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Osteo­poro­sis is a pro­gres­sive meta­bol­ic bone dis­ease that decreas­es bone den­si­ty (bone mass per unit vol­ume) with dete­ri­o­ra­tion of the bone structure. This arti­cle will discuss: The arti­cle was writ­ten by Dr. Islam Elna­gar. M.D, FRCSC, Ortho­pe­dic Surgery.

What Is Osteoporosis?

It is often called the “ silent disease “. It is a decrease in bone mass due to uncou­pling ( dis­con­nec­tion ) between osteoblast and osteo­clast activ­i­ty ( these are the cells respon­si­ble for bone for­ma­tion and bone turnover in your body, respectively ). The Nation­al Osteo­poro­sis Foun­da­tion ( NOF ) defined Osteo­poro­sis as a con­di­tion when the body los­es too much bone and/ or makes lit­tle bone. In gen­er­al, bone mass increas­es dur­ing the first 30 years of life, then it grad­u­al­ly declines. This decline is faster in women after menopause due to the decreased estro­gen level. The World Health Orga­ni­za­tion ( WHO ) defined osteo­poro­sis as hav­ing Bone Min­er­al Den­si­ty ( BMD ) less than what you should have at your age… This has been cal­cu­lat­ed in two ways ( scores ) :
  • The T‑Score, which com­pares your score to that of a mature young healthy 30 years old woman.
  • The Z‑Score, which com­pares your score to a sim­i­lar-aged group.
If your score is less than the ‑2.5 stan­dard devi­a­tion of the con­trol group, there­fore, you have Osteo­poro­sis. How­ev­er, if your score falls between ‑1 and ‑2.5, you have Osteope­nia ( less severe than Osteoporosis ). This test can be ordered by your doc­tor if there is sus­pi­cion for have Osteoporosis. Osteo­poro­sis can be age-relat­ed ( most com­mon­ly ) or sec­ondary to a patho­log­ic con­di­tion. Sec­ondary osteo­poro­sis can be more com­mon in men ( can be due to hypog­o­nadism, excess glu­co­cor­ti­coid and alcoholism ). It is more com­mon in women than men in a ratio of approx­i­mate­ly 4:1. Unfor­tu­nate­ly ( and sur­pris­ing­ly ), women above 45  spend more time in the hos­pi­tal due to osteo­poro­sis than patients who have a heart attack, dia­betes or some cancers.

When Should I Worry About Osteoporosis?

Pri­ma­ry osteo­poro­sis usu­al­ly presents in women aged 50–70 years ( post­menopausal Osteo­poro­sis ) and in men above 70 in the absence of risk factors. How­ev­er, sec­ondary osteo­poro­sis can occur at any age due to an under­ly­ing med­ical con­di­tion ( less common ). There­fore, if you are a woman less than 45 or a man less than 60–70 with no risk fac­tors and no under­ly­ing med­ical con­di­tion that would cause osteo­poro­sis, you do not have to worry.

What Are The Chances Getting Osteoporosis ?

Age­ing is the most com­mon cause of osteo­poro­sis. How­ev­er, there are oth­er fac­tors that can cause pre­dis­pose you to osteoporosis. These risk fac­tors can be clas­si­fied into two categories : 1- Unmod­i­fi­able risk fac­tors ( you have no con­trol over them ), as : Age­ing, females, white race and genet­ic factors. Genet­ic risk fac­tors can be exten­sive as poly­mor­phism in the genes for cal­ci­tonin recep­tors, estro­gen receptor‑1, vit­a­min D recep­tor, etc Late menar­che and ear­ly menopause can be risk fac­tors in females as well. 2- Mod­i­fi­able risk fac­tors ( you can con­trol to pre­vent or min­i­mize your risk of hav­ing osteoporosis ) : Seden­tary lifestyle,  low pro­tein intake, low body weight, smok­ing,  heavy drinkers and breast­feed­ing with low vit­a­min D and cal­ci­um supplements. Some dis­eases can cause sec­ondary Osteo­poro­sis as Mal­ab­sorp­tion syn­drome, hyper­thy­roidism, liv­er dis­eases, type 1 dia­betes mel­li­tus, can­cer, chron­ic renal fail­ure, Chron­ic Obstruc­tive Pul­monary Dis­ease ( COPD ), mul­ti­ple myelo­ma, inflam­ma­to­ry bow­el dis­ease, rheuma­toid arthri­tis and sarcoidosis. Some med­ica­tions can also cause sec­ondary osteo­poro­sis as pheny­toin, selec­tive sero­tonin uptake inhibitors, cyclosporin, furosemide, high dose methotrex­ate, anti­neo­plas­tic med­ica­tions, omepra­zole, glu­co­cor­ti­coids, an over­dose of levothy­rox­ine, heparin and vit­a­min A, etc… These are just exam­ples of a big­ger list of med­ica­tions; please dis­cuss with your physi­cian your med­ica­tions list, espe­cial­ly if you have oth­er risk fac­tors in devel­op­ing osteoporosis.

