Bone Health, Osteopenia and Osteoporosis
What is Osteoporosis?
Osteoporosis (porous bones) is a bone state in which the amount of bone is decreased and the structural integrity of trabecular bone is impaired. Cortical bone becomes more porous and thinner. This makes the bone weaker and more likely to fracture.
This image show trabecular bone structure in the lower spine of a healthy adult compared to an adult with osteoporosis.
Normally, the body forms enough new bone tissue to balance the amount of bone tissue broken down and absorbed by the body. This is a natural process called bone turnover. Throughout the early part of your life, the amount of bone lost and the amount gained remains balanced. Bone mass (size and thickness) increases during childhood and early adult life, reaching its maximum by the age of 20 to 25.
Menopause, which usually occurs in a woman’s 40s or 50s, dramatically speeds bone loss. Older men lose bone mass as they age, as well, but much slower. Osteoporosis develops when your body loses bone faster than it can form new bone. Over time, the imbalance between bone breakdown and formation causes bone mass to decrease, so fractures occur more easily.
Bones in the hip, spine, and wrist are especially prone to fragility fractures—fractures that would not have occurred in a younger person with stronger bones.
40% of women and 25% of men over age 50 will have an osteoporosis-related fracture in her/his remaining lifetime.
Osteopenia, or low bone mass, is a more moderate decline in bone density sometimes called pre-osteoporosis. If you have been diagnosed with osteopenia, or even osteoporosis, you can take steps to prevent further bone loss.
You need to exercise and get enough calcium and vitamin D to help keep your bones strong. You also may need to take medications for osteoporosis treatment. Ask your physician what action is right for you. Postmenopausal women and older men with osteoporosis should be medically treated to prevent fractures.
What role do hormones play in bone disease?
Too much or too little of certain hormones in the body can contribute to osteopenia and osteoporosis:
During and after menopause, the ovaries make much less of the hormone estrogen. Estrogen loss may also occur with surgical removal of the ovaries or because of excessive dieting and exercise. Estrogen helps protect bone.
Men produce less testosterone (and estrogen—produced in small amounts in males) as they age. Reductions in these hormones may also contribute to bone loss.
Bone loss can result from the damaging effects of excess cortisol, as occurs in Cushing’s syndrome or when taking corticosteroid medication such as prednisone or cortisone tablets or other steroids, used to treat inflammatory disorders like rheumatoid arthritis or asthma or used as anabolic hormones.
Thyroid cancer survivors whose treatment includes high doses of thyroid hormone also have a higher risk.
Eating disorders, especially anorexia nervosa, increase the risk of osteoporosis. Bone loss occurs partly because of poor nutrition and, in women, partly because the ovaries stop functioning normally, producing less estrogen.
Am I at risk for osteoporosis?
Excessive bone loss occurs more often in certain groups of people. Your risk of developing osteoporosis is higher if you:
are older or:
have a family history of osteoporosis
have a thin or small frame
have completed menopause
are Caucasian or Asian
have had a fracture as an adult
have a parent with hip fracture
Other factors that may increase your risk of bone loss include:
amenorrhea (missing menstrual periods)
an inactive lifestyle
a diet low in calcium or vitamin D
low testosterone (hypogonadism)
drinking too much alcohol
certain medications, including some anti-seizure medications, large doses of thyroid hormone, or steroids
Osteoporosis Signs and Symptoms:
Osteoporosis is sometimes called a “silent” disease, because bone loss often occurs without you knowing it.
These findings are similar to those in clinical trials, in which new vertebral fractures are found by xrays but only a minority of patients were aware of the occurrence of the fracture. This has several implications for the management of osteoporosis. Since vertebral fractures strongly predict future fractures, and since many of them are "silent", it makes sense to recommend spine X-rays as part of the evaluation of patients at risk for osteoporosis.
The first sign of osteoporosis is often a bone fracture. Fractures may trigger serious health problems, including disability and even premature death.
