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Osteoporosis
Important Definitions:
Osteoblasts: a type of bone cell that builds-up bone. When bones build up, they undergo both synthesis (formation) and mineralization (elements are combined).
Osteoclasts: a very large bone cell which breaks down bone tissue, also referred to as remodeling. Normal healthy bones are constantly undergoing
Bone resorption: the process where the osteoclasts break down the bone and release the minerals into the blood stream, which results in calcium moving from within the bone to the blood.
Bone Remodeling: the breaking down of mineralized bone by osteoclasts followed by the synthesis of bone matrix by osteoblasts. The bone tissue will subsequently become mineralized.
Bone Matrix: consists of about 33% organic matter (mostly collagen) and 67% inorganic matter (calcium phosphate). The integrity of the bone matrix is critical for bone strength.
Bone Density or Bone Mineral Density (BMD): is the amount of minerals, ie: calcium and phosphorous contained in a certain volume of bone.
Low Bone Mass: is diagnosed when your bone mineral density (BMD) value at either the neck of your femur (hip joint) or in your lumbar spine (low back) or both that is between -1 and -2.5 standard deviations (SDs) below the mean (average) bone density (BMD) of the value of a young, healthy female adult.
DEXA scan (Dual-Energy X-ray Absorptiometry), also called a Bone Scan or a Bone Densitometry is an imaging modality where a very small dose of ionizing radiation (like having an x-ray) will be used to produce a image of your bones, specifically your wrist, femur and spine.
Osteopenia: osteo means "bone" and penia means "decrease or deficiency". Osteopenia is diagnosed when your BMD is low. Your DEXA scan "T-scores" will fall between -1 and -2.5 standard deviations below a young female adult.
Osteoporosis: osteo means "bone" and porosis means “porous bone.” Osteoporosis is diagnosed when your BMD is very low. Your DEXA scan "T-scores" will be less then -2.5 standard deviations below a young female adult.
However, you may also be diagnosed with osteoporosis if you have had a fragile fracture (see below) or you have a moderate or high 10-year fracture via a FRAX score (see below).
What is Osteoporosis?
Osteoporosis is a condition in which the bone mass or your BMD is decreased, which often begins to occur when a woman enters into perimenopause or menopause stage of life. Once she is post-menopausal this process often accelerates, which is attributed to the woman's lack of estrogen and/or a deficiency in calcium or vitamin D.
The lower levels of estrogen occur because the woman stops ovulating. If a woman is still having monthly menstrual cycles, generally her blood estrogen remains at an adequate level to support normal healthy bone remodeling. If you would like to learn more about the menstrual cycle physiology and ovulation see my education page.
If you could view bone under a microscope, you would notice that the spaces become very widened when BMD decreases, which causes bones to become brittle and weak and thus the risk of fractures increases. There are a few types of bone fractures that are hallmarks of osteoporosis:
- Fragile fractures: are fractures that occur with only mild trauma. Such as a fall which results in a wrist fracture.
- Vertebral fractures also called compression fractures: are fractures that occur in your spine, where the vertebral body spontaneously collapse on itself. Most often these fractures are completely painless. They will show easily in a spin x-ray, and if two or three occur they can cause the woman to appear bent over as in the picture to your left (we call this kyphosis). Vertebral fractures also cause women to lose height,
- Hip fractures: hip fractures are the most serious osteoporitic fractures. According to the CDC, over 300,000 people age 65 and older are hospitalized for hip fractures. Women account for 3/4 of these.
What are Symptoms of Osteoporosis?
Well, most often women have absolutely NO symptoms at all, which is why it is so important that you educate yourself about this disease condition.
Osteoporosis is known as a “silent” disease” because oftentimes women will not be diagnosed until they have a bone fracture.
Can Younger Women get Osteoporosis?
YES, there are many conditions which can perpetuate early osteoporosis. Your bones begin to build themselves up in childhood. By about age 30, you will have built up most of your bone mass. The following are conditions that can put women at risk of developing osteopenia and/or osteoporosis many years prior to menopause.
- Functional Hypothalamic Amenorrhea (FHA): your period stops or becomes very infrequent due to expending more caloric energy that you take in via food. FHA is a common condition among athletes and women who have highly stressful lives.
- Anorexia nervosa, excessive dieting and/or poor nutrition early in life
- Hyperthyroidism: elevated thyroid hormones.
- Gastrointestinal malabsorption conditions, such as: Celiac disease and Crohn's disease.
- Vitamin D Deficiency and/or calcium Deficiency
- Hyperparathyroidism: increased parathyroid hormone (PTH) will be released if your blood levels of Vitamin D/Vitamin C are chronically low. PTH will go to the bones and cause osteoclasts to speed up bone resorption.
- Diabetes Melitus
- Cushing syndrome: chronically elevated cortisol.
- Inflammatory conditions, such as rheumatoid arthritis, Crohn's disese or ulcerative colitis.
- Alcoholism and smoking
Many medications can cause early osteoporosis:
- Corticosteroids such as prednisone
- Depo-progesterone a common medication used for birth control
- Proton pump inhibitors taken for acid reflux
- SSRIs taken for anxiety
- Anti-seizure (epilepsy) drugs
- Thyroid medication
- Diabetic medication
- Methotrexate, given for inflammatory conditions like arthritis
- Heparin if taken for longer durations.