Diagnosis Of Osteoporosis

Osteoporosis How is osteo­poro­sis diagnosed? The first step is get­ting a good his­to­ry from your physi­cian. Your doc­tor would assess your risk for osteo­poro­sis based on the risk fac­tors men­tioned earlier. Then a full phys­i­cal exam to assess your weight, height and any spine defor­mi­ty ( kypho­sis ). Neu­ro­log­ic exam­i­na­tion to assess your bal­ance and mobil­i­ty is impor­tant as well. Any phys­i­cal sign of oth­er dis­eases caus­ing sec­ondary osteo­poro­sis will be assessed by your physi­cian as well, and the appro­pri­ate inves­ti­ga­tions will be arranged. Sec­ond­ly, some lab­o­ra­to­ry tests can aid in diag­nos­ing as the blood lev­el of cal­ci­um and 25, hydrox­yvi­t­a­min D. Tests to diag­nose sec­ondary osteo­poro­sis would be direct­ed accord­ing to your his­to­ry of any of the pre-men­tioned dis­eases that could cause osteoporosis. Final­ly, the main test to diag­nose osteo­poro­sis is the Dual-Ener­gy X‑ray Absorp­tiom­e­try DEXA ( or DXA ). It mea­sures the bone min­er­al den­si­ty ( BMD ) at the prox­i­mal femur (hip) and lum­bar spine. This will be com­pared to a mature young healthy 30 years old woman to get your T‑Score and to a healthy matched group of the same age to get your Z‑Score.

When Should I Get Tested?

The indi­ca­tions for hav­ing a BMD test are :
  • Women: 65 years of age and old­er, any post­menopausal woman with low ener­gy frac­ture, inci­den­tal find­ing of radi­ograph­ic frac­ture, glu­co­cor­ti­coid treat­ment for 3 months and more, peri and post­menopausal women, menopause before 40 years old, fam­i­ly his­to­ry of osteo­porot­ic frac­ture and those with risk fac­tors pre­vi­ous­ly mentioned.
  • Men: aged 70 and above, 50 – 70 years old with risk fac­tors ( men­tioned above )

What Happens If I Have Osteoporosis?

It can be called the silent dis­ease as it is most com­mon­ly asymp­to­matic till the first frac­ture occurs, which is the most com­mon pre­sen­ta­tion. There­fore you might have osteo­poro­sis ( maybe for years ) with­out notice. The most com­mon frac­tures are in order: Ver­te­bral body frac­tures, hip frac­tures and wrist frac­tures. How­ev­er, oth­er frac­tures can occur as well like: Pubic rami frac­tures, dis­tal femur frac­tures prox­i­mal humerus frac­tures and elbow fractures. An esti­mate of 9 mil­lion frac­tures due to osteo­poro­sis occur every year world­wide. Almost one-third of women and one-fifth of men above 50 are at risk of osteo­porot­ic fractures. It can also present with kyphot­ic defor­mi­ty due to ver­te­bral body frac­tures and height loss. Ver­te­bral body frac­tures can present as back pain, loss of height, poor bal­ance and res­pi­ra­to­ry com­pro­mise( as pneumonia ). If you have any of these symp­toms, you should be assessed by your doctor. Ver­te­bral body frac­ture can be asso­ci­at­ed with a 15 % increase in mor­tal­i­ty rate with­in 5 years. One ver­te­bral body frac­ture can increase the risk of hav­ing a sec­ond one by 5 times and increas­es the risk of hav­ing a hip frac­ture by 5 folds. Hip frac­tures can be more severe than ver­te­bral ones. In gen­er­al, hip frac­tures have a 20% mor­tal­i­ty rate with­in the first year. osteoporosis Once a hip frac­ture occurs, it should be sur­gi­cal­ly treat­ed as soon as pos­si­ble ( as far as the gen­er­al con­di­tion per­mits sur­gi­cal fix­a­tion and hav­ing spinal or gen­er­al anaes­the­sia ). Data shows increased mor­tal­i­ty with delayed sur­gi­cal treat­ment for hip frac­tures. There­fore the best way to treat hip frac­tures is to pre­vent them! Only one-third of patients with hip frac­tures return to their base­line func­tion after surgery. One hip frac­ture increas­es the risk of hav­ing a sec­ond hip frac­ture by up to 10 fold. There­fore, we can­not stress enough to pre­vent falling and frac­tures ( pre­ven­tion is way bet­ter than treatment ). Luck­i­ly wrist frac­tures are not as severe as hip and ver­te­bral body frac­tures. How­ev­er, hav­ing a wrist frac­ture means you are at risk for oth­er more seri­ous fractures.

