Osteoporosis

Overview

What is osteoporosis?

The word ‘osteoporosis’ means ‘porous bone.’ It is a disease that weakens bones, and if you have it, you are at a greater risk for sudden and unexpected bone fractures. Osteoporosis means that you have less bone mass and strength. The disease often develops without any symptoms or pain, and it is usually not discovered until the weakened bones cause painful fractures. Most of these are fractures of the hip, wrist and spine.

Who gets osteoporosis?

About 200 million people are estimated to have osteoporosis throughout the world. In the U.S., the figure is about 54 million people. Although osteoporosis occurs in both men and women, women are four times more likely to develop the disease than men. There are currently about two million men in the U.S. who have osteoporosis and some 12 million more who are at risk of developing the condition.

After age 50, one in two women and one in four men will have an osteoporosis-related fracture in their lifetimes. Another 30% have low bone density that puts them at risk of developing osteoporosis. This condition is called osteopenia.

Osteoporosis is responsible for more than two million fractures each year, and this number continues to grow. There are steps you can take to prevent osteoporosis from ever occurring. Treatments can also slow the rate of bone loss if you do have osteoporosis.

What causes osteoporosis?

Researchers understand how osteoporosis develops even without knowing the exact cause of why it develops. Your bones are made of living, growing tissue. The inside of healthy bone looks like a sponge. This area is called trabecular bone. An outer shell of dense bone wraps around the spongy bone. This hard shell is called cortical bone.

When osteoporosis occurs, the "holes" in the "sponge" grow larger and more numerous, which weakens the inside of the bone. Bones support the body and protect vital organs. Bones also store calcium and other minerals. When the body needs calcium, it breaks down and rebuilds bone. This process, called bone remodeling, supplies the body with needed calcium while keeping the bones strong.

Up until about age 30, you normally build more bone than you lose. After age 35, bone breakdown occurs faster than bone buildup, which causes a gradual loss of bone mass. If you have osteoporosis, you lose bone mass at a greater rate. After menopause, the rate of bone breakdown occurs even more quickly.

Symptoms and Causes

What are the symptoms of osteoporosis?

Usually, there are no symptoms of osteoporosis. That is why it is sometimes called a silent disease. However, you should watch out for the following things:

  • Loss of height (getting shorter by an inch or more).
  • Change in posture (stooping or bending forward).
  • Shortness of breath (smaller lung capacity due to compressed disks).
  • Bone fractures.
  • Pain in the lower back.

Who is at risk for developing osteoporosis?

There are many risk factors that increase your chance of developing osteoporosis, with two of the most significant being gender and age.

Everyone’s risk for osteoporosis fractures increases with age. However, women over the age of 50 or postmenopausal women have the greatest risk of developing osteoporosis. Women undergo rapid bone loss in the first 10 years after entering menopause, because menopause slows the production of estrogen, a hormone that protects against excessive bone loss.

Age and osteoporosis affect men also. You might be surprised to know that men over the age of 50 are more likely to have an osteoporosis-induced bone break than to get prostate cancer. About 80,000 men per year are expected to break a hip, and men are more likely than women to die in the year after a hip fracture.

Your risk of developing osteoporosis is also linked to ethnicity. Caucasian and Asian women are more likely to develop osteoporosis. However, African-American and Hispanic women are still at risk. In fact, African-American women are more likely than white women to die after a hip fracture.

Another factor is bone structure and body weight. Petite and thin people have a greater risk of developing osteoporosis because they have less bone to lose than people with more body weight and larger frames.

Family history also plays a part in osteoporosis risk. If your parents or grandparents have had any signs of osteoporosis, such as a fractured hip after a minor fall, you may have a greater risk of developing the disease.

Finally, some medical conditions and medications increase your risk. If you have or had any of the following conditions, some of which are related to irregular hormone levels, you and your healthcare provider might consider earlier screening for osteoporosis.

  • Overactive thyroid, parathyroid, or adrenal glands.
  • History of bariatric (weight loss) surgery or organ transplant.
  • Hormone treatment for breast or prostate cancer or a history of missed periods.
  • Celiac disease, or inflammatory bowel disease.
  • Blood diseases such as multiple myeloma.

