Definition

Osteoporosis is a disease in which bones become weak and brittle. If left unchecked, osteoporosis can progress painlessly until a bone breaks (fracture). Any bone can be affected, but of special concern are fractures of the hip, spine, and wrist.

Causes

Throughout life, old bone is removed and new bone is added to the skeleton. During childhood and adolescence, new bone is added faster than old bone is removed. As a result, bones become heavier, larger, and denser. Peak bone mass is reached at around age 30. From that point on, more bone is lost than is replaced. If not treated, bone losses may lead to osteoporosis. Osteoporosis is more likely to occur if optimal bone mass was not achieved during the bone-building years.

Bone density also plays a role in bone health. Bone density is determined in part by the amount of calcium, phosphorus, and other minerals contained within the framework of the bone. As the mineral content of a bone (especially calcium) decreases, the bone becomes weaker. Getting enough calcium and vitamin D and exercising regularly can help ensure that bones stay strong throughout life.

Risk Factors

A risk factor is something that increases your chance of getting a disease or condition.

• Sex: female
• Age: risk increases with age
• Body size: small, underweight women
• Race: Caucasian, Asian, and Hispanic women
• Family members with osteoporosis
• Postmenopausal status
• Abnormal cessation of menstrual periods (amenorrhea) due to anorexia nervosa , rigorous exercise, or an endocrinological problem
• Low-calcium diet
• Medications:
  • Immunosuppressants, such as prednisone and other steroids, methotrexate, cyclosporine
  • Thyroid drugs
  • Anticonvulsants
  • Aluminum-containing antacids
  • Cholesterol-lowering drugs
  • Long-term heparin therapy
  • Antidepressants including SSRIs
  • Inhaled steroids
• Low estrogen levels in women
• Low testosterone levels in men
• Inactive lifestyle
• Too little sunlight
• Depression
• Anorexia
• Cigarette smoking
• Excessive use of alcohol, coffee, and tea
• Diseases including:
  • Liver disease, including cirrhosis
  • Hyperthyroidism
  • Scurvy
  • Alcoholism
  • Marfan's, Ehler-Danlos, and osteogenesis imperfecta syndromes
  • Cushing's syndrome
  • Hyperparathyroidism
  • Cancer, including lymphoma and multiple myeloma
  • Gastrointestinal disorders, including celiac disease and other malabsorptive disorders
  • Chronic obstructive pulmonary disease (particularly men)
  • Inflammatory diseases, including rheumatoid arthritis and lupus

Symptoms

Osteoporosis does not usually cause symptoms. Pain is the only symptom, and generally occurs when the bones have broken or collapsed.

Symptoms include:

• Severe back pain with fracture of the vertebrae, wrists, hips, or other bones
• Loss of height, with stooped posture (kyphosis)

	Kyphosis
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Diagnosis

The doctor will ask about your symptoms and medical history, and perform a physical exam. Early signs of osteoporosis can be detected with bone density testing.

Bone density testing techniques include:

• Dual-energy x-ray absorptiometry—measures bone density in the entire body
• Single-energy x-ray absorptiometry—measures bone density in the arm or heel
• Dental x-rays of bone
• Ultrasound bone density measurement—measures bone density in fingers, heels, and leg bones

Other tests may include:

• Blood and urine tests—to test for calcium levels or substances created when bone is broken down

Treatment

Treatment includes:

Nutrition

Eat a balanced diet rich in calcium and vitamin D. Consider decreasing your intake of caffeinated beverages and alcohol. Calcium is abundant in:

• Dairy products
• Green leafy vegetables
• Canned fish with bones
• Calcium-fortified products

Smoking

Do not smoke. If you smoke, quit.

Exercise

Exercise improves bone health and increases muscle strength, coordination, and balance. Maximum benefits are gained from doing weight-bearing exercises, including strength-training exercises. Balance training may help prevent falls and fractures.

