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Osteoporosis

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What is osteoporosis?

Osteoporosis is a condition that affects the bones, causing them to become weak and fragile and more likely to break (fracture).

These fractures most commonly occur in the spine, wrist and hips but can affect other bones such as the arm or pelvis.

What causes osteoporosis?

In childhood, bones grow and repair very quickly, but this process slows as you get older. Bones stop growing in length between the ages of 16 and 18, but continue to increase in density until you are in your late 20s. From about the age of 35, you gradually lose bone density. This is a normal part of ageing, but for some people it can lead to osteoporosis and an increased risk of fractures.

Other things that increase the risk of developing osteoporosis include:

  • a family history of osteoporosis
  • a parental history of hip fracture
  • a low body mass index (BMI) of 19 or less
  • having an eating disorder, such as anorexia or bulimia
  • long-term use of high-dose corticosteroid treatment (widely used for conditions such as
    arthritis
    and
    asthma
    , which can affect bone strength
  • insulin dependent diabetes mellitus
  • heavy drinking and smoking
  • rheumatoid arthritis
  • malabsorption problems, as experienced in
    coeliac disease
    and
    Crohn's disease
  • some drugs used in breast cancer and
    prostate cancer
    treatment that affect hormone levels
  • long periods of inactivity, such as long-term bed rest

Read more about the

causes of osteoporosis
.

Living with osteoporosis

If you're diagnosed with osteoporosis, there are steps you can take to reduce your chances of a fall, such as removing hazards from your home and having regular sight and hearing tests.

There are ways to help your recovery from a fracture. This might include:

  • hot or cold treatments, with warm baths or cold packs
  • TENS electrical device, which is thought to reduce pain by stimulating the nerves
  • relaxation techniques

If you're worried about living with a long-term condition, speak to your doctor or nurse who may be able to answer any questions you have. Some people with osteoporosis find it helpful to talk to a trained counsellor or psychologist, or to others with the condition.

Read more about

living with osteoporosis
.

Osteoporosis symptoms

There are often no warning signs for osteoporosis until someone experiences a fracture, often after a minor

fall
.

The most common injuries in people with osteoporosis are

wrist fractures
,
hip fractures
or fractures of the spinal bones (vertebrae).

A simple cough or a sneeze may cause the fracture of a rib or the partial collapse of one of the bones of the spine.

A fractured bone in an older person can be serious, depending on where it occurs, and can lead to long-term disability. For example, a hip fracture may lead to long-term problems with mobility.

One visible sign of osteoporosis is the characteristic stooping (bent forward) position that develops in older people. It happens when the bones in the spine are fractured, making it difficult to support the weight of the body.

If your doctor suspects you have osteoporosis, or are at high risk of developing the condition, you may be referred for a

bone density scan (DEXA scan)
. This is a short and painless procedure that helps to assess your risk of a fracture.

Read more about

diagnosing osteoporosis
.

Is osteoporosis painful?

Osteoporosis usually doesn't cause pain unless a bone is broken as a result of the condition. Although not always painful, spinal fractures are the most common cause of chronic pain associated with osteoporosis.

How does osteoporosis develop?

Bones are at their thickest and strongest in early adult life and are constantly renewed and repaired through a process called bone turnover. However, as you age, this process is no longer balanced and bone loss increases. This means bone is very slowly broken down over time and your bones become less dense as you get older. This leads to the bone becoming weaker and more likely to fracture.

Who is at risk of osteoporosis?

Osteoporosis can affect men and women. It is more common in older people, but it can affect younger people, too.

Women

Women are at greater risk of developing osteoporosis than men. This is because changes in hormone levels can affect bone density. The female hormone oestrogen is essential for healthy bones. After the

menopause
, the level of oestrogen in the body falls, and this can lead to a rapid decrease in bone density. Women are at even greater risk of developing osteoporosis when:

  • they have an early menopause (before the age of 45)
  • they have a
    hysterectomy
    before the age of 45, particularly when the ovaries are also removed
  • their
    periods are absent
    for a long time (more than 6 months) as a result of over-exercising or over-dieting

Men

For most men who develop osteoporosis, the cause is unknown. However, there is a link to the male hormone testosterone, which helps to keep the bones healthy. Men continue to produce this hormone into old age, but the risk of osteoporosis is increased in men with low levels of testosterone.

