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Osteoporosis - Women Health Information Page
What Is Osteoporosis?It can happen without warning � you bend over to pick up the morning paper and feel a searing pain in your side. Later you learn you've fractured a rib. If you're an older woman, your fracture is most likely the result of osteoporosis.Osteoporosis, which means "porous bones," causes bones to become weak and brittle � so brittle that even mild stresses like bending over, lifting a vacuum or coughing can cause a fracture. In most cases, bones weaken when you have low levels of calcium, phosphorous and other minerals in your bones. Osteoporosis also can accompany endocrine disorders or can result from excessive use of drugs such as corticosteroids. In the United States, osteoporosis causes more than 1.5 million fractures every year. Usually these fractures occur in the spine, hip or wrist. Half of all white women age 50 and older can expect to have a bone fracture due to osteoporosis sometime during their remaining years. About 8 million American women and 2 million American men have osteoporosis. As many as 18 million more Americans may have low bone density. The good news about osteoporosis is that it's never too late to do something about it. If you are a women and haven't reached menopause, you can take measures to prevent osteoporosis from silently draining your bones of strength. And if you're past menopause, tests can detect the early stages of the disease and halt the bone drain before debilitating fractures rob you of your mobility and independence. Signs and Symptoms In the early stages of bone loss, you usually have no pain or symptoms. But once bones have been weakened by osteoporosis, you may have symptoms that include:
Causes The strength of your bones depends on their mass and density. And bone density depends in part on the amount of calcium, phosphorus and other minerals bones contain. When your bones contain less mineral, their strength is decreased and they lose their internal supporting structure.Scientists have yet to learn all the reasons this occurs, but the process involves how bone is made. Bone is continuously changing � new bone is made and old bone is broken down, a process called remodeling, or bone turnover. A full cycle of bone remodeling takes about 2 to 3 months. When you're young, your body makes new bone faster than it breaks down old bone, and your bone mass increases. You reach your peak bone mass in your mid-30s. After that, bone remodeling continues. But you lose slightly more than you gain � about 0.3 percent to 0.5 percent a year. Not getting enough vitamin D and calcium in your diet can accelerate the process. At menopause, when estrogen levels drop, bone loss accelerates to about 1 percent to 3 percent a year. Around age 60, bone loss slows but doesn't stop. As women reach older ages, they may have lost between 35 percent and 50 percent of their bone mass. Men may have lost 20 percent to 35 percent. Your risk of developing osteoporosis depends on how much bone mass you attained between ages 25 and 35 (peak bone mass) and how rapidly you lose it later. The higher your peak bone mass, the more bone you have "in the bank" and the less likely you'll be to develop osteoporosis as you lose bone during normal aging. Getting enough calcium and vitamin D in your diet, which is essential for absorbing calcium, and exercising regularly can help ensure that your bones stay strong throughout your life. Risk Factors Early detection is important in osteoporosis. You may be able to slow the disease if you find out you have it or prevent it if you discover you're likely to develop it. Consider the following risk factors, then discuss your risk with your doctor and plan your prevention strategy. If you're a woman, it's best to do this well before menopause. Risk factors include:
Screening And Diagnosis Doctors can detect early signs of osteoporosis with a simple, painless bone density test (densitometry). Until recently, the best screening test for osteoporosis was dual energy absorptiometry (DEXA or DXA).In 1998 the Food and Drug Administration (FDA) approved a new device that can assess your risk for osteoporosis in less than 1 minute. The device, called the Sahara Clinical Bone Sonometer, transmits painless sound waves through the heel of your foot to measure your bone density. The more dense your bone is, the healthier it is, and the longer it takes for sound waves to pass through it. The sonometer is a portable, inexpensive device that may make screening more accessible for everyone who's at risk for osteoporosis. Although the sonometer is accurate enough for screening, it's not currently as sensitive a diagnostic tool as DEXA. If you're a woman, the National Osteoporosis Foundation recommends that you have a bone density test if you aren't taking estrogen and any of the following conditions apply to you:
Doctors don't generally recommend osteoporosis screening for men because the disease is far less common in men than in women. Complications Fractures are the most frequent and serious complication of osteoporosis. Fractures often occur in your spine or hips � bones that directly support your weight. Wrist fractures from falls are also common.Spinal fractures can occur without any fall or injury. The bones in your back (vertebrae) become so weakened that they begin to compress. Compression fractures can cause severe pain and require a long recovery. If you have many such fractures, you can lose several inches of height as your posture becomes stooped. Sometimes you may have relatively mild pain and only minimal compression of your vertebrae. But over time even minor compression can cause an appreciable loss of height and a stooped posture. Hip fractures, the second most common type of osteoporotic fracture, usually result from a fall. Although most people do relatively well with modern surgical treatment, hip fractures can result in disability and even death from postoperative complications. Treatment Right now, hormone replacement therapy (HRT) is the best way to prevent osteoporosis in women. Recent studies also indicate that estrogen may offer protection from Alzheimer's disease. Because estrogen may slightly increase your risk of uterine cancer, most women who have not had hysterectomies also take progestin, which helps protect against uterine cancer.If you're considering HRT, you should know that estrogen therapy may cause side effects, including uterine bleeding and breast tenderness. There are treatments, however, that can reduce these effects. In addition, HRT may or may not slightly increase your risk of developing breast cancer. Some studies indicate that hormone therapy may slightly increase your risk for breast cancer while other studies actually show a decreased risk. But many doctors and researchers believe that the protection HRT provides for your bones and memory far outweighs any known risks. Women with a history of breast or uterine cancer were once discouraged from using HRT, but doctors now believe the benefits of treatment may outweigh the risk for some of these women as well. American Heart Association (AHA) guidelines, issued in July 2001, conclude that there is insufficient evidence to support claims that estrogen protects against heart disease. And for those who have heart disease, it may increase heart problems during the first year of use. Accordingly, the AHA recommends that the decision of whether or not to take HRT be based on known benefits and risks not related to heart disease protection. HRT is available in a variety of forms, including tablets, patch, cream and vaginal ring. Talk to your doctor about which form of estrogen would be best for you. If you can't or don't want to take estrogen, other prescription drugs can help slow bone loss and may even increase bone density over time. But these drugs may not offer protection against heart disease and Alzheimer's disease. They include:
Prevention The following measures can greatly reduce your risk of osteoporosis. If you already have osteoporosis, these steps can help prevent your bones from becoming weaker. In some cases you may even be able to replace bone you've lost.
