Osteoporosis

Signs & symptoms

Osteoporosis means "porous bones." If you have osteoporosis, your bones don't look any different, but they lose substance as well as calcium and other minerals. As a result, your bones have less strength and are more likely to fracture, particularly if you fall.

The most common osteoporosis fractures resulting from falls are in your wrist or hip. You are much more likely to have compression fractures in your vertebrae, the bones in your spine. A compression fracture is the result of the weakened bone cracking from the normal pressure of being upright. This often results in the curvature of the spine at the shoulders in older people sometimes called a "widow's hump."

The appearance of a widow's hump or a fractured wrist or hip from a fall may be the first actual symptoms of osteoporosis unless your doctor has been measuring your bone density. Men also should watch for a loss of height, change in posture or sudden back pain. There are a number of risk factors that increase a person's likelihood of having osteoporosis.

Risk Factors for Women

• European or American ethnic background
• Personal history of fracture as an adult
• Poor general health
• Smoking tobacco
• Low body weight, less than 127 pounds
• Estrogen deficiency
• Early menopause, before age 45
• Surgical removal of the ovaries before age 45
• Prior to menopause, having a time in your life when you went more than a year without a menstrual period
• Taking medical therapy that lowers estrogen levels, such as for breast cancer or endometriosis
• Lifelong low calcium intake
• Alcoholism
• Poor vision despite correction, like wearing glasses
• Falling
• Inadequate physical activity

Risk Factors for Men

• Heredity
• Race -- White men appear to be at the greatest risk for developing osteoporosis, although the condition can affect people of all ethnic groups
• Undiagnosed low levels of testosterone
• Falling
• Inadequate physical activity
• Age -- Bone loss increases with age
• Chronic disease that alters hormone levels and affects the kidneys, lungs, stomach and intestines
• Smoking tobacco
• Alcoholism
• Lifelong low calcium intake
• Low body weight

In addition, having a history of one of the following diseases can increase both a woman and man's risk of developing osteoporosis:

• Hyperparathyroidism, having an overactive parathyroid gland
• Hyperthyroidism, having an overactive thyroid gland
• Severe liver disease
• Kidney failure
• Pituitary tumor
• Adrenal disease
• Malabsorption
• Multiple sclerosis
• Rheumatoid arthritis
• Multiple myeloma
• Lymphoma
• Leukemia
• Diabetes

Taking one of the following medications can increase one's risk as well:

• Seizure medication
• Immunosuppressive drugs
• Steroids (prednisone, hydrocortisone, dexamethasone)
• Heparin
• Lithium
• Excess Thyroxine, thyroid replacement

Diagnosis

The single best predictor of bone strength is bone density. Bone density cannot be determined from plain X-rays, but a specialized low-dose X-ray technique called bone densitometry can be used to measure the amount of bone present in different parts of the skeleton. Research over the past decade has shown conclusively that bone density is related to risk of fracture, in much the same way that blood cholesterol is related to the risk of heart disease. The lower the bone density, the greater the risk of fractures due to osteoporosis.

Take our quiz to find out if you are a good candidate for a bone density test. If you answer "yes" to one or more of these questions, talk to your doctor about getting a bone density test.

Types of Bone Density Tests

We offer a variety of techniques to diagnose osteoporosis by determining the density of your bones. Expert consultation is available to assist in ordering the appropriate diagnostic examination. The different scanning techniques are:

• Dual X-ray absorptiometry (DXA) This is the most common way to measure bone density. The DXA uses fan beam technology allowing for rapid scanning with very low-energy X-rays. The spine and hip exams each take about five minutes. DXA of the forearm also may be helpful, especially if both hips have been replaced surgically. The Hologic Delphi scanner at Mount Zion also can perform a low-dose X-ray to evaluate for spinal fractures. DXA tests are painless. You will be asked to change into a hospital gown to prevent any clothing or metal objects from interfering with the test. You will lie on a table and the scanning arm is moved slowly over the parts of the body to be scanned. You are not in a tunnel as with an MRI. The test takes about 10 to 15 minutes.
• Ultrasound Bone density of the heel predicts overall fracture risk. However, ultrasound of the heel is not as good at predicting hip and vertebral fractures as DXA of the hip and spine. There are some instances in which your doctor might select this exam instead of, or in addition to, a DXA.

