By Laura Ryan, MD
Clinical Assistant Professor of Medicine
Division of Endocrinology, Diabetes, and Metabolism
Assistant Director for Special Programs, Center for Women’s Health
The Ohio State University Wexner Medical Center
Q: What Is Osteoporosis?
A: Osteoporosis is a condition characterized by bone loss and a reduction of bone structure and strength, which leads to weakness and an increased likelihood of fracture. The condition is most common in postmenopausal women, and bone loss is most often caused by estrogen deficiency. Bone loss is also seen in men, however, especially those 70 and older; and when men develop osteoporosis, they are slightly more likely to fracture than women of a comparable age and with similar bone density.
Q: What Are The Risk Factors Of Osteoporosis?
A: A history of osteoporotic bone fracture is the most significant risk factor. Having had an osteoporotic fracture anywhere in the body predicts all other osteoporotic fractures. An osteoporotic fracture is generally defined as one that occurs after a fall from standing height. In other words, a broken bone from a car crash or after falling off a roof is not likely from osteoporosis.
Other risk factors include family history. Genetics plays a big role in the likelihood of an individual’s risk of fracture; we are still trying to understand which genes might be involved. Smoking even five cigarettes a day increases the chance of fracture; taking any dose of daily steroids is also a risk. Interestingly, having a weight less than 127 pounds is also an independent risk factor for fracture; I often think I am the only doctor encouraging my thin patients to put on some weight! Having a little padding on the hips has been shown in clinical trials to reduce the chance of a fracture with a fall.
Q: What Are The Symptoms Of Osteoporosis?
A: Osteoporosis is generally an asymptomatic disease and does not cause bone or joint pain; however, there are some indicators of the condition’s progression, most notably fractures.
One specific type of fracture— vertebral compression fracture— can cause height loss. A vertebral compression fracture occurs when one of the many vertebrae that make up the spine partially or fully collapses after a stressor is placed on the spine, such as the weight of a heavy toddler or the act of lifting a suitcase out of the trunk.
Vertebral compression fractures cause pain in more than 50 percent of episodes, but 40 percent of compression fractures are actually painless, and the fracture is found only with a measurement of height. These fractures can cause the so-called dowager’s hump that patients with osteoporosis can develop. Vertebral compression fractures are the most common osteoporotic fractures.
The other fractures most frequently seen as a result of osteoporosis are wrist fractures and hip fractures. Hip fractures are more likely to occur in our seventies or eighties, but they carry the most risk of morbidity and mortality. Twenty-five percent of people die within one year of a hip fracture; 50 percent of people who suffer a hip fracture never regain their full function or independence. This is why it is so important to diagnose and treat osteoporosis.
Q: How Is Osteoporosis Diagnosed?
A: Osteoporosis is diagnosed with a bone-density test, also known as a DXA, which is short for dual-energy X-ray absorptiometry. The DXA is a quick test that exposes the patient to only one-tenth the amount of radiation of a chest X-ray. Bone-density tests also reveal a more modest bone loss called osteopenia, which is more common than osteoporosis. Not everyone with osteopenia needs medication; whether to begin therapy often depends on the patient’s set of risk factors, and each case should be considered individually.
Osteoporosis may also be diagnosed in someone who has had a broken bone after a fall from standing height or other minimal trauma, regardless of their bone-density result.
The current recommendation is that postmenopausal women have their first bone-density test at age 65, unless they have specific risk factors for fracture, such as those discussed above, in which case the test should be closer to the onset of menopause. Men should be tested at age 70. Very few menstruating women require a bone-density test.
Q: What Role Do Calcium And Vitamin D Play In Preventing Or Treating Osteoporosis?
A: The current recommendations are that all postmenopausal women ingest 600 to 800 milligrams (mg) of calcium per day, and 400 to 800 international units (IU) of vitamin D. Some patients who are unable to absorb nutrients require higher doses of calcium or vitamin D. Those who live farther from the equator often require vitamin D doses of 1,000 to 2,000 IU during the late fall and winter.
It is preferable to get calcium from the diet rather than from supplements. If a patient is able to consume three full servings of dairy per day, there really is no need for additional calcium supplements. The best sources of dietary calcium are milk and yogurt as well as some other calcium-fortified drinks such as rice milk, almond milk, soy milk, or other supplemental drinks. (Unfortunately, ice cream doesn’t have as much calcium as some of my patients wish!)