Most people with a broken hip need to have major surgery; ~50% of patients with a hip fracture can never walk again without help, and ~25% need long-term care. A broken hip is a major risk factor for death in elderly people.
Some people have spine fractures that lead to a curve in their upper back, sometimes called a dowager's hump (see figure below, the fractured spinal body is wedge shaped).
The first suggestion of spinal fractures and one of the first symptoms of osteoporosis may be when you realize you are not as tall as you used to be. If you have lost more than one inch from your (accurately measured) height as a young adult, you may wish to speak with your doctor about testing for osteoporosis.
Other signs and symptoms are back pain and stooped posture.
More serious problems may occur after a hip fracture, because some people lose the ability to walk normally, perform activities of daily living, or live independently.
Osteoporosis is a silent condition - and physical findings are rarely specific. Dr. Schneider may check the distance between your ribcage and the hip bone to get a sense of your spinal bones. In most of cases we would have to obtain a bone density measurement to check your bone mass.
Bone Density - The DEXA Scan
In 1994, the World Health Organization defined osteoporosis based on bone density. The bone density is the weight of mineral per volume of bone. The most common technique to measure this is with a bone density machine (DEXA, Dual Energy X-ray Absorptiometry), and the results are standardized using "T-scores" because the different kinds of machines do not measure bone the same way. It is mandatory to bring in your printed results to your visit, including the bone density graphs so that Dr. Schneider can interpret the results correctly.
1. Normal bone (T-score better than -1)
2. Osteopenia (T-score between -1 and -2.5)
3. Osteoporosis (T-score below -2.5)
4. Severe osteoporosis (low T-score and a fragility fracture)
Many risk factors lead to fractures, see above. Some of these factors plus the bone density can be used to estimate the risk for fractures by means of an algorithm, the FRAX score. The FRAX score sometimes helps with the right treatment decision: if the FRAX score is high, you probably need treatment for osteoporosis even if your bone density is still in the osteopenia range.
Ultrasound measurements are usually performed at the heel bone and it is not possible to measure sites of osteoporotic fracture such as the hip or spine. Ultrasound at the heel can sometimes predict hip fractures.
Who should be tested?
If you are a woman or a man at risk for bone loss — and especially if you have experienced a fracture after age 50 — you should have a bone mineral density test to monitor the mass of your bones.
All women aged 65 and older, and men aged 70 or older, should have a bone density test.
Adults with a condition, such as rheumatoid arthritis, or taking a medication, such as corticosteriods, that may contribute to bone loss
Anyone whose doctor is considering prescribing osteoporosis drug therapy
Postmenopausal women who are discontinuing estrogen therapy
Osteoporosis Prevention and Treatment
The cornerstone of Osteoporosis prevention and treatment include exercise, nutrition, vitamin D and the right amount of calcium in your diet. Medications do not work as well (if at all) in patients who have poor nutrition, vitamin D deficiency, or lack of exercise. In frail women and men, fall prevention should be part of the plan.
How much Calcium do I need?
Calcium, the main element needed to keep your bones strong and healthy, is found mainly in dairy products.
Great calcium sources include milk, yogurt, and cheese. Other sources of calcium include some green vegetables such as broccoli and kale.
Click here to download a list with calcium content of some foods.
If you cannot get all the calcium you need (1000-1200mg per day) from food alone, you may need to take calcium supplements. Likewise, if you are lactose intolerant or limit dairy foods in your diet for other reasons, you can supplement your diet with calcium tablets.
How much Vitamin D do I need?
To form and maintain strong bones, vitamin D is essential. Vitamin D helps maintain a normal level of calcium in the blood by helping the body absorb calcium properly, and has other health benefits as well. Low levels are linked to an increased risk of many diseases including heart disease, diabetes, cancer and low mood. Fortified milk, egg yolks, liver, saltwater fish, and fish oils are among the few foods that contain vitamin D.
Sunlight on your skin activates the production of vitamin D in your body, but many people do not get enough sun to make sufficient vitamin D. While most people need at least 1,000 IU of vitamin D each day, many men and women need even higher doses. Dr. Schneider may order a blood test to see if you are getting enough vitamin D and advise you on how to increase your intake if necessary.
