Osteoporosis is a condition in which there is decreased quantity of bone, causing your bones to become weak and more likely to fracture or break.
The amount of bone increases during childhood and early adult life, reaching a maximum by the age of 30. Normally, the body forms enough new bone tissue to balance the amount of bone tissue that is broken down and absorbed by the body (a process called bone turnover). After menopause in women, and in some older men, there may be breakdown of bone leading to osteoporosis. In people with osteoporosis, this balanced process is lost – more bone is broken down than is formed, and bones become extremely weak.
Over time, bones become thinner and some of the supporting connections are lost. Bones weigh less and can handle less stress. They can, therefore, break or fracture much more easily, such as from a fall from a standing position to the ground. Fractures can occur at the hip, spine, wrist and other body sites. Because the bone is weak, these are known as fragility fractures.
Osteopenia is a more moderate decrease in the amount of bone quantity – less than in osteoporosis. If a person has osteopenia, there are things they can do to prevent further bone loss.
Depending on the level of bone loss, a person may need to exercise, and take calcium and vitamin D to keep their bones strong. Some people may need to take medications. Ask your physician what action is right for you. Physicians agree that postmenopausal women and older men with osteoporosis should be medically treated to prevent fractures. (See Treatment Options)
What role do hormones play in bone disease?
- As women age, their ovaries stop functioning during menopause. These small organs, which had produced eggs each month, no longer make the hormone estrogen. Estrogen helps to protect bone and can be used to treat osteoporosis. Other reasons for estrogen loss include removal of the ovaries or excessive dieting and exercise.
- In men, decreasing function in the testicles and loss of sex hormones (either estradiol or testosterone) increase the risk of osteoporosis.
- Cushing’s syndrome is a condition in which the adrenal glands produce very high levels of cortisol, causing there to be too much cortisol in the body. (Sometimes this happens because of a tumor.) Cushing’s syndrome can also develop if a person is taking corticosteroid (cortisol-like) medications, such as prednisone and cortisone, which are often used to treat conditions such as rheumatoid arthritis, lupus, and asthma. Bone loss can occur because of the damaging effects of extra cortisol produced naturally or because of the long-term effects of cortisol-like medication.
- Other hormonal conditions that may increase the risk of osteoporosis include an overactive thyroid gland, type I diabetes, hyperprolactinemia (overproduction of the hormone prolactin by the pituitary gland), and abnormal function of the ovaries brought on by too much exercise or stress. Thyroid cancer survivors who take large 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 partly because the ovaries stop functioning normally (produce less estrogen) with this disorder.
According to the National Institutes of Health, osteoporosis is a major public health threat for more than 28 million Americans. Today 10 million people already have osteoporosis and 18 million more have osteopenia (reduced bone mass) and are at risk for developing osteoporosis. Women make up 80% of the cases of osteoporosis.
Excessive bone loss occurs more often in certain types of people. Your risk of developing osteoporosis is higher if you are:
- Thin or have a small frame
- Caucasian or Asian, although African-Americans and Hispanics also are at risk.
- A man with low testosterone (hypogonadism)
- Using some medications, including corticosteroids (anti-inflammatory medicines such as prednisone and cortisone that are used to treat a variety of conditions such as asthma, arthritis, lupus, etc.); some anti-seizure medicines; and overusing thyroid hormone.
Or if you have:
- A family history of osteoporosis
- Completed menopause
- Absent menstrual periods
- Anorexia nervosa or other eating disorders
- An inactive lifestyle
- A diet low in calcium
- Inadequate amounts of vitamin D in your diet
And also, if you:
- Smoke cigarettes
- Drink too much alcohol
Osteoporosis is a “silent” disease caused by a loss of bone mass that happens without your knowing it. The first symptom of osteoporosis is a fracture, a break in the bone, which may cause serious health risks. Many women and men go through life without knowing they have severe bone loss until they break their hip, spine, or wrist and experience the consequences of an otherwise “silent” disease.
Data from the National Osteoporosis Foundation (NOF) show that fractures are common and costly. One in two women and one in four men over age 50 will have an osteoporosis-related fracture in their remaining life span. The estimated national direct costs (hospitals and nursing homes) for osteoporotic and related fractures was $17 billion in 2001 ($47 million each day), and the cost is rising.
Some people have spine fractures that lead to a curve in their upper back, sometimes called a dowager’s hump. You may learn from a doctor’s visit that you are not as tall as you used to be. You may have back pain, stooped posture, and spine deformities because of osteoporotic fractures. If you have lost more than 1 inches from your height as a young adult, you may wish to speak with your doctor about testing for osteoporosis.