If I have Osteoporosis, How Can I Avoid or Minimize The Risk Of Having a Fracture?

If you have poor bal­ance and low base­line mobil­i­ty, the best way to avoid falling is to use a walk­ing aid like a walk­er or at least a cane. Age is just a num­ber at the end, so if you know you have trou­bles with your walk­ing (while hav­ing osteo­poro­sis ) regard­less of your numer­ic age, there is no harm in using aids to have a safe walk. Using an aid is way bet­ter than being in the hos­pi­tal hav­ing surgery for frac­ture fixation!. A safe house envi­ron­ment is impor­tant as well, with a good set­up for your bedroom/bathroom and easy access to your house.

Would Osteoporosis Affect My Elective Orthopaedic Surgery?

Yes, even if you have no his­to­ry of frac­tures. Osteo­poro­sis has a bad impact on your elec­tive joint replace­ment surgery. Some data showed that if you are hav­ing a shoul­der arthro­plas­ty, the chances of hav­ing a frac­ture around the implant ( peri-pros­thet­ic frac­ture ) after surgery with­in the first 2 years is high­er than those who do not have osteo­poro­sis. Sim­i­lar data sup­ports the same for your low­er extrem­i­ty arthro­plas­ty ( total hip and total knee replacements ).

Treatment Of Osteoporosis

Osteoporosis So what are the prevention/ treat­ment meth­ods for osteoporosis? First of all, is lifestyle mod­i­fi­ca­tions as being active in your dai­ly rou­tine, exer­cis­es ( resis­tance as weight lift­ing or rub­ber bands and weight-bear­ing exer­cis­es as walk­ing, jog­ging, run­ning, etc.), healthy food, smok­ing ces­sa­tion and lim­it­ing alco­hol are keys to pre­vent­ing osteo­poro­sis and lots of oth­er diseases. The Cen­tres for Dis­ease Con­trol report­ed that from 120–300 min­utes of mod­er­ate to severe exer­cise per week was asso­ci­at­ed with few­er hip frac­tures in old­er adults. Vit­a­min D and Cal­ci­um sup­ple­ments: Vit­a­min D of 800 IU dai­ly is rec­om­mend­ed for pre­ven­tion, and a Cal­ci­um dose of 1000–1200 mg dai­ly is the rec­om­mend­ed dose.

Pharmacologic Treatment Indications :

The Nation­al Osteo­poro­sis Foun­da­tion Guide­lines for Osteo­poro­sis treat­ment sug­gests phar­ma­co­log­i­cal agents be con­sid­ered for cer­tain cat­e­gories, as : Post­menopausal women and men who are above 50 years of age plus hav­ing one of the following : 
  • Pre­vi­ous or cur­rent hip and/or ver­te­bral fracture 
  • T score between ‑1.0 and ‑2.5 at the hip ( femoral neck )or spine and one of the fol­low­ing 2 risks :
    • ≥ 3% hip frac­ture risk in the fol­low­ing 10 years or
    • ≥ 20% relat­ed frac­ture risk in the fol­low­ing 10 years as per FRAX cal­cu­la­tion or
  • T score ‑2.5 or less at the hip ( femoral neck )or spine.
( Dis­cuss this with your physi­cian as the expla­na­tion of these indi­ca­tions and scores is beyond the scope of this arti­cle ) ( Also, please remem­ber this arti­cle is not intend­ed to diag­nose nor to treat your condition).

What Medications Can Be Used For Treatment ?

Sev­er­al phar­ma­co­log­ic agents can be pre­scribed as :
  • Cal­ci­um and Vit­a­min D
  • Bis­pho­s­pho­nates
  • Estro­gen-only replace­ment (ERT)
  • Con­ju­gat­ed Estro­gen-prog­estin hor­mone replace­ment (HRT)
  • Salmon cal­ci­tonin 
  • Ralox­ifene
  • Teri­paratide
Like any oth­er med­ica­tions, these agents are asso­ci­at­ed with var­i­ous side effects/complications depend­ing on which drug you are tak­ing as osteonecro­sis of the jaw with intra­venous bis­pho­s­pho­nate and atyp­i­cal femur frac­tures with long-term bisphosphonates. Please review what med­ica­tion you are on and be aware of its poten­tial side effects, which is beyond this arti­cle’s scope.

In conclusion

Osteo­poro­sis is a preva­lent con­di­tion world­wide. It can be asymp­to­matic till the first frac­ture occurs.  The key is to iden­ti­fy in which cat­e­go­ry you are and mod­i­fy your risk fac­tors to min­i­mize or pre­vent it from happening. The best treat­ment for osteo­poro­sis is its pre­ven­tion. And the ear­li­er the diag­no­sis and treat­ment, the bet­ter the out­comes would be.
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