cords, area rugs, and avoid slippery surfaces that might cause you to trip or fall. Keep your house brightly lit, fit grab bars just inside and outside your shower door, and make sure you can get into and out of your bed without any difficulty.

9 Risks and Complications

Most people with osteoporosis have a number of risk factors for osteoporosis, but some people may not have identified risk factors. There are some risk factors that you are not able to change, and others that can be modified. Various factors can increase your likelihood of developing osteoporosis — including your age, race, lifestyle choices, and medical conditions and treatments.

Some risk factors of osteoporosis are out of control, including:

  • Gender: Your risk of developing osteoporosis is greater if you are a woman because of lower peak bone mass and comparatively smaller bones than men. Women also tend to have more rapid bone loss in middle age due to the striking decrease in estrogen levels associated with menopause.
  • Age: Bone loss increases with advancing age, and your bone becomes weak as you get old. The older you are, the greater is your risk of osteoporosis.
  • Race: Caucasian women are at a greatest risk of osteoporosis.
  • Family history: The predisposition to osteoporosis appears to be hereditary as people tend to have reduced bone mass and increased risk of fractures if their parents or siblings have had a history of osteoporosis.
  • Body frame size: Men and women with a thin and taller body frame are at a higher risk of osteoporosis as they will have very less bone mass to draw from when they grow older.

Risk factors you can or may be able to change:

  • Hormone levels: Osteoporosis is common in people with certain hormonal imbalances in their body. Examples include:
  • Sex hormone deficiency: Lowered estrogen levels in postmenopausal women increase their risk of developing osteoporosis. Certain cancer treatment in women may also lead to a drop in estrogen levels. A gradual reduction in the testosterone levels occurs in menas age advances. Low testosterone and estrogen levels in men undergoing treatment for prostate cancer also increases the risk of osteoporosis.
  • Thyroid problems: Abnormally high levels of thyroid hormone can cause bone loss. This occurs if your thyroid gland is overactive or if you are taking excessive thyroid hormone medications to treat hypothyroidism.
  • Other glands: Osteoporosis is also associated with overactive parathyroid and adrenal glands.
  • Dietary factors: Osteoporosis is more likely to occur in people who have:
  • Low calcium intake: A lifelong lack of calcium plays a major role in the development of osteoporosis. A diet low in calcium and vitamin D contributes to reduced bone density, early bone loss, and an increased risk of fractures. Inadequate intake of calories and excessive dieting is detrimental to bone health.
  • Eating disorders: People with an eating disorder called anorexia nervosa are malnourished and have abnormally low body weight that adversely affects bone health and increases the risk of osteoporosis. In women, anorexia can cause amenorrhea (absence of menstruation), which can lead to weak bones. In men, anorexia reduces the level of sex hormones in the body that leads to weak bones.
  • Certain medical conditions: Certain genetic, endocrine, gastrointestinal, blood, and rheumatic disorders—are associated with a greater risk for osteoporosis. Late onset of puberty and early menopause decreases the lifetime estrogen exposure in women, and thereby increases the risk of osteoporosis. 
  • Steroids and other medications: Continual use of oral or injected corticosteroid medications, such as prednisone and cortisone, interferes with the bone-rebuilding process leading to bone loss and increased risk of osteoporosis. Osteoporosis has been associated with medications used to combat or prevent:
  • Seizures
  • Gastric reflux
  • Cancer
  • Transplant rejection

Other medications that may cause bone loss include anticoagulants such as heparin, immunosuppressive drugs such as cyclosporine, and drugs used to treat prostate cancer.

Lifestyle choices

Some habits can increase your risk of osteoporosis. For example:

  • Inactive lifestyle or prolonged bed-rest: People with a sedentary lifestyle have a higher risk of osteoporosis than do those who are physically active. Extended periods of inactivity or low levels of physical activity can lead to an increased rate of bone loss. Weight-bearing exercises and activities that promote balance and good posture are beneficial for your bones, but walking, running, jumping, dancing, and weightlifting are especially helpful.
  • Consumption of large amounts of alcohol:Long-term consumption of more than two alcoholic drinks a day significantly increases your risk of osteoporosis.
  • Smoking and tobacco use: Tobocco use contributes to weak bones, but the exact reason for the harmful effects of smoking and tobacco use is unclear.
  • Bone fractures, particularly in the spine or hip, are the most serious complications of osteoporosis.

Hip fractures, commonly are a result of a fall, and cause disability and even death due to postoperative complications, especially in older adults. Sometimes, spinal fractures may occur even if you have not fallen. The bones that make up your spine (vertebrae) may become so weak that they may collapse, which results in back pain, loss of height, and a hunched forward posture.

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