These suggestions may help you relieve symptoms and maintain your independence if you have osteoporosis:
Related Information
Additional Resources Boning Up on Osteoporosisby Carolyn J. StrangeConsider an insidious condition that drains away bone--the hardest, most durable substance in the body. It happens slowly, over years, so that often neither doctor nor patient is aware of weakening bones until one snaps unexpectedly. Unfortunately, this isn't science fiction. It's why osteoporosis is called the silent thief. And it steals more than bone. It's the primary cause of hip fracture, which can lead to permanent disability, loss of independence, and sometimes even death. Collapsing spinal vertebrae can produce stooped posture and a "dowager's hump." Lives collapse too. The chronic pain and anxiety that accompany a frail frame make people curtail meaningful activities, because the simplest things can cause broken bones: Stepping off a curb. A sneeze. Bending to pick up something. A hug. "Don't touch Mom, she might break" is the sad joke in many families. Osteoporosis leads to 1.5 million fractures, or breaks, per year, mostly in the hip, spine and wrist, and costs $10 billion annually, according to the National Osteoporosis Foundation. It threatens 25 million Americans, mostly older women, but older men get it too. One in three women past 50 will suffer a vertebral fracture, according to the foundation. These numbers are predicted to rise as the population ages. Osteoporosis, which means "porous bones," is a condition of excessive skeletal fragility resulting in bones that break easily. A combination of genetic, dietary, hormonal, age-related, and lifestyle factors all contribute to this condition. Changing attitudes and improving technology are brightening the outlook for people with osteoporosis. Nowadays, many women live 30 years or more--perhaps a quarter to a third of their lives--after menopause. Improving the quality of those years has become an important health-care goal. Although some bone loss is expected as people age, osteoporosis is no longer viewed as an inevitable consequence of aging. Diagnosis and treatment need no longer wait until bones break. There is no cure for osteoporosis, and it can't be prevented outright, but the onset can be delayed, and the severity diminished. Most important, early intervention can prevent devastating fractures. The Food and Drug Administration has revised labeling on foods and supplements to provide valuable information about the level of nutrients that help build and maintain strong bones. FDA has also approved a wide variety of products to help diagnose and treat osteoporosis, including several in the last few years. Bone Life Bone consists of a matrix of fibers of the tough protein collagen, hardened with calcium, phosphorus and other minerals. Two types of architecture give bones strength. Surrounding every bone is a tough, dense rind of cortical bone. Inside is spongy-looking trabecular bone. Its interconnecting structure provides much of the strength of healthy bone, but is especially vulnerable to osteoporosis. "We tend to think of the skeleton as an inert erector set that holds us up and doesn't do much else. That's not true," says Karl. L. Insogna, M.D., director of the Bone Center at Yale School of Medicine, New Haven, Conn. Every bit as dynamic as other tissues, bone responds to the pull of muscles and gravity, repairs itself, and constantly renews itself. Besides protecting internal organs and allowing us to move about, bone is also involved in the body's handling of minerals. Of the 2 to 4 pounds of calcium in the body, nearly 99 percent is in the teeth and skeleton. The remainder plays a critical role in blood clotting, nerve transmission, muscle contraction (including heartbeat), and other functions. The body keeps the blood level of calcium within a narrow range. When needed, bones release calcium. A complex interplay of many hormones balances the activity of the two types of cells--osteoclasts and osteoblasts--responsible for the continuous turnover process called remodeling. Osteoclasts break down bone, and osteoblasts build it. In youth, bone building prevails. Bone mass peaks by about age 30, then bone breakdown outpaces formation, and density declines. The skeleton is like a retirement account, but in our skeletal "account" we can deposit bone only during our first three decades. After that, all we can do is try to postpone and minimize the steady withdrawals. Osteoporosis is the bankruptcy that occurs when too little bone is formed during youth, or too much is lost later, or both. "You've got to get as much bone as you can and not lose it," Insogna says. "The most important risk factor for osteoporosis is a low bone mass." "The upper limit of bone mass that you can acquire is genetically determined," says Mona S. Calvo, Ph.D., in FDA's Office of Special Nutritionals. "But even though you may be programmed for high bone mass, other factors can influence how much bone you end up with," she says. (See "Reducing Your Risk.") For instance, men tend to build greater bone mass, which is partly why more women face osteoporosis. But there's another reason. With the decline of the female hormone estrogen at menopause, usually around age 50, bone breakdown markedly increases. For several years, women lose bone two to four times faster than they did before menopause. The rate usually slows down again, but some women may continue to lose bone rapidly. By age 65, some women have lost half their skeletal mass. Because the changes at menopause increase a woman's risk, many physicians feel it's a good time to measure a woman's bone density, especially if she has other risk factors for osteoporosis. "The best way to gauge a woman's risk for osteoporotic fracture is to measure her bone mass," says Insogna. Routine x-rays can't detect osteoporosis until it's quite advanced, but other radiological methods can. FDA has approved several kinds of devices that use various methods to estimate bone density. Most require far less radiation than a chest x-ray. Doctors consider a patient's medical history and risk factors in deciding who should have a bone density test. The method used is often determined by the equipment available locally. Readings are compared to a standard for the patient's age, sex and body size. Different parts of the skeleton may be measured, and low density at any site is worrisome. Bone density tests are useful for confirming a diagnosis of osteoporosis if a person has already had a suspicious fracture, or for detecting low bone density so that preventative steps can be taken. "There's a profound relationship between bone mass and risk of fracture," says Robert Recker, M.D., director of the Osteoporosis Research Center at Creighton University, Omaha, Neb. Readings repeated at intervals of a year or more can determine the rate of bone loss and help monitor treatment effectiveness. However, estimates are not necessarily comparable between machine types because they use different measurement methods, cautions Joseph Arnaudo, in the Center for Devices and Radiological Health. "You always want to go back to the same machine, if you can," he says. Another new test provides an indicator of bone breakdown. FDA approved in 1995 a simple, noninvasive biochemical test that detects in a urine sample a specific component of bone breakdown, called NTx. Clinical labs can get results in about 2 hours. The NTx test, marketed as Osteomark, can help physicians monitor treatment and identify fast losers of bone for more aggressive treatment, but the test may not be used to diagnose osteoporosis. Expanding Treatment Options Physicians and patients now have more treatment options than ever. Under FDA guidelines, drugs to treat osteoporosis must be shown to preserve or increase bone mass and maintain bone quality in order to reduce the risk of fractures. "We want to be sure that the bone is normal or stronger than it was," says Gloria Troendle, M.D., deputy director of the division of metabolism and endocrine drug products in FDA's Center for Drug Evaluation and Research. Before 1995, the only choices were the hormones estrogen and calcitonin. While enthusiasm for new weapons against osteoporosis is warranted, one of the old ones is still the top choice. "Estrogen remains the first thing that women should consider," says Insogna, because the hormone not only helps prevent osteoporosis, but also protects against heart disease. "If you think about what's missing at menopause, it's the hormones," says Paula Stern, Ph.D., a pharmacologist at Northwestern University Medical School, Chicago, Ill. Estrogen replacement therapy is the best prevention for the drop in bone mass at menopause, and there are more ways to take it than ever. But it's not for everyone. Because estrogen increases the risk of certain cancers and other diseases, taking it may not be appropriate, or it may be given in combination with another female hormone, progesterone, which can also cause undesirable side effects. A woman and her doctor need to carefully weigh the risks and benefits. According to the National Osteoporosis Foundation, a woman's risk of developing a hip fracture is equal to her combined risk of developing breast, uterine and ovarian cancer. Women who can't or don't want to take hormones--some 30 to 50 percent--have other treatment avenues. For example, calcitonin treatment became much easier when FDA approved a nasal spray in the summar of 1996. Calcitonin, one of the hormones responsible for regulating the level of calcium in the blood, inhibits osteoclasts, the bone dissolvers. The drug, marketed as Miacalcin, is a potent, synthetic version of the hormone, and has been shown to slow and reverse bone loss. The stomach quickly destroys the drug, so before the spray was available, calcitonin had to be injected every day or two. Later in 1996, FDA approved the first nonhormonal treatment for osteoporosis. Alendronate, marketed as Fosamax, falls within a class of drugs called bisphosphonates, which hinder bone breakdown remodeling sites by inhibiting osteoclast activity. In clinical trials lasting three years, alendronate increased the bone mass as much as 8 percent and reduced fractures as much as 30 to 40 percent, depending on skeletal site. Lengthier studies are ongoing. To avoid damage to the esophagus, Fosamax should be taken according to instructions. These instructions include taking the drug in the morning upon awaking and at least a half hour before eating. The drug should be taken with 6 to 8 ounces of water, and the person should remain upright for a half hour after taking it. Fosamax should not be taken by people who cannot stand or sit upright or who have disorders that prevent esophageal emptying into the stomach. "All the drugs approved so far are things that just stop bone turnover. They're not really stimulating more bone production," says Troendle. Bone mass increases because even though osteoclasts can't start new remodeling sites, osteoblasts continue filling in existing cavities. Increases in bone mass are most pronounced in the first year or two after treatment begins, then taper off. Any gain is helpful, even if it doesn't continue, because increases in bone mass help reduce fracture risk. But experts would like to encourage even greater gains. Fluoride, known for fighting dental cavities, stimulates bone building, but early studies in osteoporosis patients found that the structure of the new bone was abnormal and weaker than normal bone. Gastrointestinal side effects were also a problem. Investigators are working to find a formulation and dosage regimen that will result in building normal bone. Drugs Not Enough Calcium and vitamin D supplements are an integral part of all treatments for osteoporosis. Everyone should make sure they get enough of these two nutrients, but especially women and others at risk for osteoporosis. Attention to diet and exercise are important not only for treatment, but also for prevention. "If you go to the doctor and get a prescription, and that's all you do, you're probably not going to be helped very much," Recker says. Calcium intake is critical, and those who need it the most--younger women and girls--don't get enough. (See "Calcium (Ac)Counts.") But calcium alone can't build bone. Without vitamin D, calcium isn't sufficiently absorbed. Most people get enough vitamin D because skin produces it in sunlight. But people confined indoors who have