Osteoporosis

 

What Is It?

Osteoporosis is a bone disorder. The bones become thinner, lose their strength and are more likely to break. People with osteoporosis have a higher risk of fractures. Their bones can fracture even during everyday movements, such as bending or coughing. Osteoporosis is not a form of arthritis, although it can cause fractures that lead to arthritis.

In the United States, osteoporosis causes more than 1.3 million fractures each year. It is much more common in women than in men because of the hormonal changes that occur during Menopause. In people with osteoporosis, the wrist usually is fractured first. This typically occurs between ages 50 and 70 in women. However, hip fractures and fractures of the spine are even more common, especially among people in their 70s.

Osteoporosis can cause a great deal of suffering, including loss of independence or even death, especially when the fracture involves the hip. Hip fractures can be difficult to heal, and reduce the person’s ability to move around, which can lead to complications and other health problems. Up to 36 percent of older people who fracture a hip die within a year of the injury.

You are more likely to develop osteoporosis if you:

  • Are female
  • Are 40 or older
  • Are postmenopausal
  • Have a diet low in calcium or an intestinal problem that prevents calcium and vitamins from being absorbed
  • Have an overactive thyroid (hyperthyroidism)
  • Lead a sedentary lifestyle, with little or no regular exercise
  • Are thin
  • Take certain medications, such as prednisone
  • Have a certain ethnic background (Caucasians and people of Asian descent are more likely to develop osteoporosis than African-Americans.)
  • Smoke
  • Drink too much alcohol — Although the precise amount that might be harmful to bone health is not clear, most experts recommend that women avoid drinking more than one drink a day and that men avoid more than two drinks a day.
  • Have a family history of osteoporosis
  • Have a history of at least one “fragility” fracture (one caused by little or no trauma)

Symptoms

Most people with osteoporosis do not have any symptoms and do not know they have the problem. One early sign can be a loss of height caused by curvature or compression of the spine, which is caused by weakened vertebrae (spine bones). The weakened vertebrae develop tiny breaks called compression fractures that cause the spine bones to collapse vertically. When this happens, the vertebrae become shorter, and the shape of each single vertebra goes from a normal rectangle to a more triangular form. Although the loss of height caused by compression fractures sometimes can cause back pain or aching, it usually does not cause any symptoms.

Osteoporosis usually does not cause pain unless a bone is fractured.

Diagnosis

During a physical examination, your doctor may find that you are shorter than you thought you were or that you have a “dowager’s hump,” a curve of the spine in the upper back that produces a hump X-Rays may show that your bones are less dense than expected. While this could be caused by osteoporosis, there are other causes, such as not enough vitamin D.

Your doctor will suspect osteoporosis if you have had a fragility fracture. A bone density test can confirm the diagnosis. Several techniques measure bone density. The most accurate is DEXA (dual-energy X-ray absorptiometry). DEXA takes 10 to 15 minutes and is painless. It uses minimal amounts of radiation and generally is done on the spine and hip. A newer test, ultrasound bone density of the heel, is even quicker and less expensive, but it is not widely available or accepted as an accurate screening test for osteoporosis. Usually, people who are found to have osteoporosis by heel ultrasound eventually go on to have DEXA of the spine and hip.

Bone density tests can diagnose osteoporosis when the condition is mild and you do not have any symptoms. This can lead to treatment that will prevent the condition from getting worse. In people with loss of height or suspicious fractures, bone density tests not only confirm the diagnosis of osteoporosis, they also serve as a baseline for treatment and can be used to follow the response to treatment.

Additional blood and urine tests may be recommended to identify a cause of osteoporosis, such as a thyroid problem. However, for most women, no clear cause (other than age and being postmenopausal) is found.

Expected Duration

Although osteoporosis is a long-term (chronic) condition, proper treatment can lead to significant improvements in bone mass and can decrease the likelihood that symptoms will appear. Even though bone mass usually does not return to normal, the risk of fracture may decrease dramatically, often by 50 percent or more, after several years of treatment.