In around half of men the exact cause of this is unknown, but known causes include:

  • the use of certain medications such as oral glucocortoids
  • alcohol misuse
  • hypogonadism – a condition that causes abnormally low testosterone levels

Diseases of the hormone-producing glands

Many hormones in the body can affect the process of bone turnover. If you have a disease of the hormone-producing glands, you may be at higher risk of developing osteoporosis. Osteoporosis can be triggered by hormone-related diseases, including:

Increased risk

Other things thought to increase the risk of osteoporosis and broken bones include:

  • a family history of osteoporosis
  • a parental history of hip fracture
  • a low body mass index (BMI) of 19 or less
  • having an eating disorder, such as anorexia or bulimia
  • long-term use of high-dose corticosteroid treatment (widely used for conditions such as
    arthritis
    and
    asthma
    ), which can affect bone strength
  • insulin dependent diabetes emllitus
  • heavy drinking and smoking
  • rheumatoid arthritis
  • malabsorption problems, as experienced in
    coeliac disease
    and
    Crohn's disease
  • some drugs used in breast cancer and
    prostate cancer
    treatment that affect hormone levels
  • long periods of inactivity, such as long-term bed rest

Osteoporosis diagnosis

Osteoporosis is often diagnosed after the weakening of the bones has led to a fracture.

If you're at high risk of osteoporosis, your doctor may refer you for a bone density scan, known as a DEXA scan.

X-rays
are not a reliable method of measuring bone density, but are a useful way of identifying fractures.

DEXA scan

A

DEXA (dual energy X-ray absorptiometry) scan
can help diagnose osteoporosis. It's a painless procedure that takes around 15 minutes to perform.

It measures your bone mineral density (BMD) and compares it to the bone density of a healthy young adult and someone who is of the same age and sex as you.

The difference between your BMD measurement and that of a healthy young adult is calculated as a standard deviation (SD) and called a T score. Standard deviation is a measure of variability based on an average or expected value. A T score of:

  • above -1 is normal
  • between -1 and -2.5 is classed as osteopenia (where bone density is lower than average but not low enough to be classed as osteoporosis)
  • below -2.5 is classed as osteoporosis

A bone density scan can help diagnose osteoporosis, but your BMD result is not the only factor that determines your risk of fracturing a bone.

Your doctor will also consider your age, sex and any previous injuries before deciding whether you need treatment for osteoporosis.

If you do need treatment, your doctor will suggest the safest and most effective treatment plan for you.

Treating osteoporosis

Although a diagnosis of osteoporosis is based on the results of your bone mineral density (DXA) scan, the decision about what treatment, if any, you have can be based on a number of factors, including your risk of fracture. If you’ve been diagnosed with osteoporosis because you’ve had a fracture, you should still be treated to try to reduce the risk of any further fractures.

You may not need or want to take drugs to treat your osteoporosis. However, you should maintain good levels of calcium and vitamin D in your body. Your healthcare team may advise a change to your diet or taking supplements to do this.

Drugs for osteoporosis

There are a number of different drug treatments for osteoporosis. Your doctor will discuss the treatments available and make sure the medicines are right for you.

Bisphosphonates

Bisphosphonates work by slowing the rate at which the cells that break down bone (osteoclasts) work. This maintains bone density and reduces the risk of fracture. There are a number of different bisphosphonates, including:

  • alendronic acid
  • ibandronic acid
  • risendronic acid
  • zolendronic acid

The main side effects associated with bisphosphonates include irritation to the oesophagus, trouble swallowing and stomach pain. It is recommended that you take bisphosphonates on an empty stomach with a full glass of water. You then need to stand or sit upright for 30 minutes. After this, you will need to wait between 30 minutes and 2 hours before eating or drinking any other fluids.

Osteoneocrosis of the jaw is a rare side effect linked with the use of bisphosphonates (more frequently with high-dose intravenous bisphosphonate treatment for cancer and not for osteoporosis). The cells in the bone of the jaw die, and this can lead to problems with healing. If you have a history of dental problems, you may need a check-up before you start this treatment. If you have any concerns, speak to your doctor.

Selective estrogen receptor modulators (SERMs)

SERMs are drugs that have a similar effect on bone as the hormone oestrogen. They help maintain bone density and reduce the risk of fracture, particularly at the spine. The only form of SERM available for the treatment of osteoporosis is raloxifene. Raloxifene is taken as a tablet every day.

Side effects associated with raloxifene include hot flushes, leg cramps and a potential increased risk of blood clots.

