Osteoporosis

Symptoms and Complications

Osteoporosis itself does not usually cause noticeable symptoms. However, weakened bones that are no longer able to support body weight can break under even slight pressure. Such fractures most commonly occur in the hipbones, wrists, or spine. Hip fractures are more frequent in people over the age of 75 years.

Some fractures caused by osteoporosis, such as hairline breaks in the spine, may cause little or no pain and may go unnoticed, even when they show up on an X-ray. By contrast, spinal compression fractures, where the vertebral column crumbles or collapses (usually in the front, resulting in a wedge shape), are much more painful and can lead to deformed posture. Another symptom caused by osteoporosis is chronic back pain. This pain can worsen even when you are making small movements such as regular activities around the house, or while coughing, laughing, or sneezing. You may even feel pain when you are standing still. Women who are very bent over with a "hump" at the top of their backs are usually victims of spinal compression fractures from osteoporosis.

Making the Diagnosis

The first step in diagnosing osteoporosis involves evaluating your bone density. If the bone density is too low, you will be diagnosed with osteoporosis. There are several effective and relatively quick methods for measuring bone density.

Bone density measurement by a method called DEXA (dual energy X-ray absorptiometry) is the most effective way to assess the risk for osteoporosis. Scanning parts of the body such as the hips or spine using a special type of scanning machine that uses a minute amount of radiation can confirm that you have an increased risk of fractures. Computerized tomography (CT) or magnetic resonance imaging (MRI) scans can also be used to check the condition of the bones. The test compares your bone density to what would be expected of a healthy adult at age 25, the usual age of maximum bone density. That is called the "T-score."

A heel ultrasound test may also be used to test bone density and estimate the risk of fracture for women over 65 years of age. However, heel ultrasound does not provide enough detail to monitor treatment for osteoporosis. If you have a heel ultrasound that detects low bone density, talk to your doctor about having your bone density tested by DEXA.

Following the diagnosis of osteoporosis, further studies are needed to look for possible causes. An examination to determine such causes might involve blood and urine tests to measure the levels of calcium and vitamin D and certain hormones, such as parathyroid hormone and thyroid hormone, produced in the body, as well as questionnaires on lifestyle and diet, to determine, for example, one's daily intake of calcium and vitamin D.

People who have a family history of osteoporosis, those suffering from anorexia nervosa and other chronic diseases, and those taking medications such as corticosteroids (that increase the risk for this condition) are recommended to undergo bone density testing even if they have no symptoms. Bone density testing is conducted every one to two years for people already receiving treatment for osteoporosis, to check how the treatment is working. People taking corticosteroids for long periods of time require preventive treatment even if their initial DEXA test is normal.

Treatment and Prevention

Osteoporosis itself has no symptoms - the problem comes when fractures occur. A tool called FRAX, which was developed by the World Health Organization, has markedly improved the decision process for treating osteoporosis. It takes into account multiple factors, including a person's age, gender, bone density, smoking habits, and family history, and calculates an estimate of future risk of fracture or bone breaking in the next 10 years. The higher the risk, the greater the likelihood of breaking a hip or major bone and the more likely medications are needed. FRAX is readily available online (e.g., http://www.shef.ac.uk/FRAX/).

Treatment of osteoporosis is aimed at preventing or reducing bone fractures and maintaining or increasing bone density. There are several treatments for osteoporosis, but prevention is still very important. Many of the treatment and prevention strategies for osteoporosis are similar.

Maintenance of good bone strength requires that you have a regular intake of calcium. The National Osteoporosis Foundation recommends 1,000 mg elemental calcium daily for men and women aged between 19 and 50 years, and 1,200 mg for men and women over the age of 50 years. They recommend vitamin D in daily doses of 400 IU to 800 IU for men and women 19 to 50 years of age, and of 800 IU to 1,000 IU for adults over 50 years of age, to help increase calcium absorption in the bones. The National Osteoporosis Foundation also recommends regular weight-bearing exercise and a healthy lifestyle with no smoking or excessive intake of alcohol.

Your doctor may recommend that you take larger amounts of vitamin D, depending on your situation. In addition, vitamin D requirements may be lower in warmer seasons if you get a great deal of sun exposure (taking precautions against skin cancer and aging).

Anyone taking corticosteroids by mouth for any extended time should be on preventive treatment even if initial bone density is normal. These people should take calcium and vitamin D supplements and medications (i.e., bisphosphonates, described below) as prescribed by their doctor.

Weight-bearing exercises play a role in strengthening bones and preventing fractures. Posture and balance can be improved through exercise and can significantly reduce the risk of bone fractures. Moderate exercise, such as walking 45 to 60 minutes 3 to 5 times weekly, is considered a safe and reasonable strategy to prevent osteoporosis.

There are several medications that can be used to treat osteoporosis. Many of these treatments may also be used to prevent osteoporosis for people who are at high risk of developing it.

Bisphosphonates (e.g., alendronate, etidronate, risedronate, ibandronate, zoledronic acid) are one of the main groups of medications that may be used to prevent and treat osteoporosis. These medications slow down bone loss and help repair bone, reducing the chance of fracture. Depending on the type, they are taken by mouth or injected into a vein.

Selective estrogen receptor modulators (SERMs) such as raloxifene may also be used to prevent and treat osteoporosis in women.

Calcitonin, a hormone normally produced by the thyroid gland, has also been shown to strengthen bone and can be injected or taken through a nasal spray.

Two or more medications may also be used in combination to treat some cases of osteoporosis. In addition, doctors usually recommend continuing to get enough calcium and vitamin D.

For men with osteoporosis due to hypogonadism, testosterone replacement therapy may be used alone or with a bisphosphonate.

A variety of hormone-replacement therapies (HRTs) are available for women who have reached menopause. Estrogen replacement helps to preserve bone, but the therapy has a number of health risks. If you are taking or are considering taking HRT, talk to your doctor about the risks and benefits.

Another class of medication called parathyroid hormone analogues (e.g., teriparatide) builds new bone faster than it breaks it down, and can be used to treat severe osteoporosis.

A non-prescription product called ipriflavone has been used by people to treat osteoporosis, but its effectiveness has not been shown and its long-term safety is unclear at this time.


*All medications have both common (generic) and brand names. The brand name is what a specific manufacturer calls the product (e.g., Tylenol®). The common name is the medical name for the medication (e.g., acetaminophen). A medication may have many brand names, but only one common name. This article lists medications by their common names. For information on a given medication, check our Drug Information database. For more information on brand names, speak with your doctor or pharmacist.

 

Michael E. Makover, MD, is a professor of medicine at NYU School of Medicine and an Adjunct Professor at NYU College of Arts and Sciences. He is in the private practice of Rheumatology, Internal Medicine and Preventive Medicine in New York, NY. Review provided by VeriMed Healthcare Network.

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