What exercises are best to prevent osteoporosis?
Exercise is the other important key to keeping your bones healthy. Exercise improves strength and balance, which may decrease the risk of falling. Before beginning any new physical activities, however, check with your doctor. A 55-year-old woman who is healthy would probably not have trouble beginning a weight-bearing regimen, but a 90-year-old woman might get a fracture doing the same type of exercise, because her bones are not as strong.
Dr. Schneider has carefully put together 9 weight-bearing and strength-training exercises that can help you stay fit and may lower the risk of fractures.
Is there a special nutrition to prevent and treat osteoporosis?:
The importance of weight is not emphasized very much, but study after study shows that low weight (BMI) is a stronger risk factor than calcium or other nutrients. WE recommend a diet rich in protein and nutrients to help maintain and build up muscle and bone ,see our separate info on nutrition. Also, please stop smoking!
Preventing fractures is important at any age. Here is a checklist to keep you safe at home:
Floors — Remove all loose wires, cords, and small rugs. Make sure your rugs are smooth and anchored. Keep furniture in its place so you won’t bump into or trip over it.
Bathrooms — Install non-skid tape in the tub and shower, and install grab bars.
Kitchen — Install non-skid mats near sink and stove. Clean spills right away.
Stairs — Do not leave piles of clothing or other items on your stairs. Make sure the hand rails and carpeting are secure.
Lighting — Install good lighting in your halls, stairways, and entrances. Install night lights in your bathroom. Turn on your lights if you have to get up during the night.
In general — Ask your doctor if any of your medications might make you dizzy or more likely to fall. If you drink alcohol, drink only in moderation. If you feel unsteady, wear only flat, rubber-soled shoes.
Bone loss is a natural part of aging, but there are steps you can take to stay strong during every stage of your life.
Addition of pharmaceutical treatment should be based on the risk of fractures. Using the bone density, age, presence of fracture, other risk factors, and general health, a risk of fracture can be estimated, using the Fracture Risk Calculator.These risks have been derived from observations of over 100,000 people world-wide, so they are fairly accurate.
Bisphosphonates: Alendronate, Risedronate, Ibandronate, Zoledronic Acid
Bisphosphonates inhibit the breakdown of bone and are used to prevent and treat postmenopausal osteoporosis by slowing bone loss while increasing bone mass. Bisphosphonates help reduce the risk of spine, non-spine, and hip fractures.
Alendronate, risedronate, and zolderonic acid have also been approved for the treatment of steroid-induced osteoporosis in women and men who require long-term use of medications to treat inflammatory conditions or transplantation.
Side effects of bisphosphonates are uncommon, but may include abdominal, bone, or muscle pain. These medications may also cause nausea or heartburn. Irritation of the esophagus may occur with the tablet forms of this medication.
If you are taking an oral bisphosphonate, you should take the drug upon arising in the morning after an overnight fast, with one full glass of water. Stay in an upright position after taking the dose.
If you are taking alendronate or risedronate, do not drink or eat anything else for the following 30 minutes so your body can absorb the medication. If you are taking ibandronate, you must wait 60 minutes to eat or drink anything.
Relatively high-dose, long-term bisphosphonate therapy, which might be administered during cancer treatment, for example, has been linked to osteonecrosis (degeneration) of the jaw bone. This problem tends to arise most frequently after dental operations. Another very rare side effect are unusual (atypical) fractures of the thigh bone (femur).
Bisphosphonates are not recommended for pre-menopausal women who may become pregnant.
Denosumab (DENsity of bOne in hUmans Monoclonal AntiBody, Prolia®)
s a fairly new class of osteoporosis medication that inhibits bone resorption. It dampens the function of osteoclasts, the "bone eating cells". The dose is 60mg given as sub-cutaneous injection once every 6 months up to 10 years, and it is tremendously important to get the doses on time and to never miss a dose. Denosumab is a very potent osteoporosis medication. If a dose is late or skipped, bone break-down will occur at an extremely rapid rate, leading to a rapid bone loss. Please never stop Denosumab treatment without speaking to Dr. Schneider first.
