osteoporosis

What is osteoporosis?

Osteoporosis is a condition characterized by a decrease in the density of bone, decreasing its strength and resulting in fragile bones. Osteoporosis literally leads to abnormally porous bone that is compressible, like a sponge. This disorder of the skeleton weakens the bone and results in frequent fractures (breaks) in the bones. Osteopenia is a condition of bone that is slightly less dense than normal bone but not to the degree of bone in osteoporosis.

Normal bone is composed of protein, collagen, and calcium, all of which give bone its strength. Bones that are affected by osteoporosis can break (fracture) with relatively minor injury that normally would not cause a bone to fracture. The fracture can be either in the form of cracking (as in a hip fracture) or collapsing (as in a compression fracture of the vertebrae of the spine). The spine, hips, ribs, and wrists are common areas of bone fractures from osteoporosis although osteoporosis-related fractures can occur in almost any skeletal bone.

What are osteoporosis symptomsand signs?

Osteoporosis can be present without any symptoms for decades because osteoporosis doesn't cause symptoms until bone fractures. Moreover, some osteoporotic fractures may escape detection for years when they do not cause symptoms. Therefore, patients may not be aware of their osteoporosis until they suffer a painful fracture. The symptom associated with osteoporotic fractures usually is pain; the location of the pain depends on the location of the fracture. The symptoms of osteoporosis in men are similar to the symptoms of osteoporosis in women.

Fractures of the spine (vertebra) can cause severe "band-like" pain that radiates from the back to the sides of the body. Over the years, repeated spinal fractures can lead to chronic lower back pain as well as loss of height and/or curving of the spine due to collapse of the vertebrae. The collapse gives individuals a hunched-back appearance of the upper back, often called a "dowager hump" because it commonly is seen in elderly women.

A fracture that occurs during the course of normal activity is called a minimal trauma, or stress fracture. For example, some patients with osteoporosis develop stress fractures of the feet while walking or stepping off a curb.

Hip fractures typically occur as a result of a fall. With osteoporosis, hip fractures can occur as a result of trivial slip-and-fall accidents. Hip fractures also may heal slowly or poorly after surgical repair because of poor healing of the bone.

What are osteoporosis risk factors and causes?

The following are factors that will increase the risk of developing osteoporosis:

  • Female gender
  • Caucasian or Asian race
  • Thin and small body frame
  • Family history of osteoporosis (for example, having a mother with an osteoporotic hip fracture doubles your risk of hip fracture)
  • Personal history of fracture as an adult
  • Cigarette smoking
  • Excessive alcohol consumption
  • Lack of exercise
  • Diet low in calcium
  • Poornutrition and poor general health
  • Malabsorption (nutrients are not properly absorbed from the gastrointestinal system) from conditions such as celiac sprue
  • Low estrogen levels in women (such as occur in menopause or with early surgical removal of both ovaries)
  • Low testosteronelevels in men (hypogonadism)
  • Chemotherapythat can cause early menopause due to its toxic effects on the ovaries
  • Amenorrhea(loss of the menstrual period) in young women is associated with low estrogen and osteoporosis; amenorrhea can occur in women who undergo extremely vigorous exercise training and in women with very low body fat (for example, women with anorexia nervosa)
  • Chronic inflammation, due to chronic diseases such asrheumatoid arthritisor liver diseases
  • Immobility, such as after astroke, or from any condition that interferes with walking
  • Hyperthyroidism, a condition wherein too much thyroid hormone is produced by the thyroid gland (as in Grave's disease) or is ingested as thyroid hormone medication
  • Hyperparathyroidismis a disease wherein there is excessive parathyroid hormone production by the parathyroid gland, a small gland located near or within the thyroid gland. Normally, parathyroid hormone maintains blood calcium levels by, in part, removing calcium from the bone. In untreated hyperparathyroidism, excessive parathyroid hormone causes too much calcium to be removed from the bone, which can lead to osteoporosis.
  • When vitamin D is lacking, the body cannot absorb adequate amounts of calcium from the diet to prevent osteoporosis.Vitamin D deficiencycan result from lack of intestinal absorption of the vitamin such as occurs in celiac sprue and primary biliary cirrhosis.
  • Certain medications can cause osteoporosis. These include long-term use of heparin (a blood thinner), antiseizure medications such asphenytoin(Dilantin) and phenobarbital, and long-term use of oral corticosteroids (such as prednisone).
  • Inherited disorders of connective tissue, including osteogenesis imperfecta,Marfan syndromeEhlers-Danlos syndrome, homocystinuria, and osteoporosis-pseudoglioma syndrome.

How is osteoporosis diagnosed?

A routine X-ray can reveal osteoporosis of the bone because the bones appear much thinner and lighter than normal bones. Unfortunately, by the time X-rays can detect osteoporosis, at least 30% of the bone has already been lost. In addition, X-rays are not accurate indicators of bone density. Thus, the appearance of the bone on X-ray often is affected by variations in the degree of exposure of the X-ray film.