Many adults cannot tolerate significant quantities of dairy, in which case calcium supplementation of 600 to 800 mg daily is both safe and positive for bone health. Remember, human intestines can absorb only 500 mg of calcium at a time, so try to separate calcium supplements from one another by at least four hours. It is much more difficult to get vitamin D in the diet, so a supplement (such as that found in a women’s 50+ multivitamin or even a plain over-the-counter vitamin D tablet) is often required.
Q: What Role Does Exercise Play In Osteoporosis?
A: The role of exercise in osteoporosis is less clear than is often believed. While many people are under the impression that high-impact exercise like running or power walking can directly increase bone density, that concept has actually been poorly proven in well-designed clinical trials. The type of exercise that has been best studied and has shown to improve bone density is intensive weight lifting; however, that same study showed a rapid reduction in bone density after the weight lifting was reduced.
The real goal of exercise in osteoporosis should not necessarily be to increase bone density or change the DXA result but rather to improve strength, flexibility, and agility, so that if a person stumbles over an uneven bit of sidewalk, he or she doesn’t actually fall, thereby preventing a fracture through prevention of falling. As such, any type of exercise that is likely to be enjoyed or maintained, even swimming, will achieve this goal.
The one caution that I give to patients is that they need to be particularly careful of their back, as certain exercises such as intense crunches may increase the chance of a vertebral compression fracture. Patients should work with their physician and a physical therapist to understand which forms of exercise might be best for them.
Q: If I Am Diagnosed With Osteoporosis, What Should I Know About Current Pharmaceutical Treatments?
A: Almost everyone who is identified as having osteoporosis should strongly consider medical therapy. In patients who require medical therapy in addition to calcium and vitamin D, the current recommendation is to first use medications from the bisphosphonate family; these includes Fosamax® (alendronate), Actonel® (risedronate), Boniva® (ibandronate), and the once-yearly Reclast® (zoledronic acid). These are considered first-line therapy because they have been around for a long time, are generally very safe and well tolerated, and have been proven to not only increase bone density but also reduce fractures.
Most bisphosphonates, if taken for a minimum of three years, reduce vertebral compression fractures by 70 percent and hip fractures by 35 to 40 percent. This class of medication is also beneficial because two well-designed trials have shown that if you take one of these medications for four to five years, you can stop it for two to four years and enjoy ongoing protection from fracture. This is the basis behind the so-called drug holiday. However, a drug holiday is not appropriate for everyone.
Estrogen has also been proven to prevent fractures, but it has many other potential risk factors associated with it, so it is often not used as initial therapy. Prolia® (denosumab) is a slightly newer medication that both significantly increases bone density and reduces fracture risk; this is an injection that you receive in the doctor’s office every six months. Forteo® (teriparatide) is a daily injection that patients give themselves; this is also an excellent medication that rapidly improves bone density and reduces the risk of a broken bone, but it is often reserved for patients with the highest likelihood of fracture.
Each of these medications has a unique set of potential side effects and more rare adverse reactions, and a thorough discussion with your doctor should inform the decision-making process. After medication has been started, checking bone density every 24 months helps assess the extent of improvement. Of course, the best effect is the absence of any broken bones!
Osteopenia and osteoporosis are not uncommon in postmenopausal women, and some men. The evaluation of someone’s bone health should depend strongly on a good sense of the patient’s history and risk factors for fracture. Medication to improve bone density and strength is sometimes required, but attention to calcium and vitamin D intake, as well as regular exercise and the prevention of falls, is an integral part of caring for bone loss. Finally, a good working relationship with a physician is important, as each case of osteoporosis presents its own unique needs and opportunities.
Laura Ryan, MD, joined The Ohio State University Wexner Medical Center in 2001. She received her undergraduate degree from Miami University and her medical degree from The Ohio State University College of Medicine. She serves as the clinical assistant professor of medicine for the Division of Endocrinology, Diabetes, and Metabolism and the assistant director for special programs at the Center for Women’s Health at Wexner Medical Center. Repeatedly cited as one of “America’s Best Doctors,” Dr. Ryan has a special focus on the evaluation and management of metabolic bone disease, particularly osteoporosis.