Dietary Supplements

People who cannot consume enough calcium from food might want to consider calcium supplements. Calcium citrate has the best absorption and is well tolerated. Other vitamins and minerals may be recommended, including vitamin D, magnesium, potassium, and vitamin K. A recent study showed that Japanese postmenopausal women who took vitamin K supplements experienced a reduced rate of fractures. Due to side effects and medication interactions, talk to your doctor or dietician before you begin taking dietary supplements.*

Medications

These include medications to prevent bone loss, increase bone density, and reduce the risk of spine and hip fractures.

• Raloxifene (Evista)—one of a class of drugs known as selective estrogen receptor modulators (SERMS) that appears to prevent bone loss of the hip, spine, and total body. It is approved for both prevention and treatment of osteoporosis.
• Bisphosphonates (alendronate [Fosamax], risedronate [Actonel])—reduce bone loss, increase bone density, and reduce the risk of spine and hip fractures
• Calcitonin—slow bone loss, increase spinal bone density, and may relieve pain from bone fractures
• Fluoride—low doses of monofluorophosphate to decrease pain and fractures in the spine
• Recombinant parathyroid hormone (Teriperitide)—Given as a subcutaneous injection, this is the only medication that not only prevents vertebral and hip fractures but actually builds bone. Teriperitide is prescribed for refractory patients at high risk for fracture.

Hormone Replacement Therapy (HRT)

Although HRT (including estrogen replacement therapy, or ERT) may cut the risk of osteoporosis in half, it’s important to note that recent research shows a strong association between longer-term ERT or HRT use and a significantly increased risk of invasive breast cancer, strokes, heart attacks, and blood clots. Be sure to discuss all of the health risks and benefits of hormone therapy with your doctor to determine if it is right for you.

HRT therapy may include:

• Estrogen alone (also referred to as estrogen replacement therapy or ERT)
• Estrogen combined with progestin—frequently preferred for women with an intact uterus because ERT slightly increases the risk of uterine cancer
• Foods containing soy—may improve bone mass because these foods contain plant estrogens

HRT can:

• Reduce bone loss
• Increase bone density
• Reduce the risk of hip and spinal fractures in postmenopausal women

Safety Measures

Because falls can increase the likelihood of fracture in someone with osteoporosis, the following measures are recommended:

• Use a cane or walker for added stability.
• Wear rubber-soled shoes for traction.
• Use plastic or carpet runners when possible.
• Keep rooms free of clutter.
• Install grab bars in bathrooms.

Prevention

Building strong bones throughout the early years is the best defense against osteoporosis. There are four steps to prevent osteoporosis, none of which is likely to be effective by itself.

• A balanced diet rich in calcium and vitamin D
• Weight-bearing exercise
• Healthful lifestyle (no smoking and moderate alcohol)
• Bone density testing and medications where appropriate:
  • Fosamax
  • Actonel
  • Evista

RESOURCES:

National Osteoporosis Foundation
http://www.nof.org

The National Institutes of Health Osteoporosis and Related Bone Diseases
http://www.osteo.org

CANADIAN RESOURCES:

Osteoporosis Canada
www.osteoporosis.ca

Women's Health Matters
http://www.womenshealthmatters.ca/index.cfm

References:

Khosla L, Melton LJ. Clinical practice: osteopenia. N Engl J Med. 2007;356:2293-2300.

National Osteoporosis Foundation website. Available at: http://www.nof.org.

Nelson M. Strong Women, Strong Bones: Everything You Need to Prevent, Treat, and Beat Osteoporosis. Putnam; 2000.

Sambrook P, Cooper C. Osteoporosis. Lancet. 2006;367(9527):2010-2018.

*Updated section on Dietary Supplements on 10/6/06 according to the following study, as cited by DynaMed's Systematic Literature Surveillance DynaMed's Systematic Literature Surveillance: Cockayne S, Adamson J, Lanham-New S, et al. Vitamin K and the prevention of fractures: systematic review and meta-analysis of randomized controlled trials. Arch Intern Med. 2006 Jun 26;166(12):1256-61.

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