Some medications cause side effects that may damage bone and lead to osteoporosis. These include steroids, treatments for breast cancer, and medications for treating seizures. You should speak with your healthcare provider or pharmacist about the effect of your medications on bones.

It may seem as though every risk factor is related to something that is out of your control, but that’s not true. You do have control over some of the risk factors for osteoporosis. You can discuss medication issues with your healthcare provider. And—you are in charge of your:

  • Eating habits: You are more likely to develop osteoporosis if your body doesn’t have enough calcium and vitamin D. Although eating disorders like bulimia or anorexia are risk factors, they can be treated.
  • Lifestyle: People who lead sedentary (inactive) lifestyles have a higher risk of osteoporosis.
  • Tobacco use: Smoking increases the risk of fractures.
  • Alcohol use: Having two drinks a day (or more) increases the risk of osteoporosis.

Diagnosis and Tests

How is osteoporosis diagnosed?

Your healthcare provider can order a test to give you information about your bone health before problems begin. Bone mineral density (BMD) tests are also known as dual-energy X-ray absorptiometry (DEXA or DXA) scans. These X-rays use very small amounts of radiation to determine how solid the bones of the spine, hip or wrist are. Regular X-rays will only show osteoporosis when the disease is very far along.

All women over the age of 65 should have a bone density test. The DEXA scan may be done earlier for women who have risk factors for osteoporosis. Men over age 70, or younger men with risk factors, should also consider getting a bone density test.

Management and Treatment

How is osteoporosis treated?

Treatments for established osteoporosis may include exercise, vitamin and mineral supplements, and medications. Exercise and supplementation are often suggested to help you prevent osteoporosis. Weight-bearing, resistance and balance exercises are all important.

What medications are used to treat osteoporosis?

There are several classes of medications used to treat osteoporosis. Your healthcare provider will work with you to find the best fit. It’s not really possible to say there is one best medication to treat osteoporosis. The ‘best’ treatment is the one that is best for you.

Hormone and hormone-related therapy

This class includes estrogen, testosterone and the selective estrogen receptor modulator raloxifene (Evista®). Because of the potential for blood clots, certain cancers and heart disease, estrogen therapy is likely to be used in women who need to treat menopause symptoms and in younger women.

Testosterone might be prescribed to increase your bone density if you are a man with low levels of this hormone.

Raloxifene acts like estrogen with the bones. The drug is available in tablet form and is taken every day. In addition to treating osteoporosis, raloxifene might be used to reduce the risk of breast cancer in some women. For osteoporosis, raloxifene is generally used for five years.

Calcitonin-salmon (Fortical® and Miacalcin®) is a synthetic hormone. It reduces the chance of spine fractures, but not necessarily hip fractures or other types of breaks. It can be injected or it can be inhaled through the nose. Side effects include runny nose or nosebleed and headaches for the inhaled form. Side effects include rashes and flushing for the injected form. It is not recommended as a first choice. There are possible more serious side effects, including a weak link to cancer.

Bisphosphonates

Bisphosphonate osteoporosis treatments are considered antiresorbtive drugs. They stop the body from re-absorbing bone tissue. There are several formulations with various dosing schemes (monthly, daily, weekly and even yearly) and different brands:

  • Aledronate: Fosamax®, Fosamax Plus D®, Binosto®.
  • Ibandronate: Boniva®.
  • Risedronate: Actonel®, Atelvia®.
  • Zoledronic acid: Reclast®.

You may be able to stop taking bisphosphonates after three to five years and still get benefits after you stop. Also, these drugs are available as generic drugs. Of these products, Boniva and Atelvia are recommended only for women, while the others can be used by both women and men.

Possible side effects of bisphosphonates include flu-like symptoms (fever, headache), heartburn, and impaired kidney function. There are potentially serious side effects also, such as the rare occurrence of jaw bone damage (osteonecrosis of the jaw) or atypical femur fractures (low trauma fractures of the thigh). The risk of these rare events increases with prolonged use of the medication (>5 years).

Biologics

Denosumab (Prolia®) is product that is available as an injection given every six months to women and men. It is often used when other treatments have failed. Denosumab can be used even in some cases of reduced kidney function. Its long-term effects are not yet known, but there are potentially serious side effects. These include possible problems with bones in the thigh or jaw and serious infection.