a poor diet--which includes many older Americans--or who live in northern latitudes in winter may be deficient. A lifelong habit of weightbearing exercise, such as walking or biking, also helps build and maintain strong bone. The greatest benefit for older people is that physical fitness reduces the risk of fracture, because better balance, muscle strength, and agility make falls less likely. Exercise also provides many other life-enhancing psychological and cardiovascular benefits. Increased activity can aid nutrition, too, because it boosts appetite, which is often reduced in older people. The biggest reason older people don't get enough calcium, Recker says, is that they simply don't eat much. "The truth is, you don't have to do very much to get most of the benefits of exercise," Recker says. He suggests 30 minutes of brisk walking five days a week. Add a little weightlifting, and that's even better. It's always smart to ask your doctor before starting a new exercise program, especially if you already have osteoporosis or other health problems. Brighter Horizons "A number of new things seem to be in the offing, eventually to come to us, and we're looking forward to getting some additional treatments for osteoporosis," says Troendle. Uses of existing drugs may be broadened. Early drug trials are often conducted with patients who have severe disease, often after a fracture has occurred or bone loss is quite serious. Some studies under way are testing to see if certain drugs are effective in less severe cases, if they can be started sooner, or used in combination. The search for bone-building drugs continues. Some naturally occurring bone-specific growth factors have been identified and their use as drugs is being investigated. "The way I visualize the ideal future is that we'll be able to give Drug X that builds up bone to where it's stronger and the risk of fracture is no longer present, then Drug Y maintains it by preventing breakdown," says Stern. In the realm of devices, researchers are exploring the use of ultrasound to assess bone health. Such tests would eliminate radiation exposure and probably cost less. The study of risk factors also continues. "We consider that to be the research that has the greatest public health significance," says Sherry Sherman, Ph.D., of the National Institute on Aging. The institute has begun the Study of Women's Health Across the Nation, a large-scale national examination of the health of women in their 40s and 50s. Researchers expect to learn a great deal about the factors affecting women's health during these transitional years and beyond. Studies of genetics, biochemical markers, and life habits are already turning up new insights. Osteoporosis has been described as an adolescent disease with a geriatric onset, highlighting the importance of beginning to take steps--in exercise and diet--early in life to reduce its disabling impact in later years. Carolyn J. Strange is a science and medical writer living in Northern California. Reducing Your RiskA host of factors can affect your chances of developing osteoporosis. The good news is that you control some of them. Even though you can't change your genes, you can still lower your risk with attention to certain lifestyle changes. The younger you start, and the longer you keep it up, the better. Here's what you can do for yourself:
Other factors are beyond your control. Being aware of them can provide extra motivation to help yourself in the ways you are able, and aids you and your doctor in health-care decisions. These risk factors are:
Calcium (Ac) CountsYour skeletal calcium bank has to last through old age. Frequent deposits to this retirement account should begin in youth and be maintained throughout life to help minimize withdrawals. Most women get much less calcium than they need--as little as half.Nutritionists recommend meeting your calcium needs with foods naturally rich in calcium. Adequate calcium intake in childhood and young adulthood is critical to achieving peak adult bone mass, yet many adolescent girls replace milk with nutrient-poor beverages like soda pop. "Bone health requires a lot of nutrients and you're likely to get most of them in dairy products," says Connie Weaver, Ph.D., who heads the department of food and nutrition at Purdue University, Indiana. "They're a huge package rather than just a single nutrient." With so many low-fat and nonfat dairy products available, it's easy to make dairy foods part of a healthy diet. People who have trouble digesting milk can look for products treated to reduce lactose. A serving of milk or yogurt contains about 350 milligrams (mg) of calcium. Fortified products have even more. "People who don't consume dairy foods can meet their calcium needs with foods that are fortified with calcium, such as orange juice, or with calcium supplements," says Mona S. Calvo, Ph.D., in FDA's Office of Special Nutritionals. Other good sources of calcium are broccoli and dark-green leafy vegetables like kale, tofu (if made with calcium), canned fish (eaten with bones), and fortified bread and cereal products. Nutrition labels can help you identify calcium-rich foods. But keep in mind that the label value is a guideline based on a FDA's Daily Value for calcium, which is 1,000 mg, and your calcium needs may be greater, Calvo says. What about too much calcium? As much as 2,000 mg per day seems to be safe for most people, but those at risk for kidney stones should discuss calcium with their doctors. Calcium is critical, but even a high intake won't fully protect you against bone loss caused by estrogen deficiency, physical inactivity, alcohol abuse, smoking, or medical disorders and treatments. --C.J.S.
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Osteoporosis: Current Evaluation and Treatment
Osteoporosis is a chronic bone disease that affects 25 million Americans, 80% of whom are women, usually after the onset of menopause. It is characterized by low bone mass and deterioration of bone at the microscopic level resulting in increased fragility and high risk of fractures. Osteoporosis accounts for more than a million fractures a year in the US, including 500,000 fractures of vertebrae in the spine and 300,000 hip fractures. Hip fractures cause an excess mortality of up to 20% at the one-year mark, with as much as half of patients requiring admission to a nursing home. In 1995, direct medical costs related to osteoporosis were about $13.8 billion. As the population ages, osteoporosis will become even more common and medical costs are expected to triple by 2020. Sometime in their life, half of the world's population of white women will have a fracture related to osteoporosis. Writing in the journal Comprehensive Therapy (Vol. 26 No. 3), Medical College of Wisconsin faculty outline the current standards of osteoporosis evaluation and treatment. Joan L. Milott, MD, Assistant Professor of Internal Medicine, was the lead author with assistance from Sandra S. Green, MD, Assistant Professor of Internal Medicine, and Marilyn M. Schapira, MD, MPH, Associate Professor of Internal Medicine. Bone is a living tissue that remodels itself throughout life. However, peak bone mass is reached at about age 30 and begins to decline thereafter. Menopause increases the rate of bone mass loss. Cigarette smoking, body weight of less than 127 pounds, alcohol abuse, low sun exposure, family history, and a history of fractures as an adult are other risk factors for osteoporosis. Postmenopausal osteoporosis is more common in white and Asian women than in women of other races.
DiagnosisMeasuring bone mineral density may be done in several ways. Single-energy X-ray absorptiometry measures of bone density in the radius in the forearm or the heel bone may help to predict hip fractures. Dual-energy X-ray absorptiometry (DEXA) can measure the same areas as well as the hip and spine for bone mineral density. DEXA is more expensive, but most institutions consider it the preferred diagnostic method. Ultrasound of the heel and shin may also be used, or computerized tomography (CT scan). To accurately diagnose osteoporosis a physician must be able to exclude other causes of low bone mass. A complete medical history and physical exam, including a gynecological exam, is recommended. The National Osteoporosis Foundation suggests that all postmenopausal women under age 65 with one additional risk factor should be tested for osteoporosis. All women over age 65, postmenopausal women with fractures, and women on prolonged hormone replacement therapy (HRT) should also be tested. In many cases, Medicare will cover bone mass measurements. Follow-up measurements spaced less than two years apart are of dubious value.
Prevention and TreatmentFundamental to all prevention and treatment efforts is adequate intake of calcium and vitamin D. In postmenopausal women, calcium supplementation alone can reduce the rate of loss or even increase bone mass. Women with osteoporosis, who are older or have low calcium intake show the most benefit from calcium supplementation. The National Institutes of Health Consensus Conference recommends 1000mg of calcium a day for women 65 years and younger on estrogen HRT, and 1500mg a day for women younger than 65 and not on estrogen HRT and for women older than 65 years of age. The most commonly used form of calcium supplementation is calcium carbonate, such as OsCal 500 or TUMS. Vitamin D deficiency is common in the elderly, often from a poor diet, low exposure to sunlight or aging skin's inability to synthesize vitamin D3. Vitamin D, 400 IU per day, should be added in these cases. Estrogen replacement therapy, raloxifene, alendronate and calcitonin are all FDA-approved pharmacological treatments to prevent and/or treat osteoporosis. Estrogen hormone-replacement therapy, the mainstay of both prevention and treatment of the disease, stimulates bone formation and prevents bone loss. Estrogen HRT, such as conjugated equine estrogen (Premarin), estradiol (sold under several brand names) or estropipate (Ogen, Ortho-Est), has been shown to reduce the risk of fractures in various groups of women. For women who have retained their uterus, estrogen must be supplemented with progestin therapy to prevent potential changes in uterine tissue. Estrogen HRT may also alleviate menopausal symptoms and prevent heart disease. However, it may also increase the risk of breast cancer. Raloxifene is an alternative to estrogen HRT for prevention of osteoporosis. Raloxifene (Evista) has demonstrated a beneficial effect on bone mineral density and is well tolerated. It should not be used by women who are pregnant or have a history of blood clots. It may cause menopausal symptoms such as hot flashes. Raloxifene has been found to cause an increase in BMD of the total body and hip similar to estrogen HRT, but has less of an effect on BMD of the lumbar spine (lower back). Raloxifene has also been shown to lower LDL cholesterol and is being studied as a way to prevent breast cancer. Alendronate is another alternative to both prevent and treat osteoporosis. Studies have shown that it increases bone mineral density at all skeletal sites and decreases the rate of fractures. Alendronate (Fosamax) must be taken on an empty stomach and may cause gastrointestinal discomfort. It should not be taken by patients with a history of swallowing difficulties or abnormal narrowing of the esophagus. Calcitonin is FDA-approved for treatment, but not prevention, of osteoporosis, although trials have shown it prevents loss of spinal BMD. Salmon calcitonin (Calcimar, Miacalcin) is also available as a nasal spray (Miacalcin). Calcitonin use decreases the rate of vertebral fractures in women with osteoporosis. It also may provide pain relief in some patients with fractures. Phyto-estrogens comprise an alternative therapy being studied for its effect on bone mineral density. The precursors of these substances are found in soybean products, seeds, berries and whole-grain cereal foods. Intestinal bacteria then convert them to hormone-like compounds. A patient's medical history, including risk of cardiac disease, breast cancer and osteoporosis, will largely determine which pharmacological treatment is most appropriate. Drs. Milott and Green practice in the Froedtert & Medical College Primary Care Center, and Dr. Schapira practices at the Zablocki VA Medical Center. Froedtert Hospital and the VA Medical Center are major affiliates of the Medical College of Wisconsin.