Other bone related examinations also may be helpful, depending on your particular circumstances:

• Quantitative computerized tomography (QCT) This exam uses a standard CT scanner. Two vertebrae in the lower back are selected for single cross-sectional scans, which are analyzed with special densitometry software. The entire procedure takes about 15 minutes. This exam sometimes is used if you have a lot of arthritis in your back, which makes the DXA test less reliable. This exam isn't always covered by insurance and isn't covered by Medicare.
• Lateral radiographs Using a conventional X-ray unit, views of the upper and lower spine are taken to see if you have any fractures. This is a 15-minute exam.

The recommended clinical examination consists of DXA of the spine and hip. QCT and lateral radiographs of the spine may be needed depending on the DXA results and your particular circumstances.

Treatments

Your bone density test will tell your doctor if your bone density is normal, osteopenic (low bone mass) or osteoporotic. Based on these results and your risk factors for fracture, you and your doctor may select among the following treatment options.

Treatment for Women

No matter what your bone density is, all women should optimize their lifestyle to help prevent bone loss. This includes:

• Adopting a regular exercise regimen of weight-bearing exercises, such as walking or jogging, dancing, weight lifting, racquet sports and using resistance machines.
• In addition, it is important to get enough vitamin D. A daily intake of 400 IU, but no more than 800 IU, each day is recommended. Obtaining adequate amounts of vitamin D from our food may be difficult. The main sources of dietary vitamin D are fortified milk (100 IU/cup), egg yolks (25 IU/yolk) and oily fish (vitamin D content varies). Sunlight exposure causes vitamin D production in the skin, but this effect is blocked by sunscreen. Many people will need vitamin D supplements to achieve an adequate intake. Most multi-vitamins contain 400 IU of vitamin D.
• Ensuring a daily calcium intake of 1,000 mg per day to age 50, and 1,200 to 1,500 mg per day for those over age 65 also is recommended. Our Calcium Counter offers a basic guideline for maintaining good bone health through adequate calcium consumption.

Treating Fractures

Our goal is to prevent fractures from occurring. But sometimes, despite all our efforts, they occur. The most common osteoporotic fractures are in the wrist, spine and hip. Wrist and hip fractures may require casting, hospitalization or surgery depending on how the bone is broken. Vertebral fractures can be very painful and there are now some options to treat them.

Medication

If your bone mass and risk factors put you at high risk for fracture, your doctor also may want you to take medication either to treat or prevent osteoporosis. There are many medications available. All have risks and benefits. Only you and your doctor can select which medication is right for you.

• Estrogen The female hormone estrogen is very effective at preventing bone loss, especially around the time of menopause. It also can help regain bone mass in older women. Estrogen reduces hip and spine fractures by about 30 percent to 40 percent. There is a small increase in risk for breast cancer and vascular disease such as heart attacks and strokes. There also is a small risk of developing blood clots on estrogen therapy. The risks and benefits of estrogen therapy must be weighed carefully for each woman.
• Bisphosphonates These medications are very effective in increasing bone mass at all ages and reduce fractures by about 40 percent to 50 percent. Current bisphosphonates approved for osteoporosis include alendronate (Fosomax) and risidronate.(Actonel). These medications can be hard to absorb and they must be taken on an empty stomach first thing in the morning with water only. You then must remain upright for at least 30 minutes before eating or drinking anything else. Rarely, these medications can cause esophageal irritation and ulceration. There are daily and weekly regimens of bisphosphonates; both appear equally effective at increasing bone density.
• Calcitionin This medication is a nasal spray and some evidence suggests it may reduce vertebral fractures although the studies are small. Unlike other medications, it appears to help reduce the pain associated with fractures.
• Raloxifene (Evista) This medication acts like estrogen at some parts of the body (bone, heart) and opposes estrogen effects at other parts (breast, uterus). It reduces the risk of vertebral fractures by 40 percent. Similar to estrogen, it increases the risk of blood clots and can increase hot flashes if used around the time of menopause. It appears to reduce the risk of breast cancer in low-risk women by about 75 percent. It has not been tested for effects on hip fracture.
• Parathyroid Hormone (PTH) Teriparatide, a form of parathyroid hormone, has been shown to stimulate bone formation and increase bone mineral density. In postmenopausal women who took the drug, fracture reduction of 50 percent to 70 percent was seen in the spine, hip, foot, ribs and wrist. Teriparatide is self-administered as a daily injection for up to two years.