Anabolic agents

These products build bone in people who have osteoporosis. There are three of these products currently approved:

  • Romososumab-aqqg (Evenity®) has been approved for postmenopausal women who are at a high risk of fracture. The product both enables new bone formation and decreases the breakdown of bone. You will get two injections, one right after the other, once per month. The time limit is one year of these injections.
  • Teriparatide (Forteo®) and Abaloparatide (Tymlos®) are injectable drugs given daily for 2 years. They are parathyroid hormones, or products similar in many ways to the hormones.

When should osteoporosis be treated with medication?

Women whose bone density test shows T-scores of -2.5 or lower, such as -3.3 or -3.8, should begin therapy to reduce their risk of fracture. Many women need treatment if they have osteopenia, which is bone weakness that is not as severe as osteoporosis. Your doctor might use the World Health Organization fracture risk assessment tool, or FRAX, to see if you qualify for treatment based on your risk factors and bone density results. People who have had a typical osteoporosis fracture, such as that of the wrist, spine or hip, should also be treated (sometimes even if the bone density results are normal).

Supplements

It’s important to remember that dietary supplements, although available everywhere over-the-counter and online, aen't regulated in the same way that prescription medications are. Also, even though something is ‘natural,’ that doesn’t mean that it is safe for everyone at all times.

You might be told by your healthcare provider to get adequate amounts of calcium and vitamin D. This is important if you have osteoporosis or if you are trying to prevent it. It’s best if you can meet those needs with a food plan, but you might not be able to do that. There are plant-based calcium supplements, some of which are based on algae.

The recommended amount of daily calcium intake is 1,000 mg to 1,200 mg daily via diet and/or supplements. Taking more than this amount of calcium has not been shown to provide additional bone strength but may be associated with an increased risk of kidney stones, calcium buildup in the blood vessels and constipation.

There are different ideas about the necessary levels of vitamin D, but it’s true that many people do not have adequate levels and might need to take supplements. Your healthcare provider might test your blood levels and then make recommendations based on these results.

There are other supplements that have been touted as useful for osteoporosis. One of these is strontium, which has never been approved in the U.S. for osteoporosis. A prescription version of strontium ranelate had been available in the E.U., but it was taken off the market due to serious side effects.

You and your healthcare provider will always need to discuss whether the benefits of taking something, whether is a prescription drug or a supplement, outweigh the risks.

Prevention

How can you prevent osteoporosis?

Your diet and lifestyle are two important risk factors you can control to prevent osteoporosis. Replacing lost estrogen with hormone therapy also provides a strong defense against osteoporosis in postmenopausal women.

Diet

To maintain strong, healthy bones, you need a diet rich in calcium throughout your life. One cup of skim or 1 percent fat milk contains 300 milligrams of calcium.

Besides dairy products, other good sources of calcium are salmon with bones, sardines, kale, broccoli, calcium-fortified juices and breads, dried figs, and calcium supplements. It is best to try to get the calcium from food and drink.

For those who need supplements, remember that the body can only absorb 500 mg of calcium at a time. You should take your calcium supplements in divided doses, since anything more than 500 mg will not be absorbed.

Recommended daily allowance of calcium

Age and sexAmount
Adults, 19-50 years1,000 mg
Adult men, 51-70 years1,000 mg
Adult women, 51-70 years1,200 mg
Adults, 71 years old and older1,200 mg
Pregnant and breastfeeding teens1,300 mg
Pregnant and breastfeeding adults1,000 mg

Vitamin D is also important because it enables the body to absorb calcium. The recommended daily allowances of vitamin D are listed below. Vitamin D can also be obtained from sunlight exposure a few times a week or by drinking fortified milk.

Recommended daily allowance of Vitamin D

People by ageAmount
Infants 0-6 Months400 IU
Infants 6-12 months400 IU
1-3 years old600 IU
4-8 years old600 IU
9-70 years old800 IU
Over 70 years old800 IU
14-50 years old, pregnant/lactating600 IU

Talk with your healthcare provider about these numbers. In some cases, you might be told to take more vitamin D. Your provider might also have suggestions about the calcium type; for instance, you might be told to take calcium citrate instead of calcium carbonate. Calcium citrate does not need acid to work, so it may be a better choice for people who take antacids.