27 February 2001
Diagnosis and Treatment of Osteoporosis in Older Men
Osteoporosis, a well-known condition in women following menopause, also affects nearly 1.5 million men in the US age 65 and older. An additional 3.5 million are at risk. Osteoporosis is characterized by thinning bone mass and deterioration of bone tissue at the microscopic level. This makes bones more fragile and susceptible to fracture. In elderly individuals, broken bones -- hip fractures from falling are particularly common -- are slow to heal and can actually lead to death. While osteoporosis is less frequent in men than women, almost one-third of all hip fractures in the world occur in men. The death rate of men over age 75 from hip fractures is 30%, compared to 9% in women of the same age. After age 80, one in every six men will have a hip fracture, and osteoporosis may be a key factor. Bone is a living tissue that continually "remodels" itself throughout life. The rate of bone reformation slows after peak bone mass is reached, usually in a person's 20s. The rate of bone remodeling in elderly people is not great enough to maintain bone mass. In elderly men, certain steroidal treatments (i.e., glucocorticoids), medications to prevent convulsions, lowered testosterone levels and excessive alcohol consumption may increase the rate of bone loss. Genetic, environmental and nutritional factors are also important. African-American men are less likely to develop osteoporosis than Caucasian men. Declining kidney function and vitamin D deficiency may play a role in osteoporosis. A lack of calcium in the diet, or a limited ability of the intestines to absorb calcium, can lead to bone loss, too. Smoking and consuming excessive amounts of sodium, caffeine and anti-acids containing aluminum are also risk factors. Medications given to patients with kidney, heart or liver transplants can cause severe osteoporosis. A study of 820 men in Australia aged 60 and older found certain risk factors for osteoporosis-related fractures. These risk factors included a lower bone mineral density at the top of the thigh bone (where it enters the hip), weakness of the quadriceps muscles above the knee, low body weight, a shorter height than earlier in life, falls in the preceding year and a history of fractures in the previous five years. The study found that the following factors protected against osteoporosis fractures: higher rates of physical activity, moderate intake of alcohol, and the use of thiazide diuretics (typically to treat high blood pressure). Diagnosis and Treatment Bone mass is usually measured in terms of bone mineral density (BMD). The World Health Organization defines osteoporosis in terms of a patient's BMD as compared to a normal, healthy, young adult's. However, the criteria were developed based on studies of Caucasian women, which may lead to inaccuracies when diagnosing men. Osteoporosis may be suspected in men with a history of bone fractures from falls or other "low-trauma" causes, bone loss or abnormality present on a standard X-ray, or who have a significant risk factor, such as long-term use of corticosteroids. If osteoporosis is suspected, a BMD measurement should be conducted using a dual energy X-ray absorptiometry (DEXA) scan, preferably of the hip and spine. A complete survey of drug history, lifestyle habits and dietary intake should be conducted. Laboratory tests that measure such things as testosterone, calcium and thyroid function should also be performed. In some cases, the presence of osteoporosis may not yet be evident, but lifestyle changes and another BMD measurement two or three years later may be recommended. For men diagnosed with osteoporosis, medication and lifestyle changes may be prescribed. Quitting smoking, ensuring adequate calcium and vitamin D intake, limiting alcohol to four cans of beer or two ounces of liquor per day and receiving regular exercise are recommended for men with osteoporosis. Men over 65 should receive 1,500 mg per day of calcium, preferably through diet, rather than supplements. For adults over age 70, 600 IU (international units) of vitamin D is recommended. Measures may be taken to avoid falling, such as changing room layouts, correcting visual impairment and taking precautions with medications that may cause dizziness. Hip padding may also be worn for protection. There is not a great deal of research data on the effectiveness of medications to treat men with osteoporosis. However, bisphosphonates and calcitonin are prescribed for men with osteoporosis because, in theory, they should have the same positive effects as in women. Alendronate sodium (Fosamax) has been approved for use in certain men with osteoporosis. Some men with osteoporosis may also benefit from testosterone replacement. However, before diagnosis and treatment can occur, elderly men must understand that, like women their age, they also may be at risk for osteoporosis.
Edmund H.
Duthie, MD
Dr. Duthie and Kaup R. Shetty, MD, Professor of Medicine (Geriatrics), were
co-authors of a September, 1999, article on this topic with Nadeem A. Siddiqui,
MD, then a fellow in Geriatrics at the Medical College. The article appeared in
Geriatrics (Vol. 54, No. 9).
Chief and Professor of Medicine (Geriatrics) Medical College of Wisconsin Geriatrician
29 June 2001
OsteoporosisPart 1: Basics What is osteoporosis? The definition of osteoporosis is decreased density of normal bone. Unlike conditions such as osteomalacia or Rickets, the mineralization of bone is normal in osteoporosis. Osteoporosis causes a decrease in bone mass, often referred to as thinning of bone. When this occurs, the patient with osteoporosis will have weaker bones and have a higher risk of bone fracture. There are two main categories of osteoporosis, Type I and Type II. Type I osteoporosis occurs only in post-menopausal women, and is due to estrogen deficiency. Type II osteoporosis occurs in both men and women (about two times more frequently in women), and is due to aging, and calcium deficiency over many years. What causes osteoporosis? Both men and women achieve their �peak bone mass� in the third decade of life. After that point in time, their bone mass gradually, but steadily decreases. In pregnant and lactating women the rate of bone loss will temporarily increase if the increased calcium demands are not met by dietary intake. In women, there is also a significant decrease of bone mass in the immediate postmenopausal period. As people age, the rate of bone loss tends to slow, but it continues to decrease. Therefore, age and sex are the two most important factors in determining who is at risk of developing osteoporosis. Other important factors that can contribute to developing osteoporosis include Northern European ancestry, hypothyroidism, anticonvulsant medications, and a sedentary lifestyle. Americans are especially prone to developing osteoporosis, the exact cause of this is not known. This is not entirely related to ancestry, as studies have shown that individuals who immigrate into the United States from other countries develop an American's risk of osteoporosis. How is osteoporosis diagnosed? Osteoporosis most commonly is found either on routine examination, or following a pathologic fracture. X-rays usually show a generalized loss of bone density. Laboratory studies are not too helpful in showing evidence of osteoporosis, rather they are very helpful in showing conditions that can have symptoms similar to osteoporosis. Laboratory studies can show evidence of osteomalacia, kidney failure, parathyroid gland insufficiency, or other problems that can mimic osteoporosis and cause bone weakness. When screening for osteoporosis, or trying to detect the early stages of the disease, the most useful test is called bone densiometry, or DEXA scan. While these tests do require special equipment, they are safe, expose the patient to minimal radiation, and are very useful in detecting the early stages of osteoporosis. Fractures are the most common problem associated with osteoporosis. A pathologic fracture is a broken bone that occurs because of an abnormality of the bone. When a fracture occurs in an area of osteoporotic bone, it is called a pathologic fracture. The most commonly fractured bones due to osteoporosis are the vertebral bones, the femur (thigh bone), the humerus (arm bone), the tibia (shin bone), and the radius (forearm bone, usually near the wrist). Osteoporosis
Common areas of the body where osteoporosis fractures occur:
Bone tissue is a rigid, living structure that is constantly renewing itself. It is not an unchanging skeleton made of calcium. Microscopic holes are constantly created by bone eating cells called osteoclasts. Once these bone cavities are created, bone building cells called osteoblasts form new bone. This process rejuvenates the bone and repairs any damage. In early childhood and adolescent years our bones grow rapidly. Good dietary calcium intake and regular exercise in these formative years are important for good bone health and peak bone mass. Bones may reach their mature length or height in the late teens but bone density and strength continue to build along with body weight and muscle strength into one's 20's and possibly 30's. Once peak bone mass is reached, both women and men start losing bone at a rate of 1/2 to 1% loss per year (see Figure 1). In women, the hormone estrogen contributes to the bone-building process, so as estrogen levels fall when women approach menopause, the bone loss accelerates to a rate of 2 to 3% per year.
As we approach our later decades of life, many changing conditions make us more susceptible to fractures related to osteoporosis. The most important of these are decreased bone strength and increased risk of falls.
