Diseases

Osteoporosis

Osteoporosis is a bone disease that causes loss of bone strength and increases the risk of fractures. It occurs most commonly in the hips and spine.

Osteoporosis can be a silent disease that results in reduced strength of the skeleton. Many people do not know they have osteoporosis until it creeps up on them and they suffer a fracture.

It is important to take osteoporosis seriously and seek treatment.

Understanding Osteoporosis

Symptoms

Osteoporosis can be a silent disease. Often, it may not be diagnosed until a person suffers a fragility fracture. Fractures of the vertebrae (spine) are most common. People with a vertebral fracture often have back pain. Sometimes, there are no symptoms, but there might be loss of height.. This can result in a hump-back appearance. Some people may also feel like they are gaining weight as the excess abdominal fat moves to the front of their body. The hunching over can also result in the ribs rubbing on the pelvis, which can be painful.

Diagnosis

Osteoporosis can be diagnosed either after a fracture or through a bone mineral density test (BMD).

A bone mineral density test is a special x-ray that measures the density of the bone. The lower the bone density, the higher the chance of fracture. All women over 65 should have a bone mineral density test performed. In addition, adults between the ages of 50 and 65 with other risk factors for osteoporosis should have a bone mineral density test done.

Osteoporosis is also diagnosed after a fracture that results from a fall from standing height. This is called a “fragility fracture.” The most common locations for fragility fractures are the wrist, hip and spine.

Sometimes, “thin bones” can be seen on an X-ray. This can be a first clue and may prompt further testing.

If you are at risk of osteoporosis, your doctor will take a complete history and perform a thorough physical examination. This is usually followed by blood tests, X-rays and other types of tests.

Blood tests to look for secondary causes of osteoporosis may also be performed. These might include:

  • Serum calcium and phosphate levels
  • Parathyroid hormone levels to look for hypoparathyroidism
  • Creatinine test to determine renal function, which affects calcium and vitamin D levels
  • Liver enzymes – chronic liver disease; affects calcium and vitamin D levels
  • Thyroid-stimulating hormone – chronic thyroid levels can leach calcium from bone
  • Testosterone levels in men

Causes

There are many causes of osteoporosis. One key factor that affects a person’s risk of developing the disease is how much bone mass their body makes early in life. Most people reach peak bone mass in their 30s. After that, most people’s bodies make less bone tissue and we slowly start to absorb our skeletons. The amount of bone mass we produce is based on genetics, frame size, age and sex. Environmental influences such as malnutrition, low physical activity, chronic steroid use, smoking and high alcohol intake can also influence bone mass. Excessive steroid hormone, either due to Cushing’s disease or resulting from prolonged use of prescription steroids, can cause bone loss. Vitamin D deficiency can also cause bone loss.

There are also several factors that affect how much bone mass we lose over time. Men lay down more bone tissue in early life, and they lose less as they age. Women, on the other hand, experience more bone loss after menopause due to declining estrogen. Sex steroids such as estrogen are important for maintaining a type of bone called “trabecular bone.” This is like the scaffolding of our bones. It is found mainly in the hips, pelvis and spine.

You can think of osteoporosis like a cement building. You need struts (trabecular bone) to provide the scaffolding and cement (calcium) to provide strength to the building. Loss of bone integrity in osteoporosis is like the struts in a cement building breaking down. No matter how much more cement you pour in, if the struts are compromised so will be the strength of the building.

There are three common groups who are at risk for osteoporosis. The highest incidence occurs in postmenopausal women. Old age is also a risk factor. In men and women, bone strength continues to decrease with age, so the risk of osteoporosis increases. Osteoporosis can also affect people who have used glucocorticoid medications for a long time without proper protective strategies.

Other groups at risk for osteoporosis are patients with chronic diseases such as rheumatoid arthritis or lupus, or with hormone disorders such as thyroid disease. Cancer, chronic organ dysfunction and malabsorption diseases such as celiac disease or anorexia are also risk factors.

Treatments

If you are diagnosed with osteoporosis, the first thing is to make sure you are getting enough calcium and vitamin D. It is important to get 1,000 to 1,200 mg of elemental calcium per day, especially for post-menopausal women. Dairy products and canned salmon are good sources of dietary calcium. You should also aim for 1,000-2,000 IU of vitamin D per day. There are many foods fortified with vitamin D. Your doctor may recommend a supplement of 1,000 to 2,000 IU of vitamin D per day.

Exercise for Osteoporosis

Exercise, especially weight-bearing exercise, is very important for people with osteoporosis. It increases bone density and improves muscle strength. This can improve balance and reduce the risk of falls. Aim for 30 minutes of aerobic exercise 3 times per week. Any kind of exercise will do, as long as you can stick to it.

A trained physiotherapist can help design an exercise program focussed on muscle strengthening, flexibility and resistance training to reduce the risk of falls.

Medications for Osteoporosis

There are several medications for osteoporosis. Your doctor will first estimate your fracture risk before deciding if you require medication and what kind is best. The “FRAX assessment tool” helps to predict your risk of fracture over the next 10 years. You will be assigned one of three risk categories: mild, moderate and severe.

Adequate intake of calcium and vitamin D is important no matter what your fracture risk. A supplement might be required to help you obtain adequate intakes. If you have had a prior fracture, then treatment with medication will likely be required.

Mild Fracture Risk (<10% chance of fracture in 10 years)

If the risk of fracture is low, no medications are required. If you are a smoker, it is essential to quit. Exercise is also important as it reduces bone loss and helps to improve balance, which can prevent falls that may lead to fracture.

Moderate Fracture Risk (10-20% chance of fracture in 10 years)

Quitting smoking and increasing exercise is also key component in this risk category. Prescription medication may be recommended and you should discuss this with your doctor.

Severe Fracture Risk (>20% chance of fracture in 10 years)

Quitting smoking and increasing exercise is also key component in this risk category. There are several medications for the treatment of osteoporosis. The medication used may depend on cost, convenience, availability and other variables.

Oral bisphosphonates such as alendronate (Fosamax, Fosavance) or risedronate (Actonel) allow help prevent further thinning of the bones. There is also a bisphosphonate called zoledronic acid (Aclasta) given by intravenous infusion once per year.

A treatment called denosumab (Prolia) is a biologic that prevents loss of bone. It is given two times per year by an injection under the skin.

For women with menopausal symptoms and osteoporosis, hormone therapy (estrogen/progesterone) may be recommended. With menopause, your body produces less estrogen and progesterone, which results in reduced bone density.

For more information about specific medications used to treat osteoporosis, refer to Medications section of this website.