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:
- diseases of the hormone producing glands – such as an overactive thyroid gland (hyperthyroidism)
- a family history of osteoporosis
- long-term use of certain medications that affect bone strength or hormone levels, for example, oral prednisolone
- malabsorption problems
- heavy drinking and smoking
Read more about the causes of osteoporosis.
Symptoms of osteoporosis
There are often no warning signs for osteoporosis until someone experiences a fracture, often after a minor fall.
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.
Treatment for osteoporosis is based on treating and preventing fractures and using medication to strengthen your bones.
However, the decision about what treatment, if any, you have will depend on your risk of fracture. This will be based on a number of things such as the results of your DEXA scan and your age.
Read more about how osteoporosis is treated.
It's important that people at risk of osteoporosis take steps to help keep bones healthy and reduce their risk of developing the condition. This may include:
- regular exercise
- healthy eating
- lifestyle changes, such as quitting smoking and reducing alcohol intake
Read more about preventing osteoporosis.
Who is affected
Although commonly associated with post-menopausal women, osteoporosis can also affect men, younger women and children.
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 develops slowly over several years. It's likely there will be no warning signs or symptoms until a minor fall or sudden impact causes a bone fracture.
Healthy bones should be able to withstand a fall from standing height, so a bone that breaks in these circumstances is known as a fragility fracture.
The most common injuries in people with osteoporosis are:
- wrist fractures
- hip fractures
- 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.
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.
Osteoporosis is caused by bones losing their density. Some people are more at risk than others.
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 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
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:
- hyperthyroidism (overactive thyroid gland)
- disorders of the adrenal glands, such as Cushing's syndrome
- reduced amounts of sex hormones (oestrogen and testosterone)
- disorders of the pituitary gland
- hyperparathyroidism (overactivity of the parathyroid glands)
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
- long-term use of high-dose corticosteroid treatment (widely used for conditions such as arthritis and asthma), which can affect bone strength
- 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 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.
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.
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 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 alendronate, etidronate, ibandronate, risedronate and zolendronic acid. They are given as a tablet or injection.
The main side effects associated with bisphosphonates include irritation to the oesophagus, trouble swallowing and stomach pain, but not everyone will experience these. 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.
Strontium ranelate appears to have an effect on both the cells that break down bone and the cells that create new bone (osteoblasts). It can be used as an alternative treatment if bisphosphonates are found to not be suitable. Strontium ranelate is taken as a powder dissolved in water.
The main side effects associated with strontium ranelate are nausea and diarrhoea. A few patients have reported a rare, severe allergic reaction to the treatment. If you develop a skin rash while taking strontium ralenate, stop taking it and speak to your doctor immediately.
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
Calcium and vitamin D supplements can benefit older men and women and reduce their risk of hip fracture. 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. If you are not getting enough calcium in your diet, ask your doctor for advice about taking a calcium supplement. To have the right effect on your bones and help prevent falls or fracture, or in treatment of osteoporosis, you need the right dose of calcium (1.2g a day) and vitamin D (20 micrograms). These doses only occur in a small number of branded formulations prescribed by doctors, so any pills you buy over the counter may not have enough calcium and generally no vitamin D.
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.
Calcitonin is a hormone made by the thyroid gland. It inhibits the cells that break down bone (osteoclasts), which increases bone density. Calcitonin or salcatonin are taken as a nasal spray or an injection every day. Side effects include nausea, vomiting and diarrhoea.
Testosterone treatment for men is useful when osteoporosis is due to an insufficient production of male sex hormones (hypogonadism).
Although your genes determine your potential height and the strength of your skeleton, lifestyle factors such as diet and exercise can influence how healthy your bones are.
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 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 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.
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. Vitamin D can be found in eggs, milk and oily fish. However, most vitamin D is made in the skin in response to sunlight. A short exposure to sunlight, without sunscreen (10 minutes twice a day) throughout the summer should provide you with enough vitamin D for the whole year.
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 or who keep covered up in sunlight because they wear total sun block or adhere to a certain dress code, and women who are pregnant or breastfeeding. If you're at risk of not getting enough vitamin D through your diet or lifestyle, you can take a vitamin D supplement. For adults, 10 micrograms a day of vitamin D is recommended. The recommended amount for children is 7 micrograms for babies under 6 months, and 8.5 micrograms for children aged 6 months to 3 years. Talk to your doctor for more information.
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