Obviously, efforts should be made to minimize osteoporosis fractures before they happen. Physicians can identify individuals at high risk of osteoporotic fractures by doing a bone density test. It is also important to investigate whether the person is at a higher risk than normal for falling, especially if something can be done to reduce that risk.
John
P. Wade, MD, in association with medbroadcast.com
OsteoporosisStatistics
What is Osteoporosis? Osteoporosis is a disease of the skeletal system. The bones lose density, become brittle and prone to fracture. It is the major cause of bone fractures in older people, especially postmenopausal women. What causes it?A certain amount of bone density is lost as a part of aging. During the mid-30s, everyone begins to lose very small amounts of bone. Bone loss accelerates at menopause, with some women losing up to 30% of bone mass in the first five years. There are certain risk factors that increase a person's chance of having osteoporosis. Some are unavoidable such as being a post-menopausal female, being thin or "small boned" and aging. However many are avoidable. Smoking, alcohol use, long term use of corticosteroids, lack of exercise and low intake of dietary calcium all can contribute to the development of osteoporosis. What are the symptoms? Most times there are no symptoms until a fracture occurs or a vertebrae collapses. How is it diagnosed? Bone density loss can be diagnosed through the use of a DEXA (dual-energy X-ray absorptiometry) scan. This is a painless test very similar to an x-ray. How is it treated? Although the best treatment is prevention, there are a number of medications
currently available that may help to increase bone density. What research is being done? Several medications are currently under investigation and may someday expand the treatment options available. These include new forms of bisphosphonates, sodium fluoride, additional selective estrogen receptor modulators, parathyroid hormone, and vitamin D metabolites. Some of the related information found on Arthritis Insight: For support visit our Chat
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Is Osteoporosis A Childhood Issue?Your child is decades away from being eligible for retirement. Health concerns that are common amongst the elderly are not even a thought at this time. Then why are we making this association? Should health issues be a concern this early in the game? They should if you are aware of the latest news out on osteoporosis. Osteoporosis, a debilitating condition, which weakens the bones as one gets older. The condition affects more than 30 million Americans and results in tens of billions of dollars being spent each year on its treatment of. As a result of the condition, bones may fracture more easily, simply because there is insufficient calcium in the skeletal structure to keep them strong. What we know about osteoporosis is that it can be prevented with proper nutrition during childhood, adolescence and young adulthood. Individuals are more susceptible for the condition if, during childhood, intakes of calcium and vitamin D are insufficient. This is what results in low bone mass and the development of osteoporosis during ones aged years. However, ample supplies of calcium and vitamin D during the formative years can completely prevent osteoporosis as an older adult. According to Thomas Schmalzried, MD, Associate Director of the Joint Replacement
Institute at Orthopedic Hospital, "If you think of your child's bone density
as a bank account, every time you make a `deposit' (by adding calcium and vitamin
D), you are securing their future in the form of stronger bones. Our bodies
are programmed to incorporate calcium into bone when we are young. Our physiology
changes in the mid-to-late 30's and both men and women start to lose bone mass.
If you have built up enough bone mass during your younger years, you can `afford'
this normal, age-related bone loss -- and Women who are nursing need to make sure they get even more calcium as the nutrients flowing to her infant is taken from her own available supply of calcium and other nutrients. If there is insufficient amounts of calcium available, it will be taken from the bone structure, which increases the risks for osteoporosis in later years. The suggested intake calcium during childhood and early adulthood are as follows: AGE DAILY CALCIUM (see note) Food Sources for Calcium:
OSTEOPOROSISOsteoporosis is a condition characterized by substantial bone loss. When the extent of bone loss reaches a critical point fractures may occur as a result of very minor stress. Osteoporosis affects the entire skeleton, but fractures occur most notably in the vertebrae, hips and wrists.The bones become so weak that normal workloads overcome their capacity. A simple fall can result in a broken hip. Spinal vertebrae can collapse and in extreme cases cause a "dowager's hump." Gradual weakening or thinning out of bones occurs normally with age. The longer we live, the less bone mass we have and the more prone we are to fractures. Scientists do not know what causes osteoporosis. They do know a lot about factors which can worsen or lessen the extent of bone loss. Osteoporosis is a very complex disease where many different factors influence the rate of bone loss. Advanced age and being a postmenopausal white female are the predominant risk factors. Advanced age and being a postmenopausal white female are the predominant risk factors. Other risk factors include hormonal imbalance, nutrient deficiencies (particularly calcium) and immobility. The role of dietary calcium in the prevention or treatment of osteoporosis is not clear. Calcium may ameliorate or prevent only bone loss directly related to calcium deficiency, but not bone loss due to other causes. Calcium deficiency, however, is common in women. Most bone loss is influenced by hormonal deficiencies. Evidence suggests that exercise helps reduce bone loss. However, too much exercise can be counterproductive for women, because it may lower estrogen levels. At this time, the most effective treatment of osteoporosis is prevention. The stronger the bones are when people are young, the less likely they are to fracture easily later in life. An effective preventive treatment in postmenopausal women is estrogen replacement therapy (ERT). Other treatments, such as calcitonin therapy, may help if estrogen replacement is not advisable for health reasons. In some persons, osteoporosis cannot be prevented, but steps can be taken to slow bone loss as much as possible. Once osteoporosis has proceeded to a very advanced stage, involving fractures, it is difficult to treat. Many of the more promising treatments are still experimental. Advanced osteoporosis interferes with a person's ability to lead a normal life. A simple fall, a wrong movement or even minor stress on the bones can make the difference between an independent or a dependent lifestyle. As the population ages, the relative percentage and absolute number of elderly will increase, leading to an increase in all diseases associated with aging, including osteoporosis. In 1991, osteoporosis resulted in over 1.5 million fractures, costing over $10 billion in health care. These numbers are expected to increase. Osteoporosis Overview
Osteoporosis, or porous bone, is a disease characterized by low bone mass and structural deterioration of bone tissue, leading to bone fragility and an increased susceptibility to fractures of the hip, spine, and wrist. Men as well as women suffer from osteoporosis, a disease that can be prevented and treated. Facts and Figures
What is Bone? Bone is living, growing tissue. It is made mostly of collagen, a protein that provides a soft framework, and calcium phosphate, a mineral that adds strength and hardens the framework.This combination of collagen and calcium makes bone strong yet flexible to withstand stress. More than 99% of the body's calcium is contained in the bones and teeth. The remaining 1% is found in the blood. Throughout your lifetime, old bone is removed (resorption) and new bone is added to the skeleton (formation). During childhood and teenage years, new bone is added faster than old bone is removed. As a result, bones become larger, heavier, and denser. Bone formationcontinues at a pace faster than resorption until peak bone mass (maximum bone density and strength) is reached around age 30. After age 30, bone resorption slowly begins to exceed bone formation. Bone loss is most rapid in the first few years after menopause but persists into the postmenopausal years. Osteoporosis develops when bone resorption occurs too quickly or if replacement occurs too slowly. Osteoporosis is more likely to develop if you did not reach optimal bone mass during your bone building years. Risk Factors. Certain factors are linked to the development of osteoporosis or contribute to an individual's likelihood of developing the disease. These are called "risk factors." Many people with osteoporosis have several of these risk factors, but others who develop osteoporosis have no identified risk factors. There are some risk factors that you cannot change, and others that you can: Risk factors you cannot change:
Risk factors you can change:
Prevention To reach optimal peak bone mass and continue building new bone tissue as you get older, there are several factors you should consider: Calcium. An inadequate supply of calcium over the lifetime is thought to play a significant role in contributing to the development of osteoporosis. Many published studies show that low calcium intakes appear to be associated with low bone mass, rapid bone loss, and high fracture rates. National nutrition surveys have shown that many people consume less than half the amount of calcium recommended to build and maintain healthy bones. Good sources of calcium include low fat dairy products, such as milk, yogurt, cheese and ice cream; dark green, leafy vegetables, such as broccoli, collard greens, bok choy and spinach; sardines and salmon with bones; tofu; almonds; and foods fortified with calcium, such as orange juice, cereals and breads. Depending upon how much calcium you get each day from food, you may need to take a calcium supplement. Calcium needs change during one's lifetime. The body's demand for calcium is
greater during childhood and adolescence, when the skeleton is growing rapidly,
and during pregnancy and breastfeeding. Postmenopausal women and older men also
need to consume more calcium. This may be caused by inadequate amounts of vitamin
D, which is necessary for intestinal absorption of calcium. Also, as you age,
your body becomes less efficient at absorbing calcium and other nutrients. Older
adults also are more likely to have chronic medical problems and to use medications
that may impair calcium absorption.
