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Osteoporosis

Overview

Osteoporosis is a condition that weakens bone. Healthy bone is very dense and has high concentrations of minerals like calcium and phosphate that keep your bones strong. However, people with osteoporosis, which means "porous bones," have low bone density. Over time, the loss of bone density and essential minerals makes the bones brittle, weak, and more likely to fracture easily.

Osteoporosis and the fractures that result from it are a major public health concern. More than 1.3 million people experience an osteoporosis-related fracture every year in the United States. Early diagnosis and treatment of bone loss can reduce or eliminate the risk of fractures.

It's important to know that:

• Women 65 and over and men 70 and over are at high risk for osteoporosis, and they should talk to us about bone mineral density testing.
• Women are at higher risk, especially just after menopause when estrogen levels begin to decrease with time.
• Osteoporosis is under diagnosed. Since osteoporosis can be prevented and treated, it is important to talk to your personal physician or Ob/Gyn about it.
• Fractures, especially of the spine and hips, often lead to loss of quality of life and permanent disability for elderly women and men.
• You can reduce your risk of developing osteoporosis and fractures by improving your diet, especially by increasing your calcium and vitamin D intake. Regular exercise and avoiding or quitting smoking also reduce your risk of fracture.
  

Symptoms

People with osteoporosis often have no visible symptoms, until they fracture a bone. The condition has a number of symptoms that include:

Fractures

• If you have osteoporosis, a minor fall can cause a bone to fracture.
• Fractures of the vertebrae, the bones that make up the spine, are the most frequent type of fracture, but fractures in the hips and wrists are also common.
• Vertebral fractures might not cause any pain, though sometimes curvature of the spine may result in a loss of height. Sometimes we find these fractures when we order X-rays to evaluate another problem, like a cough or abdominal pain.

Loss of height and spinal changes

• Fractures of the vertebrae can cause you to become shorter and may lead to an increased curvature of the spine, known as kyphosis.

Pain

• Pain at the site of the fracture is often the main symptom. However, vertebral fractures do not always  cause pain, and so they are often not diagnosed.

Causes and Risk Factors

Causes

Osteoporosis is characterized by bone loss and subsequent bone weakness. There are several reasons why you may lose bone:

• Aging
• Insufficient calcium, phosphorus, or vitamin D in your diet
• Decreased or abnormal production of the hormones that control bone formation

Your bones grow the most during your teens and your 20s. After age 30, that growth slows down and your body begins to absorb more bone than it produces, making your bones thinner. If your diet did not include enough calcium and vitamin D to support healthy bone growth during your teens and 20s, you are at increased risk of developing osteoporosis later in life.

Bone thinning occurs in both men and women. However, bone loss in women accelerates in the years after menopause because women stop producing estrogen, a hormone that protects against bone loss. This means that women are more likely to develop osteoporosis than men.

Risk Factors

Age is the primary risk factor for osteoporosis. Women who are 65 or older and men 70 or older are at risk for osteoporosis. Other factors that increase your risk for developing osteoporosis include:

• Gender. Females are 4 times more likely than males to have osteoporosis.
• Race. Northern European Caucasians and Asians are at higher risk.
• Body size. Small bones or low body weight. Weighing less than 127 pounds or having a body mass index (BMI) of less than 21.
• Family history. Having a parent, brother, or sister with history of hip fractures and/or osteoporosis.
• Lack of menstruation.
• History of injuries. Prior fracture due to fragile bones or having a history of falls.
• Certain medications. For example, use of oral corticosteroid drugs like prednisone at doses 7.5 mg/day or greater for more than 3 months increases your risk of developing osteoporosis.
• Lifestyle. Smoking, excessive alcohol use, and lack of exercise also seem to increase your risk of developing osteoporosis. Being hit, hurt, or threatened can also seriously affect your health. There is help if this is happening to you.

If you have two or more of these risk factors and are a woman younger than 65 or a man younger than 70, talk to us about early screening and other ways to reduce your risk for developing osteoporosis. A man or woman with risk factors may be screened as early as age 50; we can discuss the screening plan that's best for you.

Screening and Diagnosis

We recommend that women 65 and older and men 70 and older get screened for osteoporosis. During screening, we evaluate your medical history to assess your risk factors. We may recommend a bone mineral density test to evaluate the thickness of your bones or use a tool called a FRAX calculator that can help in predicting your individual fracture risk.