Much more serious problems can occur after a hip fracture, because some people lose the ability to walk normally. According to data from the NOF, the 300,000 Americans who have hip fractures each year face a higher risk of death or serious disability:
- 25% of people with hip fracture die within the first year;
- 20% more deaths occur among people with hip fractures compared with those of the same age without factures;
- 25% of those with hip fractures need nursing home care or long-term care; and
- 50% of those with hip fractures never regain the function they had before their fracture. At six months after a hip fracture, only 15% of hip fracture patients can walk across a room unaided.
If you know you are at risk for bone loss, and especially if you have experienced a fracture after age 50, you probably need to get tested. This is true for both men and women. Ask your doctor about a DXA scan (dual X-ray absorptiometry scan), a bone density test. This is a very safe, simple and non-invasive test that takes a few minutes and measures the amount of bone present, which helps diagnose osteoporosis. Medicare and many insurance carriers will pay for this test.
Women who have gone through menopause are at particular risk for bone loss. The National Osteoporosis Foundation recommends that women who have gone through menopause, aged 50 and older, should have a bone density test. The U.S. Preventive Services Task Force recommends that all women aged 65 and older should have a bone density test, and that women aged 60 to 64 with risk factors for osteoporosis also should be tested.
Other women who need to be tested include:
- Older (postmenopausal) women who have fractures or significant height loss
- Women who are considering therapy because they are concerned about developing osteoporosis
- Women who have been taking hormone replacement therapy for a long time
Osteoporosis Treatment Options
The key to good osteoporosis care is knowing the risk for having bones break. The DXA scan can help you learn about your risk for osteoporotic fractures (see Symptoms).
Treatment for osteoporosis always includes exercise and the right amount of calcium in the diet. Calcium pills may also be taken if your diet is not providing enough calcium to keep your bones strong. Vitamin D helps your body absorb calcium. Older men and women probably should take vitamin D supplements. Younger women may want to take vitamin D supplements, too.
A well-balanced diet with calcium-rich foods plus calcium and vitamin D supplements may not be enough to protect bones in all people. Everyone’s body and family history are different. Some people may need to take medications.
There are several drugs that have been approved by the U.S. Food and Drug Administration for preventing and treating osteoporosis. These drugs include:
Bisphosphonates: Alendronate and Risedronate
The non-hormonal bisphosphonate drugs, alendronate and risedronate, prevent and treat postmenopausal osteoporosis. They have been shown in clinical trials to reduce the risk of spine, non-spine and hip fractures. Both have also been approved for the treatment of glucocorticoid-induced (steroid-induced) osteoporosis in men and women who require long-term use of these medications (e.g., prednisone and cortisone) to treat another conditions such rheumatoid arthritis, lupus, and asthma. Alendronate has been approved to treat osteoporosis in men as well.
If you are taking a 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 (sitting or standing) after taking the dose and do not drink or eat anything else for the following 30 minutes, in order to permit your body to absorb the medication. Alendronate and risedronate are available in a once-a-week form or a daily form. Side effects for bisphosphonates are uncommon, but may include abdominal or musculoskeletal pain, nausea, heartburn, or irritation of the esophagus
Calcitonin is a naturally-occurring hormone involved in calcium regulation. Calcitonin reduces the risk of spinal fractures but has not been shown to decrease the risk of non-spine fractures. Because calcitonin is a protein, it cannot be taken by mouth – it would be digested. Calcitonin is most commonly used as a nasal spray. While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and side effects including red face and hands (flushing), urinary frequency, nausea and a skin rash. Side effects for nasal calcitonin are uncommon, but may include nasal irritation, backache, bloody nose, and headaches.
Selective Estrogen Receptor Modulators (SERMs): Raloxifene
Raloxifene is approved for preventing and treating osteoporosis in women who have gone through menopause. It is from a class of drugs called SERMs that have been developed to give estrogen-like benefits without estrogen’s potential risks. Raloxifene increases bone density and reduces the risk of spine fractures, but it has not been shown to decrease the risk of non-spine fractures. Preliminary information suggests that raloxifene may also decrease the risk of breast cancer, but the issue is still under active investigation. Raloxifene is taken in pill form, once a day with or without meals. While side effects are uncommon, they may include hot flashes and deep vein thrombosis (blood clots).
Teriparatide is a fragment or portion of parathyroid hormone, which is involved in calcium regulation. It is approved for those with severe osteoporosis, for both men and women who have a high risk of a fracture. This is the first osteoporosis treatment to stimulate new bone formation rather than preventing bone breakdown. Teriparatide is taken in a daily, self-administered injection for up to two years. Side effects are uncommon but can include leg cramps and dizziness.
Each of these medications has certain benefits and side effects. You should work with your doctor to find the treatment that is right for you. To find an endocrinologist, please visit our physician referral directory.
Estrogen can be taken as estrogen therapy (ET) or as part of hormone therapy (HT; estrogen plus a progestin).