- Hormonal drugs to breast and prostate cancers
- Diuretics taken for high blood pressure or leg edema
- Lithium taken for some mental health disorders
What are the Risks of Osteoporosis?
Diet:
Women who have eating disorders, who have dieted excessively, or who have had poor diets are at greater risk of developing osteoporosis. Thus, it is very important all for women to have adequate protein, calcium and Vitamin D throughout their lifespan.
Weight:
Women who have a BMI < 24 and who are smaller typically have thinner bones to begin with, so they will be at a greater risk to develop osteoporosis.
Ethnicity:
White and Asian women are at the highest risk.
Family history:
Genetics plays a role. If your mother, aunts, sisters, or grandmother has had osteoporosis or if they had bone fractures, you are probably at higher risk.
Alcohol use:
Excessive alcohol is a significant risk factor for osteoporosis.
Smoking:
Nicotine use (vaping, smoking) is a risk factor for osteoporosis.
Medications:
See list of medications above, "Can Younger Women Get Osteoporosis?"
Life Style Changes to Prevent and Treat Osteoporosis
Diagnosis of Osteoporosis
The diagnosis of osteoporosis is no longer made simply by DEXA scores, there is a bit more to making this diagnosis now, and how we manage this condition.
Your DEXA Scan shows you now have osteoporosis... what next?
First, I will meet with you for a visit to discuss your DEXA results, and to help you understand what they mean. We will be focusing on three parameters in your report:
- total hip
- femoral neck
- lumbar spine =
Next we will do a Fracture Risk Assessment using a standardized tool called the American Bone Health Fracture Risk Calculator (see below). The calculator will give us the following information:
- 10-year risk of any fracture
- Average risk of any fracture for your age
- 10-year risk of hip fracture
DEXA results and FRAX scores along with your Fracture Risk Assessment scores will tell us if you are:
- Low Risk
- Moderate Risk
- High Risk
- Very High Risk
Next we will discuss treatment options that are recommended for you. Please click the "Pharmacological Management of Osteoporosis" button below.
The American Bone Health Fracture Risk ASSESSMENT
Patients:
American Bone Health is a national nonprofit organization dedicated to providing educating about bone health and fracture risk and prevention. Click here to take a quick quiz to learn your personal 10-year fracture risk.
Medical Providers:
Click into the "Health Care Professional" tab to access the the American Bone Health Fracture Risk Calculator™ PRO, which is a validated tool that estimates fracture risk for your patients over age 45. The Endocrine Society Guidelines recommends you assess your patients' risk of fracture in order to move forward with an appropriate treatment plan.
It is very important for health care providers to understand that :
we no longer provide medication based solely on the patient's DEXA scores.
Who should receive pharmacological treatment for osteoporosis?
Per the 2020, Endocrine Society Guidelines, recommended pharmacological management of osteoporosis in postmenopausal women is as follows:
- For women with low risk of fracture, NO pharmacological treatment recommended. Rather we will work on optimizing Life Style Changes, and I will ask you to repeat the DEXA scan 2 yrs.
- For women with moderate risk, we should consider treatment. Thus, this will be a discussion between the individual patient and myself during your follow up visit to discuss your DEXA results.
- For women with a high to very high risk of fracture, pharmacological treatment is recommended.
- Noted: high risk determined by T-score of < -3.0 in the absence of fractures or -2.5 in the presence of fragile fractures or multiple vertebral fractures.
Exactly how do we determine the patient's risk?
Per Clinical Practice Guidelines published in 2018, entitled: "Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society, our risk assessment would include:
Low Risk:
- No prior hip or spine fractures,
- AND a BMD T-score at the hip and spine both above -1.0
- AND a 10-year hip fracture risk < 3%
- AND a 10-year risk of major osteoporotic fractures <20%
Moderate Risk:
- No prior hip or spine fractures
- AND a BMD T-score at the hip and spine both above -2.5,
- OR a 10-year hip fracture risk < 3%,
- OR a risk of major osteoporotic fractures risk < 20%
High Risk:
- A prior spine or hip fracture,
- OR a BMD T-score at the hip or spine of - 2.5 or below,
- OR a 10-year hip fracture risk >/= 3%,
- OR a risk of major osteoporotic fracture risk >/=20%
Very High Risk:
- Multiple spine fractures
- AND a BMD T-score at the hip or spine of -2.5 or below.
Pharmacological Management of Osteoporosis
Mediations Used to Treat Osteoporosis:
***** Do not take unless under medical supervision *****
BISPHOSPHONATES:
- Bisphosphonates are commonly used with efficacy in post-menopausal women with decreased bone mineral density.
- This medication is well known to incorporate itself into bone and be retained for years, hence the risk of femur fractures with long term use.
DENOSUMAB:
- Denosumab is a human monoclonal antibody directed against the receptor activator of nuclear factor-kB ligand.
- This mediation works well, in post-menopausal women, by limiting bone resorption via inhibition of osteoclast maturation.
TERIPARATIDE (rPTH):
- Teriparatide is commonly used and effective in post-menopausal women with decreased bone density.
- However, it should be noted that this medication carries a Black Box Warning in that is has been shown to be associated with an increased incidence of osteosarcoma in rats.