DXA test also typically measures bone density in the hip, the spine, and the forearm. The test takes only five to 15 minutes to perform, exposes patients to very little radiation (less than one-tenth to one-hundredth of the amount used on a standard chest X-ray), and is quite precise

treatment

Once the appropriate medical history, physical exam and diagnostic tests have been obtained and a diagnosis of primary osteoporosis has been made, treatment is warranted. Treatment for osteoporosis typically includes education on diet/nutrition, exercise (if no fractures) and medications. The goal of osteoporosis treatment is to prevent fractures.

First, education regarding the appropriate calcium and Vitamin D intake, as well as overall nutrition, is necessary. As appropriate, exercise and fitness is also important to help maintain bone density and reduce the risk of falls.

Doctors initially treat osteoporosis by:

  • Making sure the person gets enough calcium daily and prescribing calcium if dietary sources are not adequate
  • Prescribing vitamin D
  • Recommending weight-bearing exercises
  • Modifying other risk factors

Medications

For women, many medications are available to treat osteoporosis. These include:

  • Bisphosphonates. These are the drugs used most often to treat osteoporosis in postmenopausal women. Bisphosphonates inhibit the breakdown of bone. They may even increase bone density. Most are taken as a tablet, by mouth. But some may be given intravenously.

Bisphosphonates can cause side effects. These include nausea, abdominal pain, irritation of the esophagus and difficulty swallowing. One rare but serious side effect is death of the jawbone caused by poor blood supply.

Bisphosphonates include:

  • Selective estrogen receptor modulators (SERMs). SERM s treat osteoporosis by mimicking the effects of estrogen to increase bone density.
    • Raloxifene (Evista)
  • Calcitonin (Miacalcin). Calcitonin is a hormone produced by the thyroid gland. It is given as a nasal spray. Calcitonin inhibits bone breakdown.
  • Teriparatide(Forteo). Teriparatide is a form of parathyroid hormone. It stimulates the growth of new bone. Teriparatide is given by a daily injection. It is not yet recommended for long-term therapy.
  • Denosumab(Prolia). Denosumab is a type of biological therapy. It is an antibody that targets a protein involved in bone breakdown. By attacking this protein, it helps stop bone loss.
  • Estrogen replacement therapy. Rarely recommended because of associated risks. Replaces estrogen lost during menopause. Estrogen slows the breakdown of bone.

Long-term estrogen therapy has been associated with many risks. These include an increased risk of heart disease, stroke, breast cancer and gallstones. Estrogen replacement therapy is rarely used to prevent or treat osteoporosis.

Among men, a low level of testosterone is the most common cause of osteoporosis (other than aging). Testing can reveal if testosterone levels are low. In this case, other tests will look for the cause so that treatment can be started. Men also can use alendronate and raloxifene.

If you have osteoporosis, it’s not too late to benefit from a diet that provides your body with enough calcium and vitamin D every day to support bone health. Keep these ideas in mind:

In addition to dairy products, you can get calcium from leafy green vegetables, broccoli, and beans as well as from supplements and foods that are fortified with calcium, such as some breakfast cereals and orange juice.

Vitamin D is a partner with calcium so you may need to take supplements if you are not getting enough vitamin D from foods or sun exposure. To get adequate vitamin D from sunlight, your body requires at least 15 minutes of unprotected sunlight a day.

Consider cutting out certain foods and beverages that interfere with your ability to process calcium, including caffeinated or carbonated drinks, excessive alcohol, and very high amounts of protein.

Exercise

Staying in motion helps your bones and muscles stay healthy. Learning how to be safely active will help you preserve your mobility and independence for many years to come.

If you have osteoporosis you might have to learn new types of exercises, especially weight-bearing exercises (any physical activities that are done standing up), which have been shown to be most effective in building and maintaining bone strength.

You'll also want to learn which exercises or weight machines you should avoid to help prevent injury. For example, machines or exercises that cause you to twist your torso may actually increase your risk of fracturing vertebrae.

Fall and Fracture Prevention

In addition to eating a bone-healthy diet, getting the right kind of exercise, and possibly taking medications, it's a good idea to learn how to prevent falls and fractures in your daily life. Fractures and breaks are the outcome of osteoporosis that you and your medical team most want to avoid because of the pain, loss of mobility, and challenging recovery involved. Remember that:

Even medications that reduce the risk of fracture do not completely eliminate that risk.

When you have osteoporosis, you can suffer a fracture as a result of an impact that might not have caused a fracture in earlier years, and from doing ordinary, not even strenuous, movements. You'll need to be more careful in general.

There are a multitude of fracture prevention steps you can take as part of your osteoporosis treatment plan. Some of the most important are making sure you have enough light to see where you are going if you have to get up at night, picking up clutter, and moving tripping hazards around your home.

Prevention

Three factors essential for keeping your bones healthy throughout your life are:

  • Adequate amounts of calcium
  • Adequate amounts of vitamin D
  • Regular exercise

 Men and women between the ages of 18 and 50 need 1,000 milligrams of calcium a day. This daily amount increases to 1,200 milligrams when women turn 50 and men turn 70.

If you find it difficult to get enough calcium from your diet, consider taking calcium supplements.

Vitamin D improves your body's ability to absorb calcium. Many people get adequate amounts of vitamin D from sunlight.

Exercise can help you build strong bones and slow bone loss. Exercise will benefit your bones no matter when you start, but you'll gain the most benefits if you start exercising regularly when you're young and continue to exercise throughout your life.