Vitamin D. Vitamin D plays an important role in calcium absorption and in bone health. It is synthesized in the skin through exposure to sunlight. While many people are able to obtain enough vitamin D naturally, studies show that vitamin D production decreases in the elderly, in people who are housebound, and during the winter. These individuals may require vitamin D supplementation to ensure a daily intake of between 400 to 800 IU of vitamin D. Massive doses are not recommended. Exercise. Like muscle, bone is living tissue that responds to exercise by becoming stronger. The best exercise for your bones is weight-bearing exercise, that forces you to work against gravity. These exercises include walking, hiking, jogging, stair-climbing, weight training, tennis, and dancing. Smoking. Smoking is bad for your bones as well as for your heart and lungs. Women who smoke have lower levels of estrogen compared to nonsmokers and frequently go through menopause earlier. Postmenopausal women who smoke may require higher doses of hormone replacement therapy and may have more side effects. Smokers also may absorb less calcium from their diets. Alcohol. Regular consumption of 2 to 3 ounces a day of alcohol may be damaging to the skeleton, even in young women and men. Those who drink heavily are more prone to bone loss and fractures, both because of poor nutrition as well as increased risk of falling. Medications that cause bone loss. The long-term use of glucocorticoids (medications prescribed for a wide range of diseases, including arthritis, asthma, Crohn's disease, lupus, and other diseases of the lungs, kidneys, and liver) can lead to a loss of bone density and fractures. Other forms of drug therapy that can cause bone loss include long-term treatment with certain antiseizure drugs, such as phenytoin (Dilantin�) and barbiturates; gonadotropin releasing hormone (GnRH) analogs used to treat endometriosis; excessive use of aluminum-containing antacids; certain cancer treatments; and excessive thyroid hormone. It is important to discuss the use of these drugs with your physician, and not to stop or alter your medication dose on your own. Prevention Medications. Various medications are available for the prevention, as well astreatment, of osteoporosis. See section entitled "Therapeutic Medications." Symptoms. Osteoporosis is often called the "silent disease" because bone loss occurs without symptoms. People may not know that they have osteoporosis until their bones become so weak that a sudden strain, bump, or fall causes a hip fracture or a vertebra to collapse. Collapsed vertebra may initially be felt or seen in the form of severe back pain, loss of height, or spinal deformities such as kyphosis, or severely stooped posture. Detection. Following a comprehensive medical assessment, your doctor
may recommend that you have your bone mass measured. Bone mineral density (BMD)
tests measure bone density in the spine, wrist, and/or hip (the most common
sites of fractures due to osteoporosis), while others measure bone in the heel
or hand. These tests are painless, noninvasive, and safe. Bone density tests
can:
Treatment. A comprehensive osteoporosis treatment program includes a focus on proper nutrition, exercise, and safety issues to prevent falls that may result in fractures. In addition, your physician may prescribe a medication to slow or stop bone loss, increase bone density, and reduce fracture risk. Nutrition. The foods we eat contain a variety of vitamins, minerals, and other important nutrients that help keep our bodies healthy. All of these nutrients are needed in a balanced proportion. In particular, calcium and vitamin D are needed for strong bones as well as for your heart, muscles, and nerves to function properly. (See Prevention section for recommended amounts of calcium.) Exercise. Exercise is an important component of an osteoporosis prevention and treatment program. Exercise not only improves your bone health, but it increases muscle strength, coordination, and balance and leads to better overall health. While exercise is good for someone with osteoporosis, it should not put any sudden or excessive strain on your bones. Asextra insurance against fractures, your doctor can recommend specific exercises to strengthen and support your back. Therapeutic Medications. Currently, estrogen, calcitonin, alendronate, raloxifene, and risedronate are approved by the U. S. Food and Drug Administration (FDA) for the treatment of postmenopausal osteoporosis. Estrogen, alendronate, risedronate, and raloxifene are approved for the prevention of the disease. Alendronate is approved for the treatment of osteoporosis in men. Alendronate and risedronate are approved for use by men and women with glucocorticoid-induced osteoporosis. Estrogen. Estrogen replacement therapy (ERT) has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spinal fractures in postmenopausal women. ERT is administered most commonly in the form of a pill or skin patch and is effective even when started after age 70. When estrogen is taken alone, it can increase a woman's risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin in combination with estrogen (hormone replacement therapy or HRT) for those women who have not had a hysterectomy. ERT/HRT relieves menopause symptoms and has been shown to have beneficial effects on both the skeleton and heart. Experts recommend ERT for women at high risk for osteoporosis. ERT is approved for both the prevention and treatment of osteoporosis. ERT is especially recommended for women whose ovaries were removed before age 50. Estrogen replacement should also be considered by women who have experienced natural menopause and have multiple osteoporosis risk factors, such as early menopause, family history of osteoporosis, or below normal bone mass for their age. As with all drugs, the decision to use estrogen should be made after discussing the benefits and risks and your own situation with your doctor. Raloxifene. Raloxifene (brand name "Evista") is a drug that is approved for the prevention and treatment of osteoporosis. It is from a new class of drugs called Selective Estrogen Receptor Modulators (SERMs) that appear to prevent bone loss at the spine, hip, and total body. Raloxifene has been shown to have beneficial effects on bone mass and bone turnover and can reduce the incidence of vertebral fractures by 30-50%. While side-effects are not common with raloxifene, those reported include hot flashes and deep vein thrombosis, the latter of which is also associated with estrogen therapy. Additional research studies on raloxifene will be ongoing for several more years. Alendronate. Alendronate (brand name "Fosamax") is a medication from the class of drugs called bisphosphonates. Like estrogen and raloxifene, alendronate is approved for both the prevention and treatment of osteoporosis. Alendronate is also used to treat the bone loss from glucocorticoid medications like prednisone or cortisone and is approved for the treatment of osteoporosis in men. In postmenopausal women with osteoporosis, the bisphosphonate alendronate reduces bone loss, increases bone density in both the spine and hip, and reduces the risk of both spine fractures and hip fractures. Side effects from alendronate are uncommon, but may include abdominal or musculoskeletal pain, nausea, heartburn, or irritation of the esophagus. The medication should be taken on an empty stomach and with a full glass of water first thing in the morning. After taking alendronate, it is important to wait in an upright position for at least one-half hour, or preferably one hour, before the first food, beverage, or medication of the day. Calcitonin. Calcitonin is a naturally occurring non-sex hormone involved in calcium regulation and bone metabolism. In women who are at least 5 years beyond menopause, calcitonin slows bone loss, increases spinal bone density, and according to anecdotal reports, relieves the pain associated with bone fractures. Calcitonin reduces the risk of spinal fractures and may reduce hip fracture risk as well. Studies on fracture reduction are ongoing. Calcitonin is currently available as an injection or nasal spray. While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, urinary frequency, nausea, and skin rash. The only side effect reported with nasal calcitonin is a runny nose. Risedronate. Risedronate sodium (brand name Actonel�) is approved for the prevention and treatment of osteoporosis in postmenopausal women and for the prevention and treatment of glucocorticoid-induced osteoporosis in both men and women. Risedronate, a bisphosphonate, has been shown to slow or stop bone loss, increase bone mineral density and reduce the risk of spine and non-spine fractures. In clinical trials, side effects of risedronate were minimal to moderate and those that were reported occurred equally among people taking the medication and those taking a placebo. Risedronate should be taken with a glass of water at least 30 minutes before the first food or beverage of the day other than water. After taking risedronate, it is important to remain in an upright position and refrain from eating for at least 30 minutes. Fall Prevention is a special concern for men and women with osteoporosis. Falls can increase the likelihood of fracturing a bone in the hip, wrist, spine or other part of the skeleton. In addition to the environmental factors listed below, falls can also be caused by impaired vision and/or balance, chronic diseases that impair mental or physical functioning, and certain medications, such as sedatives and antidepressants. It is important that individuals with osteoporosis be aware of any physical changes they may be experiencing that affect their balance or gait, and that they discuss these changes with their health care provider. Some tips to help eliminate the environmental factors that lead to falls include: Outdoors. Use a cane or walker for added stability; wear rubber-soled shoes for traction; walk on grass when sidewalks are slippery; in winter, carry salt or kitty litter to sprinkle on slippery sidewalks; be careful on highly polished floors that become slick and dangerous when wet. Use plastic or carpet runners when possible. Indoors. Keep rooms free of clutter, especially on floors; keep floor surfaces smooth but not slippery; wear supportive, low-healed shoes even at home; avoid walking in socks, stockings, or slippers; be sure carpets and area rugs have skid-proof backing or are tacked to the floor; be sure stairwells are well lit and that stairs have handrails on both sides; install grab bars on bathroom walls near tub, shower, and toilet; use a rubber bath mat in shower or tub; keep a flashlight with fresh batteries beside your bed; if using a step stool for hard to reach areas, use a sturdy one with a handrail and wide steps; add ceiling fixtures to rooms lit by lamps. Consider purchasing a cordless phone so that you don't have to rush to answer the phone when it rings or you can call for help if you do fall. Author: Simon Kipersztok, M.D., University of
Florida Prevention of Post-Menopausal OsteoporosisAn understanding of the biology of bone acquisition and bone loss throughout
life can allow practitioners to utilize strategies useful in the prevention
of osteoporosis. Peak bone mass is achieved between the third and fourth decades
of life. This amount of bone is important since after its acquisition there
is a natural decline in bone mass that is more prominent in women than in men.