Parathyroid hormone (PTH) (Teriparetide)

Parathyroid hormone is produced naturally in the body. It regulates the amount of calcium in bone. Parathyroid hormone treatments (human recombinant parathyroid hormone or teriparatide) are used to stimulate cells that create new bone (osteoblasts). They are given by injection. While other drugs can only slow down the rate of bone thinning, PTH can increase bone density. However, it's only used in a small number of people whose bone density is very low and where other treatments aren’t working.

Common side effects include nausea and vomiting. Parathyroid hormone treatments should only be prescribed by a specialist.

Calcium and vitamin D supplements

Having enough

calcium
as part of a healthy balanced diet is important to maintain healthy bones. Aim to eat or drink 700mg of calcium each day. This is roughly equivalent to 1 pint of milk. However, if you are not getting enough calcium in your diet, or you have been diagnosed with osteoporosis, ask your doctor for advice about taking a calcium supplement.

Hormone replacement therapy (HRT)

HRT is used for women going through the menopause as it can help to control symptoms. In addition, HRT has been shown to maintain bone density and reduce the risk of fracture during treatment. However, HRT is not specifically recommended as a treatment for osteoporosis and is now almost never used. This is because there's a risk that HRT slightly raises the chance of developing certain conditions, such as

breast cancer
, endometrial cancer,
ovarian cancer
and
stroke,
more than it lowers the risk of osteoporosis. Discuss the benefits and risks of HRT with your doctor.

Read more information about

understanding the risk of HRT
.

Testosterone treatment

Testosterone treatment for men is useful when osteoporosis is due to an insufficient production of male sex hormones (hypogonadism).

Regular exercise

Regular exercise is essential. Adults should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity (i.e. cycling or fast walking) every week. Weight-bearing exercise and resistance exercise are particularly important in improving bone density and helping prevent osteoporosis.

If you’ve been diagnosed with osteoporosis, it’s a good idea to talk to your doctor or health specialist before you take up any new exercise activity, to make sure it’s right for you.

Weight-bearing exercises

Weight-bearing exercises are exercises where your feet and legs support your weight. High-impact weight-bearing exercises, such as running, skipping, dancing, aerobics and even jumping up and down on the spot, are all useful ways to strengthen your muscles, ligaments and joints. When exercising, wear footwear that provides your ankles and feet with adequate support, such as trainers or walking boots.

People over the age of 60 can also benefit from regular weight-bearing exercise. This can include brisk walking, keep-fit classes or a game of tennis. Swimming and cycling are not weight-bearing exercises.

Resistance exercises

Resistance exercises use muscle strength, where the action of the tendons pulling on the bones boosts bone strength. Examples include press-ups, weightlifting or using weight equipment at a gym. If you've recently joined a gym or have not been for a while, your gym will probably offer you an induction. This involves being shown how to use all the equipment and recommended exercise techniques. If you're unsure how to use a piece of equipment or how to do an exercise, ask a gym instructor for help.

Healthy eating

Eating a healthy, balanced diet is recommended for everyone. It can help prevent many conditions, including

heart disease
,
diabetes
and many forms of
cancer
, as well as osteoporosis.

Calcium
is important for maintaining strong bones. The recommended intake of calcium is at least 700mg a day. This is about equivalent to 1 pint of milk. Calcium can also be found in a number of different foods, including green leafy vegetables, dried fruit, tofu and yoghurt.

Vitamin D
is also important for bones and teeth as it helps your body to absorb calcium. Most vitamin D is made in the skin in response to sunlight. In the summer months, this is enough alongside a balanced diet. However, during autumn and winter, when there is less sunlight, it is recommended that all adults (including those who are pregnant or breastfeeding) should consider taking a daily supplement containing 10 micrograms of vitamin D.

Vitamin D can be found in eggs, milk and oily fish. But it can be difficult to get enough vitamin D just from food.

Certain groups of people may be at risk of not getting enough vitamin D. These include people who may be housebound or particularly frail, people with a poor diet, those with darker skin, or those who keep covered up in sunlight because they wear total sun block or follow a certain dress code. If you're at risk of not getting enough vitamin D through your diet or lifestyle, you can take a vitamin D supplement all year round.

Other factors

Other lifestyle factors that can help prevent osteoporosis include:

  • quitting smoking – cigarette smoking is associated with an increased risk of osteoporosis
  • limiting your alcohol intake – the recommended daily limit is 3 to 4 units of alcohol for men and 2 to 3 units for women, although it's important to also avoid binge drinking

Important: Our website provides useful information but is not a substitute for medical advice. You should always seek the advice of your doctor when making decisions about your health.