Estrogen reduces the rate of bone loss and fracture risk in the spine and hip. It can also relieve other symptoms of menopause, such as hot flashes and vaginal dryness. Estrogen is usually given in pill form, combined with a progestin (HT) to reduce the risk of cancer of the uterus. If your uterus has been removed, you do not need to take a progestin with the estrogen. However, if you are at risk for breast cancer or have had cancer of the uterus, estrogen may not be right for you. Based on recent studies, estrogen should be used in as low a dose for as short a time as necessary to relieve menopausal symptoms.
When estrogen is prescribed solely for the prevention or treatment of postmenopausal osteoporosis, a woman and her doctor should carefully consider approved non-estrogen treatments. According to the FDA, estrogens and combined estrogen-progestin products should only be considered for women with a significant risk of osteoporosis that outweighs the risks of the drug. Estrogen use increases the risk of deep vein thrombosis (blood clots). Other side effects of estrogen may include vaginal bleeding, breast tenderness, mood disturbances, and gall bladder disease.
Alendronate and teriparatide have been approved to treat osteoporosis in men. In fact, although there are fewer data, these drugs seem to be as useful in men as they are in women. None of the other drugs that are used by women who have gone through menopause have been approved for use in men by the Food and Drug Administration. Nevertheless, risedronate also appears to be effective in men.
To help men with osteoporosis, other treatments are available. Some evidence shows that calcitonin may work in men. Calcitonin may be prescribed, although its effect in men has not been thoroughly studied.
The question of whether testosterone supplementation is useful for men remains quite 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 density in these men as well, but the doses necessary and the best way to administer 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 therapy for osteoporosis in men. It is important to remember that the approved treatments for osteoporosis in men (alendronate and teriparatide) seem to be effective in men with low testosterone levels.
Osteoporosis Lifestyle and Prevention
The 2004 Surgeon General’s Report on Bone Health and Osteoporosis indicates that by the year 2020, half of all Americans over age 50 will have weak bones unless they make changes in their diet and lifestyle.
The best way to keep your bones healthy is to establish a healthy lifestyle. Good advice for everyone, of course, but especially true if you have risk factors for osteoporosis. As a start, you may try to
- Stop smoking
- Avoid drinking too much alcohol
- Take adequate amounts of calcium and vitamin D (which helps your body absorb calcium)
- Do weight-bearing exercises to stay physically fit
- Avoid high doses of thyroid hormone or cortisone-like medications. If you have to take them, work with your doctor to get the lowest possible dose to treat your condition.
Diet and Exercise Make a Difference
Diet and exercise can make a difference in the prevention of osteoporosis. Calcium, the main compound needed to keep your bones strong and healthy, is found in many foods, and exercise stimulates bone to be stronger.
About 500 – 600 mg of calcium is usually present in a normal diet, largely from dairy products. Unfortunately that is not enough. Most people only get about 400 mg of calcium per day when they should be getting about 1,000 to 1,300 mg.
In order to get the calcium that you need to keep your bones healthy, you can eat three to four servings of dairy foods daily. Great calcium sources include milk, yogurt, cheese, and some leafy and green vegetables such as broccoli and kale.
Postmenopausal women (and men with osteoporosis) should take up to 1,500 mg of calcium daily, from food and/or supplements, which is the same as drinking four to five glasses of milk each day (which has 300 mg of calcium per glass). That is hard for many people to do, so they may opt to supplement their diet with calcium in tablets.
Similarly, if you are lactose intolerant, limiting dairy foods because of body weight concerns or high cholesterol, or need more calcium because you are not getting enough in your diet, you can supplement your diet with calcium in tablets.
To form and maintain strong bones vitamin D is essential. Vitamin D helps to maintain normal levels of calcium in the blood and helps the body absorb calcium properly. Fortified milk, egg yolks, liver, saltwater fish and fish oils contain vitamin D. Sunlight on your skin can activate the process in your body that makes vitamin D. Most people need about 400 to 800 IU of vitamin D each day. Women and men over 65 years of age should get about 800 IU per day of vitamin D from a multivitamin or vitamin D supplements.
Exercise is the other important key to keeping your bones healthy. Exercise also improves strength and balance, which may decrease the risk of falling. Before beginning any new exercises or physical activities, however, check with your doctor. On one hand, a 55-year-old person who is healthy would probably not have trouble beginning a weight-bearing regimen. On the other hand, a 90-year-old person might get a fracture doing the same type of exercise, because her bones are not as strong.
Once you get your doctor’s okay, try walking more and taking stairs, or jogging and playing racquet sports. Weight-bearing and strength-training exercise can help you stay fit and lower the risk of fractures. Studies have shown that even men and women in their 90s have benefited from a gradual, personalized weight-training program.
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 will know where it is.
- Bathrooms – Install nonskid tape in the tub and shower, and install grab bars.
- Kitchen – Install nonskid mats near sink and stove. Clean up spills right away.
- Stairs – Don’t 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. Wear flat, rubber-soled shoes if you feel unsteady.