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.

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. 

 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. 

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. 

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. 

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. 

 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.