The higher the peak bone mass achieved, the lower the likelihood that later
in life a given individual will experience an increased probability of fracture.
There are many factors that can affect the acquisition of peak bone mass and
they include: nutrition, level of exercise, the effect of some medical conditions,
habits such as smoking, alcohol intake and genetic make up. For women a uniquely
important factor is the amount of circulating estrogens beyond puberty. Nutrition plays an important role in the acquisition of bone mass at many levels
and for this reason, comprehensive nutritional counseling is important in the
prevention of osteoporosis particularly for children, adolescents and young
adults who are on their way to acquire peak bone mass. The two main nutritional
components that should be addressed as part of a complete nutritional counseling
program are calcium and vitamin D. Calcium is an essential component of many biochemical processes and bone serves
as a reservoir for the mineral. Parathyroid hormone maintains calcium homeostasis
at the expense of bone integrity. In children and adolescents BMD is increased
after calcium supplementation and in post-menopausal women calcium is important
in maintaining adequate BMD although by itself it cannot prevent bone loss.
A consensus panel from the National Institutes
of Health has published guidelines for adequate calcium intake at different
ages [8]. Several calcium supplements are commercially available however absorption
from the supplements is not complete and some supplements can cause side effects
such as bloating and constipation. Several commonly ingested foods have relatively
high calcium content (see Table 3) [9]. Vitamin D plays an important role in calcium absorption and bone metabolism.
The active metabolite can be synthesized in the skin under the influence of
sunlight and therefore adequate daily supplementation is required in doses of
400-800 IU in individuals who are institutionalized or live in geographical
areas where there is inadequate sun exposure. The supplementation may also be
necessary for healthy postmenopausal women. A recent study showed that multivitamin
therapy corrected low serum levels of vitamin D in healthy postmenopausal women
living around the Atlanta, Georgia area where winters are relatively milder
than in the Northern states [10]. Milk is an excellent source of calcium and
is usually fortified with vitamin D. However, a study found that vitamin D levels
in commercially available milk bottles are not uniform and can vary widely [11].
Weight bearing exercise is also necessary for competent bone mass since individuals
with sedentary lifestyles can have lower BMD than individuals who exercise regularly.
In this regard two issues are important to women. The first one has to do with
premenopausal women who exercise to a degree where menstrual function is lost
due to down regulation of the hypothalamus and pituitary. Some of these individuals
develop exercise induced amenorrhea.
Relative or absolute hypoestrogenism in this group of women can cause accelerated
bone loss to a degree similar to that seen in postmenopausal women. This can
be treated by adjusting the exercise regimen in such a way that regular menstrual
periods occur or by replacing estrogen with HRT or oral contraceptives. The
second issue has to do with the potential for trauma that can occur at different
anatomical sites in postmenopausal women who have low bone densities and engage
in an exercise program. For those women a consultation with a physical therapist
can be helpful. Accurate diagnosis and treatment of several medical and psychiatric conditions
that can adversely affect bone mass is an important preventive strategy. Excess
thyroid hormone, either as a result of undiagnosed hyperthyroidism or as a consequence
of poorly monitored replacement for patients with hypothyroidism,
can cause bone loss. Similarly, glucocorticoid therapy for chronic rheumatologic,
renal, pulmonary or allergic conditions can cause bone loss by a direct effect
on bone and also by down regulating the hypothalamus and pituitary and causing
hypoestrogenism. Some younger women can develop eating disorders such as anorexia
nervosa and bulimia which in turn can lead to hypoestrogenism due to hypothalamic
amenorrhea
and cause subsequent bone loss. These eating disorders can be dangerous and
on occasion lead to death. Psychiatric intervention is often required and during
treatment patients can be replaced with HRT or oral contraceptives. Smoking is associated with low BMD. Compared to nonsmokers, smoking women usually
experience the menopause at an earlier age. This is possibly due to a direct
toxic effect of tobacco or its by products on the ovary. Also, smoking women
clear estrogens from their system more readily than non smoking women [12].
Similarly, individuals who drink heavily have lower BMD compared to non drinkers
or moderate drinkers. This can be the result of a direct toxic effect of alcohol
on bone metabolism or a result of the systemic effects that alcohol abuse has
on heavy drinkers. Also, heavy drinkers not uncommonly suffer from nutritional
deficiencies which in turn can have a deleterious effect on bone. When counseling
patients about the adverse effects that smoking and excessive drinking have
on their health it is important to highlight the detrimental influence that
these agents can have on bone metabolism. Whites and Asians have, on the average, lower bone masses than other ethnic
groups and this observation is thought to be due to genetic differences. While
targeting preventive strategies to ethnic groups at higher risk for the condition
makes public health sense, it is important to remember that members of any ethnic
group can still suffer from osteoporosis and its sequelae due to factors other
than genetic. What is osteoporosis?Osteoporosis {awe/stee/o/por/OH/sis} is the loss of bone mass or bone density.
As bone mass is lost, the structure of the bones becomes weak and they break
more easily. Some loss of bone mass is a natural part of the aging process.
For most of us, by the time we are 70 years old, our bones will have lost 1/3
of their density. Osteoporosis can occur in men as well as women. In women,
however, the loss of bone mass is usually greater than in men and it begins
at an earlier age (around the time of menopause or sooner if the supply of the
hormone called 'estrogen' is decreased). Risk factors for developing osteoporosis The following factors can increase the chances of developing osteoporosis:
Symptoms of osteoporosis Many people are unaware of that fact that they have osteoporosis because it causes few symptoms until a broken bone (fracture) occurs. In many cases the amount of force that caused the bone to break would not normally have caused a fracture. Common fracture sites for people with osteoporosis include:
Diagnosis Osteoporosis is typically diagnosed by doing bone x-rays and a more sophisticated
test, called a bone scan or bone density test. In some cases, blood tests can
be helpful. On occasion, a bone biopsy may be done to confirm the dignosis.
Prevention The most important things that can be done to prevent or minimize the development of osteoporosis are:
Osteoporosis
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| It is estimated that one in two women over 50 will have an osteoporosis-related fracture. |
| Osteoporosis is a threat to 28 million Americans and is currently one of the most under-diagnosed and under-treated disorders in medicine. |
| According to the National Osteoporosis Foundation, once a woman reaches 60 years of age, she has a one in four chance of breaking a bone due to osteoporosis. |
| It is estimated that osteoporosis accounts
for more than 1.5 million fractures each year. |
Osteoporosis is a disorder where the bones become weakened by loss of substance (osteopenia), leading to an increased risk of broken bones (fractures) with minimal trauma.
The thinning of the bones does not, in itself, cause much in the way of symptoms. It does, however lead to a risk of broken bones without much of an injury. In fact the bones of the spine can sometimes collapse without any obvious cause.
When the bones are significantly thinned (low in bone mass) people who fall are more likely to break their wrist, hip, or other bones. A cough or a sneeze is more likely to cause a fracture of a rib or the partial collapse of one of the bones of the spine (vertebra). Any bone is more at risk with osteoporosis.
Osteoporosis affects people in a number of ways:
Bone is constantly being replaced. Old bone is reabsorbed and new bone laid down all the time. This results in about 10% of the bone in your body being replace every year. When more bone is reabsorbed than is laid down, this results in thinning of the bones (loss of bone mass).
The substance of the bones (bone mass) builds up to a peak at about 30 years of age. After that we lose bone mass by about 1% each year.
When the menstrual periods stop in women (the menopause) there is a phase, for a few years, when women lose bone mass at a faster rate.
There are a number of types of Primary osteoporosis:
There is also secondary osteoporosis, which is connected with the following factors:
Osteoporosis can occur in anybody, but certain factors add together to increase the risk of a person developing osteoporosis.
If you fall into one or more of these groups you may be at greater risk of osteoporosis:
If you already have a fracture or bone collapse, then this will point towards the possibility of osteoporosis. Other factors which may alert the doctor to the possibility include:
Tests are likely to include Xray techniques of various types, which your doctor will arrange. The doctor may want to follow up any possible causes for the osteoporosis, if the bone density does turn out to be lower than would normally be expected for your age and sex.