Prevention

You can help to prevent osteoporosis by:

  • Getting enough calcium and vitamin D — Many doctors routinely recommend extra calcium; 500 to 1,000 milligrams daily in the form of calcium carbonate, as in Tums, and in many other inexpensive forms. You may need even more if your diet is particularly low in calcium or if you are breastfeeding. You may also need to take a daily multivitamin that contains vitamin D.
  • Regularly doing weight-bearing exercises
  • Not smoking
  • Avoiding excess alcohol

If you are a woman who has entered menopause recently, talk to your doctor about being evaluated for osteoporosis. Preventive options for menopause-related osteoporosis include estrogen replacement therapy, raloxifene (Evista), alendronate (Fosamax) or risedronate (Actonel). Because estrogen slows the breakdown of bone, the loss of estrogen during menopause leads to bone loss. Estrogen therapy and raloxifene (which behaves like estrogen on bone) help to counteract this process. Estrogen replacement therapy for preventing or treating osteoporosis has fallen out of favor because of side effects, including an increased risk of Heart disease and Stroke. Alendronate and risedronate are called bisphosphonates, a family of drugs that slow down the cells that break down bone. In this way, these drugs can help bone to become thicker. A Bone density test may make the decision easier if it shows signs of a problem. Because the loss of height caused by osteoporosis-related compression fractures may not cause any other symptoms, it is also a good idea to measure your height every year, especially if you are a woman older than age 40.

Another measure to help prevent osteoporosis is to monitor thyroid medication regularly if you take it, because too much may lead to osteoporosis and other medical problems. If you take prednisone for any reason, work with your doctor to reduce the dose to the lowest possible amount or even to discontinue the medication.

Treatment

Doctors treat osteoporosis by prescribing calcium and vitamin D, by recommending weight-bearing exercises and by modifying other risk factors. In addition, several effective medications are available. For women, estrogen replacement therapy, alendronate (Fosamax), risedronate (Actonel), raloxifene (Evista) and nasal calcitonin (Miacalcin), a spray that inhibits bone breakdown all treat osteoporosis and are approved by the U.S. Food and Drug Administration. Long-term estrogen therapy has been associated with many risks, including an increased risk of heart disease, stroke, breast cancer and gallstones. For this reason, many doctors prefer one of the other options as a first choice. Among men, a low level of testosterone is the most common cause of osteoporosis. If testing reveals that testosterone levels are low, other tests will look for the cause so that treatment can be started. Men also can use alendronate and raloxifene.

A form of parathyroid hormone, called teriparatide (Forteo), was approved for treating osteoporosis. Given by a daily injection, it will probably be reserved for the worst cases of osteoporosis, those that failed to respond to other treatments.

For people who experience problems or side effects with other treatments, two other medications are available, including etidronate (Didronel) or pamidronate (Aredia). Both are bisphosphonates, like alendronate and risedronate.

How well a treatment works is monitored by bone density measurements every one to two years. To get the most accurate comparison, all bone density measurements should be done on the same machine in the same facility.

If a person with osteoporosis fractures a hip, surgery may be needed to realign and stabilize the hip. A wrist fracture may heal well simply by being put in a cast, or surgery may be needed to restore proper alignment and function. Other treatments for fracture include pain medication and rest for a short time. Calcitonin injections may reduce spine pain from a new compression fracture.

When To Call A Professional

If you have risk factors for osteoporosis or if you have had a fracture with little or no trauma, review your options for evaluation and treatment with your doctor.

Prognosis

The outlook for people with osteoporosis is good, especially if the problem is detected and treated early. Bone density, even in severe osteoporosis, generally can be stabilized or improved, and the risk of fractures can be reduced by 50 percent or more after several years of treatment.

People with mild osteoporosis have an excellent outlook. Those who have a fracture can expect their bones to heal normally and the pain to go away within a week or two.

For people whose osteoporosis has a clear cause, such as prednisone use, the outlook is good if the cause is identified and corrected.

Last Edited: 15 Aug. 2005

Johns Hopkins patient information

Last revised: December 8, 2012
by Armen E. Martirosyan, M.D.

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