Osteoporosis is a condition characterized by low bone mass and disrupted bone microarchitecture resulting in weakened, fragile bones and an increase in the risk of fracture. It is estimated that some 53 million people in the U.S. live with it. Osteopenia is bone loss that’s not severe enough to be considered osteoporosis. Osteopenia can become osteoporosis.
During the course of our life, healthy bone is constantly being gradually broken down and new bone is being created. Our bones are at their densest at about age 30. After that, as we age, we lose bone more quickly than it is being replaced—so some bone loss is normal. At about age 50, if bone loss is outpacing bone replacement, osteopenia may occur. If this discrepancy continues, bones can become brittle and porous enough over time so that a fall or even mild stresses such as bending over or coughing, can cause a fracture. This is the hallmark of osteoporosis. Osteoporosis-related fractures most commonly occur in the hip, wrist, or spine (most common). These fractures can cause substantial pain, disability, and impaired quality of life. Most people have no symptoms of osteoporosis until they have a bone fracture, but some may have signs of osteoporosis when it’s advanced.
Osteoporosis affects men and women of all races, but women are more likely to be affected, and their risk increases as they age.
Women at higher risk for osteoporosis include: White women, Asian women, older post-menopausal women, those with a small body frame, women with a family history of fracture, women with lower sex hormone levels—such as lower estrogen levels secondary to menopause or some breast cancer treatments, those who are hyperthyroid, those with chronically inadequate dietary calcium and vitamin D intake, women who’ve had weight-loss surgery (which can cause reduced dietary calcium absorption), those who take steroid, anti-seizure, and gastric reflux medications, eat too much protein and sodium, drink too much alcohol and caffeine, smoke cigarettes, have uncontrolled stress, and are physically inactive (because lack of weight-bearing exercise weakens bones).
- Eating disorders
- Autoimmune disorders
- Digestive and gastrointestinal disorders
- Rheumatoid arthritis
- Multiple sclerosis
- Premature menopause
- Blood disorders
- Neurologic disorders such as stroke and depression
- Bed or wheelchair confinement
- Chronic kidney disease
- Liver disease
- Organ transplantation
Signs and symptoms of osteoporosis are essentially absent at the beginning, but when more advanced, osteoporosis can present as a fracture, back pain, progressive loss of height, a stooped posture, and a bone that breaks more easily than expected.
The diagnosis of osteoporosis involves the measurement of bone density, or strength. That’s usually done by the use of a bone densitometer (although there are other tests that can measure bone density). The bone density test results determine if there is osteopenia or osteoporosis, which, in turn, determines the susceptibility of a woman’s bones to fracture. The denser the bone, the lower its likelihood to fracture. The DEXA scan is most often performed on the upper part of the femur (the thigh bone) and the lower spinal, or lumbar, vertebrae. It is painless and takes only a few minutes.
The results of a DEXA scan are reported depending on a woman’s age. For older women, bone density test results are most commonly reported as the T-score. The T-score compares the bone density of the patient to that of a healthy 30 year old adult of the same sex. It is the gold-standard for the diagnosis of osteopenia and osteoporosis. A T-score between -1 and -2.5 indicates osteopenia. A T-score less than (or, more negative than) -2.5 units indicates osteoporosis.
The U.S. Preventive Services Task Force recommends that all women over age 65 have a bone density test. A bone density test should be done for a woman under age 65 if she is at high risk for fracture (for example, if there’s a family history of osteoporosis or if there was a personal history of bone fracture over age 50). Treatment recommendations for low bone density are based on an estimate of risk for bone fracture in the next 10 years using information such as the bone density test results, a risk score called the FRAX score, family history, and findings on physical exam. If the risk of fracture is low because a woman’s bones are strong, a healthy lifestyle routine can help keep them that way. Or, if there’s already some osteopenia, these same lifestyle choices can lower the chances that osteoporosis will develop. The cornerstone of a bone healthy lifestyle routine is good nutrition and regular exercise.
Osteoporosis can’t be reversed, but it can be managed. In addition to diet, exercise, and calcium/vitamin D supplements, there are medications that can be recommended to prevent further bone loss.
Women with advanced osteoporosis or those who have sustained a fracture may benefit from prescription treatments, which come in several forms: liquids, pills, injections, and infusions. Regardless of how the prescription treatments are taken, they work in one of two ways—by either slowing down bone breakdown or speeding up bone-building. The degree of osteoporosis helps determine which class of osteoporosis medications should be recommended. Of note, there is a class of medications called SERMs (Selective Estrogen Receptor Modulators) which are female hormone-like, are commonly used to treat osteoporosis. SERMs can mimic the beneficial effects of estrogen on bone density in postmenopausal women (that is, they can increase bone density by decreasing bone breakdown) without some of the negative risks associated with estrogen on the breast and uterus. However, hot flashes are a common side effect.
Women aged 18-50 need 1000 mg of calcium daily. This increases to 1200 mg when women turn 50. Calcium supplements can help maintain normal calcium levels, but it’s particularly beneficial to eat natural foods rich in calcium: spinach, broccoli, and leafy greens, as well as nonfat and low-fat cheese and yogurt, tofu, sardines and salmon.
Vitamin D improves the body’s ability to absorb calcium, so it, too, is important for good bone health. Most people need at least 600 IU (international units) of vitamin D daily. The body makes its own vitamin D when sunlight hits the skin. A few minutes outdoors helps get at least some vitamin D, but, again, it’s beneficial to eat foods rich in vitamin D: fish (salmon, tuna, and mackerel), fish liver oils, beef liver, egg yolks, fortified cereals and juices, milk, and yogurt.
Exercise – especially weight-bearing exercise, or exercise that causes you to step down on your feet, like walking, jogging, running, step aerobics, dancing, and stair climbing, and strength training with weights—helps build strong bones and slow down bone loss. One can start to exercise at any point in their life, but starting to exercise at a young age and continuing on reaps the most benefit to bone health in the long run.
Finally, it’s essential not to smoke and drink too much alcohol. Studies have shown strong independent links between cigarette smoking and excessive alcohol and lower bone density. It’s also important to cut back on caffeine and salt. Both can make the body lose more calcium and bone. Caffeinated coffee and sodas have been linked to osteopenia, as has sodium.
We at Adaptive Gynecology are ready to have the important conversation with you about maintaining a healthy lifestyle and good bone health as the best defense against osteopenia and osteoporosis.
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