Osteoporosis

What happens in osteoporosis

Bone is living tissue that is constantly broken down and rebuilt. Peak bone mass is reached around age 30. After that, breakdown gradually outpaces building. In women, bone loss speeds up sharply for 5 to 10 years after menopause, when estrogen falls. Osteoporosis develops when bone mass is low and the internal honeycomb structure becomes thin and porous, so bones break under forces that would not normally harm them (fragility fractures).

Osteopenia describes bone density that is lower than normal but not yet in the osteoporosis range. Many fractures happen in people with osteopenia, so overall fracture risk matters more than the label.

Symptoms

Osteoporosis is often called a silent disease. Signs appear once fractures occur:

• sudden back pain from a vertebral compression fracture, though many spine fractures are painless
• loss of height
• stooped posture or a rounded upper back (kyphosis)
• shortness of breath or a full stomach from a compressed chest and abdomen in severe kyphosis
• a hip fracture or wrist fracture after a minor fall

Risk factors

Factors you cannot change

• female sex
• age over 50
• menopause, especially early (before 45)
• family history of osteoporosis or a parent's hip fracture
• white or Asian ancestry (though anyone can be affected)
• small, thin body frame
• previous fragility fracture

Lifestyle factors

• smoking
• more than 2 to 3 alcoholic drinks a day
• low calcium and vitamin D intake
• inactivity
• low body weight or eating disorders

Medical conditions and medicines

• medicines: long-term glucocorticoids (such as prednisone), aromatase inhibitors, androgen deprivation therapy, some anti-seizure drugs, high-dose thyroid hormone, proton pump inhibitors long-term, and some diabetes drugs
• conditions: rheumatoid arthritis, hyperparathyroidism, hyperthyroidism, celiac disease and other malabsorption, chronic kidney or liver disease, low testosterone, diabetes, vitamin D deficiency, multiple myeloma

Diagnosis

Bone density (DEXA) scan

A quick, painless, low-radiation X-ray scan of the hip and spine. Results are reported as a T-score, compared with a healthy young adult:

Osteoporosis can also be diagnosed in anyone who has had a hip or spine fragility fracture, regardless of T-score.

Who should be screened

• all women aged 65 and older
• younger postmenopausal women with risk factors
• men aged 70 and older are often advised to be screened, and younger men with risk factors
• anyone with a fragility fracture or on long-term steroids

Other tests

• FRAX: a calculator that estimates 10-year risk of major and hip fractures
• vertebral imaging (X-ray or a DEXA spine view) to find silent spine fractures
• blood tests: calcium, vitamin D, kidney and liver function, thyroid, parathyroid hormone, and others to find secondary causes

Treatment

Foundations for everyone

• Calcium: about 1,000 to 1,200 mg a day for most adults over 50, ideally from food (dairy, fortified plant milks, canned fish with bones, leafy greens). Supplements make up any shortfall.
• Vitamin D: about 800 to 1,000 IU a day is commonly advised for older adults, with testing in those at risk of deficiency.
• Exercise: weight-bearing (walking, dancing, stair climbing), resistance training, and balance work such as tai chi. A physical therapist can tailor a safe program, especially after spine fractures.
• Fall prevention: remove trip hazards, improve lighting, install grab bars, check vision, review medicines that cause dizziness, and use walking aids if needed.
• Stop smoking and limit alcohol.

Medicines

• Bisphosphonates (alendronate, risedronate weekly or monthly tablets, or yearly zoledronic acid infusion): first-line for most people. They reduce spine fractures by about half and hip fractures by about a third to 40 percent. Tablets must be taken on an empty stomach with plain water, staying upright for 30 to 60 minutes. A "drug holiday" may be considered after 3 to 5 years in lower-risk people.
• Denosumab: an injection every 6 months. It must not be stopped without switching to another treatment, because bone loss and multiple spine fractures can follow.
• Bone-building (anabolic) medicines: teriparatide and abaloparatide (daily injections) and romosozumab (monthly injections), used for very high risk or severe osteoporosis, followed by a bisphosphonate or denosumab.
• Raloxifene: reduces spine fractures in postmenopausal women and lowers breast cancer risk.
• Hormone therapy: estrogen around menopause prevents bone loss and may suit women with menopausal symptoms.

Side effects to know about

Rare but serious side effects of bisphosphonates and denosumab include osteonecrosis of the jaw (mainly with dental extractions in high-risk people) and atypical femur fractures with long-term use. For most people with osteoporosis, the fractures prevented far outnumber these risks. See a dentist before starting if major dental work is planned.

Living with osteoporosis

• treat pain from spine fractures with pain relief, short rest, and early gentle movement
• a physical therapist can teach safe bending and lifting
• hip protectors may help in care homes
• follow-up DEXA scans every 1 to 2 years or as advised to check response

Prevention

Building strong bones early and keeping them strong:

• adequate calcium and vitamin D through life
• regular weight-bearing and strength exercise
• avoid smoking and heavy drinking
• maintain a healthy weight
• discuss bone health with your doctor at menopause or if you take bone-thinning medicines

Frequently asked questions

What are the first signs of osteoporosis?

Osteoporosis usually has no early signs. The first sign is often a broken bone from a minor fall, sudden back pain from a spine fracture, loss of height, or a stooped posture. A bone density test can detect it before a fracture.

What causes osteoporosis?

It results from bone loss outpacing bone formation, mainly with aging and falling estrogen after menopause. Other causes include steroid medicines, smoking, heavy alcohol use, low calcium and vitamin D, low body weight, and conditions such as rheumatoid arthritis and celiac disease.

Can osteoporosis be reversed?

Bone density can improve with treatment, especially bone-building medicines, and fracture risk can be cut substantially. Osteoporosis is managed rather than cured, so long-term treatment, exercise, nutrition and fall prevention are important.

What is the best treatment for osteoporosis?

Bisphosphonates such as alendronate or zoledronic acid are the usual first choice. Denosumab is an alternative. People at very high risk may start with a bone-building medicine such as teriparatide or romosozumab. All treatments work best with calcium, vitamin D and exercise.

At what age should women get a bone density test?

All women should be screened at 65. Younger postmenopausal women should be tested if they have risk factors such as a previous fracture, low body weight, smoking, steroid use, or a parent with a hip fracture.