There are a number of treatments available:
Your doctor may send you to a specialist. You are likely to have follow-up tests of bone density, to monitor progress while on treatment.
[This page contains information on Fosamax, osteoporosis, Paget's
disease, Miacalcin, Evista, Actonel, Skelid and Didronel].
Osteoporosis is a common condition in the United States. In simple terms,
osteoporosis is a weakening of the bones whereby they become brittle and easily
fractured.
Osteoporosis mostly affects post-menopausal Caucasian women although all women
can be affected. Osteoporosis is less common in men than in women.
There are conflicting theories about what causes osteoporosis. It is known
that the chronic administration of certain drugs, such as corticosteroids like
prednisone, may increase a person's risk of developing osteoporosis.
If you are a woman taking prednisone or any steroid medication (including inhaled
steroids for asthma or COPD) it is important that you get extra calcium
in your diet. Most experts agree that a woman of child-bearing age should
ingest 1,000 mg - 1,500 mg of calcium per day to reduce the risk of developing
osteoporosis. If you already have osteoporosis it is unlikely that
ingesting lots of calcium will reverse the disease.
Paget's disease is similar to osteoporosis in that it is characterized by a
weakening of the bones. Paget's disease is a metabolic condition that
causes bone cells to become weaker and have more blood vessels than normal
bone. In Paget's disease the bone's structure is irregular which makes it prone
to fracture even after a minor injury.
There are many medications used to treat osteoporosis and Paget's disease:
Actonel
(Risedronate Sodium; Procter and Gamble) Drug family - Biphosphonate
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Didronel
(Etidronate Disodium; Procter and Gamble) Drug family - Diphosphonate
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Evista
(Raloxifene HCL; Eli Lilly) Drug family - Selective estrogen receptor modulator
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Fosamax
(Alendronate; Merck) Drug family - Aminobisphosphonate
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Miacalcin
(Calcitonin; Novartis ) Drug family - synthetic calcitonin
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A major health problem, osteoporosis or "porous bone," affects an estimated 20 million Americans. This bone loss disease is most common in the elderly and in postmenopausal women. The loss of bone mass places extra stress on the thin, fragile bone structure that remains causing bones to be susceptible to fracture. Osteoporosis is estimated to cause 1.3 million bone fractures a year in people over 45 years of age. Moreover, in 1985, the national estimated cost of osteoporotic fractures was estimated to be $7 billion a year.
Osteoporosis-related fractures can occur in any of the bones, but the main fractures occur in the vertebral spinal column, the wrist, and the hip. In the spinal column, loss of bone mass starts in women during their 50s and 60s. A simple action like bending forward can be enough to cause a "crush fracture," or spinal compression fracture.
bodyOffer(4678) These vertebral fractures cause loss of height and a humped back, or a "dowager's hump. Wrist fractures called a "Colles fracture" also commonly occur among women with osteoporosis. Topically, the fracture occurs when a woman falls and uses her hand to break the fall; this results in a broken wrist. Fractures of the hip are the most severe. They are associated with more death, more disability, and higher medical costs than all other osteoporotic fractures combined. Twelve to 20 percent of older people with hip fractures die within a year after the fracture. Of the survivors, only a few return to the full level of activities that they enjoyed before the hip fracture.
Risk Factors
Many risk factors for osteoporosis have been identified. They include:
Age. The chief risk factor for this disease is age; the likelihood of developing osteoporosis increases progressively as we grow older.
Being a woman. Osteoporosis is estimated to be six to eight times more common in women than in men. In early adult life women develop less bone mass than men do. Even more critical is that for years after menopause, women lose bone mass much more rapidly because of a reduction in their production of estrogen.
Early menopause. The chances of developing osteoporosis increase during early menopause or surgical menopause (after removal of the ovaries), which causes a sudden significant drop in estrogen.
bodyOffer2() Being Caucasian. White women are at higher risk than black women, and white men are at higher risk than black men. In general, blacks have 10 percent greater bone mass than whites do.
A consistently low calcium intake.
Lack of weight-bearing exercise. The significant loss of bone mass in our astronauts who spend considerable time in the weightless environment of outer space dramatically demonstrates the importance of weight-bearing exercise.
Being underweight.
A family history of osteoporosis.
Smoking cigarettes. The concentration of estrogen in the bloodstream is lowered by cigarette smoking.
Excessive use of cortisone-like drugs such as prednisone.
Symptoms
Osteoporosis is a silent disease. Usually, it develops for many years until the bones become so weak that a minor injury can cause the bones to fracture. Detection of bone loss with ordinary x-rays does not show up until a person has lost 30 percent of their bone density. Several techniques for early detection of bone loss have been developed in recent years. In one technique, photon absorptiometry, a machine measures how much the rays like x-rays penetrate the bone (measuring how dense the bones
Bone Growth and Loss
Bone continues to grow and develop throughout childhood and adolescence. During a person's twenties, bone growth increases by 15 percent. Peak bone mass, when the bones are most dense and strong, occurs at 30 to 35 years of age. After this time bone mass gradually diminishes and the bones become less dense. There is a great need to understand how bone grows and diminishes. By studying the cellular processes responsible for bone growth, researchers hope to discover new treatments for osteoporosis. There is much active and promising research in this area.
bodyOffer3() Treatment and Prevention
Scientists now know that a leading cause of osteoporosis in women is postmenopausal estrogen deficiency. They have discovered that estrogen not only slows bone loss but also prevents bone fractures if given when a woman's production of estrogen drops. It is important that the hormone be given during or shortly after menopause because estrogen given years later is of less value. Women who have gone through menopause, and especially those with an early or surgical menopause, should discuss the benefits and risks of estrogen replacement therapy with their physicians.
Another benefit of estrogen therapy is its positive effect on the cardiovascular system. Estrogen reduces cholesterol and the concentration of other lipids (fats) in the bloodstream associated with heart disease. For women on estrogen therapy, the risk of developing endometrial cancer increases from one per 1,000 women to about four per 1,000 women. Fortunately, endometrial cancer is easy to detect and is highly curable. In fact, the death rate from endometrial cancer is lower than the death rate for osteoporotic hip fracture.
One side effect women on estrogen replacement therapy may experience is periodic bleeding. This is because estrogen therapy causes the lining of the uterus to build up. Estrogen usually is prescribed for 20 days, then the hormone is stopped for the remaining 10 days. The lining of the uterus is shed during the days off estrogen.
Progestogen, another fernale hormone, given in combination with estrogen may help reduce the risk of endometrial cancer. Women in the menopausal period are encouraged to discuss estrogen or progestogen therapy with their doctors.
Calcium Intake
The average American consumes about 450 to 550 milligrams of calcium a day. Experts recommend that both men and women take at least 1,000 milligrams of calcium daily. This is the amount of calcium contained in three eight-ounce glasses of milk. Other sources of calcium include yogurt, cheese, salmon, canned sardines, oysters, shrimp, dried beans, and dark green vegetables such as broccoli, turnip greens, and kale.
People who do not meet their daily requirements of calcium through their diet are encouraged to take a daily supplement of calcium such as calcium carbonate, calcium lactate, calcium gluconate, or calcium citrate. Older men and women should increase their calcium intake up to 1,200 to 1,500 milligrams a day, or about four to five glasses of milk, because calcium absorption from the digestive tract is reduced in the elderly.
Exercise
Research has shown clearly that inactivity leads to bone loss. Studies revealed that astronauts in space lost a great deal of bone from lack of exercise against gravity. A program of moderate weight-bearing exercise three to four hours a week, such as brisk walking, running, tennis, or aerobic dance, is recommended. Swimming is not as valuable because it is not a weight-bearing exercise.
Experimental Treatments
Several promising treatments for osteoporosis are being investigated. Calcitonin, a new drug approved by the Food and Drug Administration in 1984, slows the breakdown of bone. Calcitonin, produced naturally in the body, is a hormone produced by the thyroid gland. The synthetic form is given by daily injection and is expensive. Recently, a less expensive nasal spray of calcitonin has been developed.
Scientists also are studying fluoride combined with calcium for osteoporosis. Still experimental, flouride is promising in that it has been shown to increase bone mass. Some people experience side effects including nausea, vomiting, diarrhea, and pain in their lower extremities. Fluoride compounds currently are available for treatment- in Germany and France. However, more research is needed before this treatment can be proven to be both safe and effective.
Until recently, there were no clues as to how the hormone, estrogen, prevented osteoporosis. Now investigators have reported the discovery of estrogen receptors on bone. New methods might be harnessed to treat osteoporosis. Through continued research, there is hope for future treatments of osteoporosis.
Author's name omitted by request
Title: What is osteoporosis?
Description: Osteoporosis is a silent disease. Usually, it develops for
many years until the bones become so weak that a minor injury can cause the
bones to fracture.