If you're at a higher risk of developing osteoporosis, we may recommend that you begin screening earlier than 65 or 70 years. If you're uncertain if you are at higher risk, talk with us about whether you need a test.

Bone Mineral Density (BMD) Testing

• A BMD scan is a type of X-ray of your skeleton. The scan measures the density of your bones, which is reported as a number called the bone mineral density or BMD. Your BMD is used to calculate your T-score.
• The T-score indicates whether your bone density is above or below the average reading of a healthy person of your gender at age 35. According to the World Health Organization, T-score results indicate:
  

T-score	Condition
1 to -1	Normal
-1.1 to -2.4	Osteopenia (low bone density)
-2.5 or below	Osteoporosis (severe bone loss)

Fracture Risk Assessment

• We use the results of the BMD test along with other risk factors in a Fracture Risk Assessment Tool (FRAX*) to guide your treatment and recommend the best way for you to prevent osteoporosis and fractures.

*FRAX is a tool developed by the World Health Organization to help people determine their risk of bone fracture in the next 10 years.

Frequency of Screening

We recommend that women come in for an initial screening at 65 years of age and that men begin screening at 70 years of age. Certain men and women should begin screening at a younger age if certain risk factors are present:

• Men and women who have sustained any kind of bone fracture after the age of 50 should be screened as soon as the fracture occurs.
• Men and women who take regular oral glucocorticoid medication should have early screening to check for bone loss.

If the results of your first BMD scan are normal and:

• You have other risk factors for osteoporosis, we will discuss a schedule for screening that's best for your health.
• You have no other risk factors, we recommend that we revisit the subject of screening again in 5 years, or sooner if you develop risk factors.
  

Prevention

There are many things you can do to prevent or slow the development of osteoporosis. They include improving your diet, adding more calcium and vitamin D, exercising, minimizing your risk of falling, quitting smoking, and reducing alcohol intake.

Increase your calcium and vitamin D intake

Men and premenopausal women need 1000 mg of elemental calcium and 800 to 1200 units of vitamin D daily. Postmenopausal women need 1200 mg of calcium and 1000 to 2000 units of vitamin D daily. Here are some tips for adding vitamin D and calcium to your diet:

• Eat 3 to 4 servings of calcium-rich products every day. Milk, cheese, and yogurt all contain lactose, which enhances calcium absorption. If you are counting calories, choose low-fat or skim milk.
• Drink vitamin D-fortified milk and get some exposure to the sun. Use a good sunscreen to avoid skin damage.
• Avoid a diet high in fat and protein, as excessive fat and protein can interfere with calcium absorption in the intestine.
• Limit caffeine. Caffeine in coffee and in sodas has been implicated in calcium loss, so limit or avoid these beverages.
• Eat a nutritious, balanced diet. You may need a protein supplement if you are not eating enough, especially if you have suffered a fracture.
• Drink alcohol in moderation. It may affect your balance and make you more likely to fall.

Even with a healthy diet, many people do not get enough calcium. It's a good idea to take an over-the-counter calcium supplement twice a day with meals. If you cannot tolerate milk or dairy products for any reason, supplements are particularly important. Follow these guidelines:

• Vitamin D is necessary for calcium absorption and is available in our pharmacies without a prescription. You can safely take up to 2000 units per day.
• You should not take more than 500 mg of calcium at one time since your body cannot absorb higher doses effectively. Your body cannot absorb calcium without vitamin D, so take your vitamin D supplement at the same time.
• Calcium carbonate is the most effective and least expensive form of calcium. Take it with a meal and be aware that it may cause constipation or gas.
• Calcium citrate is easier on the gut and may be taken on an empty stomach.
• Common acid-blocking medications like famotidine (e.g., Pepcid) or omeprazole (e.g., Prilosec) affect the absorption of calcium carbonate. If you are taking these medications, use calcium citrate instead of calcium carbonate.

Exercise Regularly

Daily activity helps keep your bones strong and makes them less likely to break if you fall. Weight-bearing exercise (walking, jogging, dancing, or lifting weights) is the best way to build strong bones and muscles.