Teriparatide (Forteo®) and Abaloparatide (Tymlos®)
Teriparatide and Abaloparatide are molecules that are very similar to the body's own parathyroid hormone molecule, which is involved in calcium regulation. Both stimulate new bone formation, rather than preventing bone breakdown. Because of potential safety concerns (osteosarcoma), the use of this drug is restricted to men and women with severe osteoporosis—who have a high risk of a fracture—and can be given for no more than two years. Both are given as a daily, self-administered injection. Side effects are uncommon but may include leg cramps, headaches, and dizziness. This medication is not recommended for pre-menopausal women. If a dose is late or skipped, bone break-down will occur at an extremely rapid rate, leading to a rapid bone loss. Please never stop Forteo or Tymlos without speaking to Dr. Schneider first.
works by binding and inhibiting the activity of the protein sclerostin and, as a result, can both increase bone formation and decrease bone breakdown. Romosozumab consists of two injections given once a month by a health care professional. The bone forming effects last for 12 doses, after which it is imperative that patients are switched to a treatment that reduces bone breakdown.
Estrogen - Hormone Replacement Therapy (HRT)
In postmenopausal women, this includes taking estrogen (a hormone typically made by your ovaries whose levels drop dramatically after menopause) and, if your uterus is still in place, progesterone.
The use of estrogens in postmenopausal women is controversial. Fracture rates, however, were significantly reduced with estrogen in all ages, races, with or without progesterone. Every study about estrogen, from animal experiments to observational studies to clinical trials, has found that estrogen is beneficial to bone health. The bones are stronger as long as estrogen is used.
Estrogen side effects are different in women who start estrogen close to the time of menopause, and some of the problems with estrogen are, in fact, due to progesterone and not estrogen.
Therefore, I strongly believe that estrogen is a good choice for women who want to prevent or treat osteoporosis, but it should be started within 5 years of menopause and progesterone use should be minimized.
Selective Estrogen Receptor Modulators (SERMs): Raloxifene
Raloxifene is approved for preventing and treating osteoporosis in postmenopausal women. It is from a class of drugs called selective estrogen receptor modulators (SERMs). These estrogen-like medications were developed to benefit the bone, while avoiding the potential risks associated with estrogen therapy (such as increased risk of breast cancer or heart disease).Raloxifene increases bone density and reduces the risk of spine fractures, but it has not been shown to decrease the risk of non-spinal fractures. Raloxifene also decreases the risk of invasive breast cancer.Raloxifene is taken in pill form, once a day, with or without meals. While uncommon, side effects may include hot flushes, leg cramps, or blood clots in the legs or lungs. Raloxifene is not recommended for pre-menopausal women.
Osteoporosis in Men:
Alendronate, risedronate, zoledronic acid, and teriparatide have been approved to treat osteoporosis in men. Although there are fewer studies in men, the effects of these agents on bone mass are similar to their effects in women and are likely helpful in treating men with osteoporosis.
Is Testosterone treatment useful to prevent or treat osteoporosis?
The question whether testosterone supplementation is useful for treatment of osteoporosis in men remains controversial. In men who clearly have low levels of testosterone, treatment with testosterone appears to increase bone density.
Because testosterone levels tend to decline with age, many older men have testosterone levels that are low. Testosterone supplements may improve bone mineral density in these men as well, but the best dose and the best way to administer this treatment are unclear. There is no information about whether testosterone treatment in men is effective in reducing fracture risk.
Finally, the risks of long-term testosterone treatment in older men are unknown. At present, it is generally not recommended that testosterone be used as the primary osteoporosis treatment for men. It is important to remember that the approved osteoporosis treatments for men (alendronate, risedronate, zoledronic acid, and teriparatide) seem to be effective in men with low testosterone levels, also.