What is osteoporosis?

Osteoporosis is a condition marked by weak and brittle bones. It is a silent disease until you experience a fracture. If you’re a woman over fifty, chances are you’ll have osteoporosis in your lifetime. Eight million women (and two million men) have osteoporosis, and an estimated 30 million more people have osteopenia, a milder form of osteoporosis. Two million people per year have low-impact (fragility) fractures of the spine, hip, pelvis and wrist. Many fractures that are caused by osteoporosis can be prevented.

Osteoporosis is defined as a condition in which the amount of bone and the quality of bone is not normal (quality refers to the structure of the bone which allows it to be strong and flexible at the same time so it can support you and resist fracture).


Osteoporosis Signs and Symptoms

You are at risk for osteoporosis if any of the following apply to you. You can remember these signs and symptoms by using the mnemonic SLENDER®.

  • Slim Build
  • Low calcium intake or little exercise
  • Early menopause or even a history of irregular periods
  • No pregnancies
  • Dermatologic / ethnic background (very light-skinned people are at greater risk than darker-skinned people)
  • External factors such as smoking or excess alcohol consumption and drugs such as steroids and anti-seizure medication as well as excess thyroid hormone. Also, certain acid-inhibiting drugs and diabetes drugs (called TZDs) increase fracture risk
  • Relatives with osteoporosis (particularly your mother)

Conditions

There are a number of conditions that cause rapid loss of bone and lead to bones that are more fragile and more likely to fracture. These conditions include calcium and vitamin D deficiency, certain types of cancer, transplanted organs, certain types of liver disease, the prolonged use of the blood thinner heparin (or mast cell disease, a condition in which heparin-like substances are made by the body in excess), certain endocrine diseases, including certain pituitary disorders, adrenal disorders, and an overactive thyroid. Certain types of kidney disorders, including one in which the kidneys leak calcium that can lead to kidney stones and bone loss, and inflammatory arthritis such as rheumatoid arthritis are also conditions that may be associated with low bone mass.

What things make you more likely to have a fracture?

Factors that make you more vulnerable to fracture can be remembered by the mnemonic FAR TRIP®. They include:

  • Frailty (such as inability to get out of a chair without help)
  • Age (older people are more likely to fracture) and adiposity (thin people are more likely to fracture)
  • Relatives who have fractured
  • Tendency to fall, particularly to the side
  • Radiologic (x-ray) evidence of deformity of the spine, including partial painless fracture of the spine
  • Increased length of the part of the hip called the femoral neck, which can be seen in people of Asian descent
  • Prior history of fracture

A tool available on the internet called FRAX (fracture risk assessment) uses the bone density results and certain personal information such as height, weight, fracture history, habits, and steroid use to calculate your risk of fracture and need for medical therapy if you have osteopenia, a condition where the density is not normal but not as severe as in osteoporosis, which is defined as a bone density approximately 25% lower in the spine than a group of young people who are at their peak bone density.


Treatment

If you have been diagnosed with osteoporosis, are at high risk for fractures or have suffered a low-trauma fracture, you should begin treatment. In addition to exercise, calcium, and vitamin D supplements, you may also require one or more of the following medications:

  • Bisphosphonates (alendronate, risedronate, ibandronate, zolondronic acid) Bisphosphonates slow down excessive bone activity, stabilize BMD (bone mineral density) and reduce fracture risk
  • Calcitonin Calcitonin slows down excessive bone activity and reduces fracture risk in the spine, but not clearly in other bones such as the hip. It can also reduce pain from acute spinal fractures. Recent reports suggest that long-term use of the drug may lead to tumor growth.
  • Estrogen Estrogen reduces fracture risk, but when the estrogen is discontinued, bone loss accelerates somewhat like what happens in menopause.
  • Selective Estrogen Receptor Modulator or SERM (raloxifene) This medication reduces spine fractures and may have beneficial effects on other tissues. Reduction of fracture risk in other bones like hip is uncertain.
  • Tariparitide Tariparitide builds new bone and may be particularly helpful in people with very low bone mass, fracture while on other forms of therapy, or very poor ability to form new bone.
  • Denosumab Denosumab does not directly affect the bone, but decreases the activity of cells that cause too much bone to be removed. It may be helpful in patients who cannot tolerate other forms of treatment such as the bisphosphonates.
  • NOTE: Some of these drugs, if used for too long, may result in fragile bone (jaw and hip) that can fracture and, in the jaw, decay. Check with your doctor about when to discontinue these medications.

Prevention

To help prevent osteoporosis and bone fractures, determine whether you are getting enough calcium in your diet by using this Calcium Calculator.