• Weight-bearing exercise. If you spend less than 4 hours per day on your feet, we recommend that you do some form of daily weight-bearing exercise, like walking, aerobics, or dancing, to make your bones stronger and denser and to reduce bone loss.
• Strengthening exercise. Increasing your muscle strength will also help you prevent falls. We can help you develop an appropriate exercise program. Exercises that involve strength and balance, such as T'ai Chi, have been shown to help reduce the risk of falls. 
  

Stop Smoking and Limit Caffeine, Salt, and Alcohol

Smoking reduces bone strength and is a major risk factor for heart disease and cancer. Ask your physician or other health care professional for help quitting.

Caffeine, salt/sodium, and alcohol can all reduce bone strength. Experts recommend that women reduce caffeine and salt intake and drink no more than one alcoholic beverage each day to prevent osteoporosis.

Prevent Falls

You can protect yourself from injury by preventing falls:

• Remove throw rugs, electrical cords, and items left on the stairs that may cause you to trip and fall.
• Make sure that your home is well-lit, including stairwells and entry ways.
• Do not walk on ice, polished floors, or other slippery surfaces.
• Avoid walking in unfamiliar places.
• Use a cane or walker regularly if your balance is poor and install grab bars (e.g. in the bathroom) to keep you safe at home.
• Wear low-heeled shoes with good arch supports and rubber soles.
• Check your vision and get new glasses if you do not see well.

Medications

Bisphosphonates

We typically use a class of drugs known as bisphosphonates, such as Fosamax or alendronate, to treat osteoporosis. These medications decrease the breakdown of bone and are used to prevent and treat osteoporosis in postmenopausal women. We will talk with you about which specific medication may be best for your individual situation.

How to take your medication

• Bisphosphonates need to be taken first thing in the morning with 8 ounces of clear, still (not carbonated) water.
• You need to remain sitting or standing for half an hour before eating or taking any other medication to reduce the chances of food-pipe irritation or pain.

Common side effects

• Stomach upset can be a common side effect of bisphosphonates. Please tell us if you have stomach or chest pain when taking this medication.

Rare side effects

• Osteonecrosis of the jaw. This is a rare side effect that has been seen in some patients receiving high doses of bisphosphonates during treatment for cancer. However, this side effect is very rare in patients being treated for osteoporosis.
• Atypical fractures of the femur may be a side effect of treatment. However, the benefits of treatment far outweigh the risk of this unusual and very rare fracture.

Other drugs

Other drugs for treatment of osteoporosis include:

• Parathyroid hormone
• Calcitonin (used nasally) 
• Combinations of estrogen and bisphosphonates

Selective Estrogen Receptor Modulators (SERMS)

If you cannot tolerate bisphosphonates or can't take them for another medical reason, we will prescribe another class of medicines known as selective estrogen receptor modulators (SERMs). SERMs produce estrogen-like effects on bones and reduce the risk of vertebral fractures. They are less effective than bisphosphonates, but they can still be helpful. Choices include:

• Raloxifene (Evista). This is the most commonly used SERM for osteoporosis.
• Tamoxifen. This is not commonly used to prevent osteoporosis. It is used to prevent and treat breast cancer. However, researchers have observed that breast cancer patients who are taking tamoxifen may also be getting some bone protection.  
  

Treatments

Estrogen/progestin therapy (HRT therapy)

Hormone therapy (estrogen alone or estrogen and progesterone) is also very effective at reducing fractures. If a woman is taking hormones to relieve menopausal symptoms, she will also have the benefit of bone protection for as long as she takes the medication.

We no longer recommend HRT therapy to prevent osteoporosis because studies found that in some cases it has been associated with an increased risk of breast cancer, stroke, blood clots, and heart attacks.

Complementary/alternative treatments

A number of alternatives are available to treat osteoporosis. For example, isoflavones, plant estrogens with properties similar to estrogen, have been shown to prevent bone loss in some women and to increase bone density in others. Isoflavones are found in high concentrations in soybeans, chickpeas, and lentils. These effects are more pronounced when taken in combination with calcium and vitamin.

It is important to talk to us before using alternative therapies, as they may affect medicines that we have prescribed for you.

Related Health Tools:

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This information is not intended to diagnose health problems or to take the place of specific medical advice or care you receive from your physician or other health care professional. If you have persistent health problems, or if you have additional questions, please consult with your doctor. If you have questions or need more information about your medication, please speak to your pharmacist. Kaiser Permanente does not endorse the medications or products mentioned. Any trade names listed are for easy identification only.