Kyphoplasty

A new treatment for osteoporosis spine fractures is called kyphoplasty. Kyphoplasty is a minimally invasive procedure, which means only tiny incisions are used. Through an incision, a small balloon is inserted into the collapsed bone to restore its shape. It is then filled with a substance that hardens and helps the bone expand. Long-term trials of this procedure are ongoing.

Treatment for Men

No matter what your bone density is, all men should optimize their lifestyle to help prevent bone loss. This includes:

• Adopting a regular exercise regimen of weight-bearing exercises, such as walking or jogging, weight lifting, racquet sports and using resistance machines.
• Having an adequate vitamin D daily intake of 400 IU, but no more than 800 IU each day also is recommended. Obtaining adequate amounts of vitamin D from our food may be difficult. The main sources of dietary vitamin D are fortified milk (100 IU/cup), egg yolks (25 IU/yolk) and oily fish (vitamin D content varies). Sunlight exposure causes vitamin D production in the skin, but this effect is blocked by sunscreen. Many people will need vitamin D supplements to achieve an adequate intake. Most multi-vitamins contain 400 IU of vitamin D.
• Ensuring a daily calcium intake of 1,000 mg per day to age 50, and 1,200 to 1,500 mg per day for those over age 65 is recommended. Our Calcium Counter offers a basic guideline for maintaining good bone health through adequate calcium consumption.

Treating Fractures

Our goal is to prevent fractures from occurring. But sometimes, despite all our efforts, they occur. The most common osteoporotic fractures are in the wrist, spine and hip. Wrist and hip fractures may require casting, hospitalization or surgery depending on how the bone is broken. Vertebral fractures can be very painful and there are now some options to treat them.

Medication

If your bone mass and your risk factors put you at high risk for fracture, your doctor also may want you to take medication either to treat or prevent osteoporosis. There are many medications available. All have risks and benefits. Only you and your doctor can select which medication is right for you.

• Bisphosphonates These medications are very effective in increasing bone mass at all ages and reduce fractures by about 5 percent. Current bisphosphonates approved for osteoporosis include alendronate (Fosomax) and risidronate (Actonel). Your doctor may recommend taking bisphosphonates with supplemental calcium and vitamin D. These medications can be hard to absorb and they must be taken on an empty stomach first thing in the morning with water only. You then must remain upright for at least 30 minutes before eating or drinking anything else. Rarely, these medications can cause esophageal irritation and ulceration. There are daily and weekly regimens of bisphosphonates; both appear equally effective at increasing bone density.
• Calcitionin This medication is a nasal spray and some evidence suggests it may reduce vertebral fractures although the studies are small. Unlike other medications, it appears to help reduce the pain associated with fractures. While calcitionin is currently only FDA approved for the treatment of osteoporosis in postmenopausal women, evidence suggests that it may have similar effects of men.
• Testosterone Replacement Therapy This medication may be prescribed to men with low testosterone levels and has been shown to increase muscle mass and strength, libido, bone mass and hair growth.
• Parathyroid Hormone (PTH) Teriparatide, a form of parathyroid hormone, has been shown to stimulate bone formation and increases bone mineral density. An 11-month study conducted by E. Orwoll and the Oregon Health Science at the University of Portland, found that men with osteoporosis who took PTH had a spine bone mineral density (BMD) increase of 6 percent and a hip BMD increase of 1.5 percent. Teriparatide is self-administered as a daily injection for up to two years.

Kyphoplasty

A new treatment for osteoporosis spine fractures is called kyphoplasty. Kyphoplasty is a minimally invasive procedure, which means only tiny incisions are used. Through an incision, a small balloon is inserted into the collapsed bone to restore its shape. It is then filled with a substance that hardens and helps the bone expand. Long-term trials of this procedure are ongoing.