Age

Daily Calcium Intake

1 to 3

500 mg/day**

4 to 8

800 mg/day**

9 to 18

1,300 mg/day**

19 to 50

1,000 mg/day*

51 to 64

1,200 mg/day*

65 and older

1,500 mg/day*

Food Sources and Calcium Provided

Food

Serving Calcium (mg) Servings needed to equal the absorbable calcium in 8 oz of milk
Milk 8 ounces 300 1.0
Yogurt 8 ounces 300 1.0
Cheddar cheese 1.5 ounces 303 1.0
Pinto beans 1/2 cup, cooked 45 8.1
Red beans 1/2 cup, cooked 41 9.7
White beans 1/2 cup, cooked 113 3.9
Tofu, calcium set 1/2 cup 258 1.2
Bok choy 1/2 cup, cooked 79 2.3
Kale 1/2 cup, cooked 61 3.2
Chinese cabbage 1/2 cup, cooked 239 1.0
Broccoli 1/2 cup, cooked 35 4.5
Spinach 1/2 cup, cooked 115 16.3
Rhubarb 1/2 cup, cooked 174 9.5
Fruit punch with calcium citrate malate 8 ounces 300 0.62

Source: Linus Pauling Institute.

Preventing another fracture

If you have had a fracture that was not caused by severe trauma, as might occur in an auto accident, you are at increased risk to experience another fracture and additional measures may be required to avoid further fracturing.

To find out if you and your doctor are doing all you can to prevent another fracture, find the situation that closest describes you in the left-hand column.

Situation

You need

What should happen

Woman nearing menopause, or postmenopausal

Complete medical evaluation to ensure good health, bone mineral density test (BMD), assessment for skeletal risk factors

Discussion with your doctor about the effects of menopause, 1200 mg of calcium* daily, daily exercise program, vitamin D, consider treatment for osteopenia if FRAX score is abnormal (see above) or T score, measure of bone loss, is -2.5 or worse

Growing teenager

Assess diet, exercise, lifestyle

Regular exercise, no smoking, maintain normal weight, avoid unhealthy foods like soft drinks

Adult taking thyroid hormone

Thyroid stimulating hormone (TSH) test

Adjust thyroid dose to normalize thyroid level (normalize TSH)

Anyone taking steroids

BMD test

Take medications that counteract effect of these drugs on bone- bisphosphonates, calcium, vitamin D

Male over 50 with sexual dysfunction and/or history of osteoporosis in male family members

BMD test, endocrinologist’s evaluation for cause of sexual dysfunction

I200 mg calcium* daily, vitamin D 1000 units daily, regular exercise. Treat if BMD shows T score of -2.5 or worse or FRAX score predicts high risk of fracture; treat

Teenager with delayed or absent sexual development

Complete medical and endocrine evaluation, diet assessment

Treat hormone deficiency if present; calcium, vitamin D  daily (amount recommended by pediatrician), regular  exercise if pediatrician permits; monitor growth and development

Middle-aged woman whose mother just had a hip fracture

BMD test and risk factor assessment

Discussion about good bone health measures (1200 mg calcium, 1000 IU vitamin D); treat osteopenia / osteoporosis if BMD and/or FRAX score indicates

Anyone with chronic illness, persistent unexplained weight loss, malignant disease

Complete medical evaluation for diagnosis of illness, BMD

Treat chronic disease: 1200 mg calcium; vitamin D 1000 IU daily; treat osteoporosis / osteopenia if present

Anyone taking steroids (for example dexamethasone, prednisone, hydrocortisone)

Medical and endocrine evaluation to assess indication for cortisone and dose

Doctor to determine if dose used is equivalent to more than 5 mg of prednisone, and, if so, a bisphosphonate (for example Actonel, Fosamax), calcium and vitamin D supplements will be prescribed to protect your skeleton from the effects of your medication

Anyone with calcium levels that are higher than normal

An endocrinology evaluation for abnormal parathyroid function, vitamin D metabolism, or other causes of high calcium levels; BMD, tests for kidney function and for kidney stones

Cause of high calcium levels will be determined and treatment options fully discussed and considered

Growing healthy child with a fracture suffered at play

Only to be more careful unless fracture is low impact or unusual

 

Growing child with multiple fractures

Pediatric endocrinology evaluation

Possibility of a congenital cause of osteoporosis will be explored

Teen or young adult with sports-related stress fractures

Medical and endocrine evaluation for possible osteoporosis

BMD in some cases, hormone tests to check for normal sexual development and maturity

Any adult with a low trauma fracture

X-rays, BMD test, evaluation for causes of osteoporosis if BMD low or x-ray suspicious for osteoporosis

1200 mg calcium* and multivitamins prescribed and osteoporosis / osteopenia treated if present

Patient 65 or older treated for a hip fracture

BMD medical evaluation

Will be treated for osteoporosis regardless of BMD result

Anyone who fractures while on approved treatment for osteoporosis

Evaluation by an endocrinologist or other specialist in metabolic bone disease

Other bone diseases, such as osteomalacia will be excluded; change in medication will be considered

Anyone who has multiple fractures and can't take prescribed treatment

Evaluation by endocrinologist or other specialist in metabolic bone diseases

Medications will be changed to a more tolerable drug, or intravenous or intramuscular drugs will be considered

*NOTE: There is concern about taking excessive amounts of calcium and vitamin D. Doses given in the table are guides. Check with your physician particularly if you have kidney stones or heart and vascular disease. **Check with pediatrician

Other Bone Disorders

There are certain rare diseases such as Paget’s disease of bone which causes bone deformity, fracture, and osteogenesis imperfecta, a condition which affects bone collagen, and makes the bone more fragile.