Lifestyle

Maintaining a healthy lifestyle can reduce the degree of bone loss. Begin a regular exercise program. Exercises that make your muscles work against gravity (such as walking, jogging, aerobics, and weightlifting) are best for strengthening bones.

Do not drink too much alcohol. Do not have excessive amounts of caffeine. Don’t use tobacco at all.

Living With

What can you do if you are living with osteoporosis?

If you have osteoporosis, you should continue with the lifestyle measures mentioned earlier in terms of eating well, getting enough exercise, avoiding excessive caffeine and alcohol consumption, and not smoking. Make sure that you follow the suggestions of your healthcare provider.You should do all that you can to prevent falls inside and outside of your home. You might want to start with a medical evaluation, which could lead to your healthcare provider providing assistive devices.

Prevent falls inside your home

  • Keep your floors free of clutter, including throw rugs and loose wires and cords. Use only non-skid items if you have mats, carpets or area rugs.
  • Make sure your lighting is bright enough so that you can see well.
  • Do not use cleaners that leave your floors slippery.
  • Clean up any spills that happen immediately.
  • Use grab bars in the bathroom and railings on stairways.

Prevent falls outside your home

  • Make sure lighting is adequate in all areas outside your home.
  • Use a backpack or other type of bag that leaves your hands free.
  • Keep areas outside in good repair and free of clutter.
  • Wear sensible shoes with non-slip bottoms.

This is in no way a complete list of things that you can do to help prevent falls, but this is a starting point. Also remember to take your time. You might be less careful if you are in a hurry.

When should you call the doctor about osteoporosis?

If you have risk factors and are concerned about osteoporosis, ask your healthcare provider about being screened, even if you are not as old as 65 (for women) or 70 (for men). Osteoporosis can be serious. Fractures can alter or threaten your life. A significant number of people have osteoporosis and have hip fractures die within one year of the fracture. Always call your healthcare provider if you fall, if you are worried about bone breaks, or if you have back pain that is severe that comes on suddenly.

Remember that you are able to lead an active and fulfilling life even if you do have osteoporosis. You and your healthcare provider can work together to make this happen.

Resources

Are there resources for people with osteoporosis?

This list of organizations is not intended to be complete, but you might find it to be helpful.

Last reviewed by a Cleveland Clinic medical professional on 04/27/2020.

References

  • National Institutes of Health. NIH Osteoporosis and Related Bone Diseases National Resource Center (https://www.bones.nih.gov/) , Accessed 5/11/2020.
  • National Osteoporosis Foundation. What is osteoporosis? (https://www.nof.org/patients) Accessed 5/11/2020.
  • International Osteoporosis Foundation. Osteoporosis & Musculoskeletal Disorders. (https://www.iofbonehealth.org/osteoporosis-musculoskeletal-disorders) Accessed 5/11/2020.
  • International Society for Clinical Densitometry. Patient Information. (https://www.iscd.org/patient-information/patient-information/#VOCUS) Accessed 5/11/2020.
  • Food and Drug Administration. Osteoporosis. (https://search.usa.gov/search?query=osteoporosis&affiliate=fda1) Accessed 5/11/2020.
  • Alswat KA. Gender Disparities in Osteoporosis. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5380170/) J Clin Med Res. 2017;9(5):382-387. Accessed \5/11/2020.
  • Moritz M, Knezevich E, Spangler, M. Updates in the Treatment of Postmenopausal Osteoporosis. (https://www.uspharmacist.com/article/updates-in-the-treatment-of-postmenopausal-osteoporosis) US Pharm, 2019;44(9):32-35.
  • Sheng S, Zhenzhong S, Weimin J, Yimeng W, Qudong Y, Jinhui S. Improvement in Pulmonary Function of Chronic Obstructive Pulmonary Disease (COPD) Patients With Osteoporotic Vertebral Compression Fractures (OVCFs) After Kyphoplasty Under Local Anesthesia. Int Surg. 2015;100(3):503-9.'
  • American Bone Health. Why strontium is not advised for bone health. (https://americanbonehealth.org/medications-bone-health/why-strontium-is-not-advised-for-bone-health/) Accessed 5/11/2020.
  • Li K, Wang XF, Li DY, et al. The good, the bad, and the ugly of calcium supplementation: a review of calcium intake on human health. Clin Interv Aging. 2018;13:2443-2452.

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