Osteoporosis is a condition characterized by a decrease in bone mass and loss of bone density, leading to weakened and brittle bones. Having osteoporosis increases the risk of bone fractures, especially in the hip, spine, and wrists.
Osteoporosis is considered a disease of older women. However, osteoporosis can start much earlier. Since peak bone density is reached around the age of 25, it is important to have healthy bones by that time to maintain bone strength throughout later life. Adequate calcium intake is an important part of bone strengthening.
In the United States, nearly 10 million people suffer from osteoporosis. Another 18 million people have low bone mass, significantly increasing their risk of developing osteoporosis. With increasing life expectancy, the number of osteoporosis patients will continue to rise. Approximately 80% of osteoporosis patients are women. In individuals over the age of 50, one in every two women and one in every eight men have a high risk of fractures.
According to data from the World Health Organization, the prevalence of osteoporosis among postmenopausal women is 14% (50-59 years), 22% for ages 60-69, 39% for ages 70-79, and 70% for ages 80 and above. The frequency of osteoporosis is not heavily dependent on ethnicity, but individuals of Caucasian and Asian descent have a higher risk.
Causes Osteoporosis occurs when there is an imbalance between the formation of new bone tissue and the breakdown of old bone tissue. The body either cannot produce enough new bone tissue or it breaks down more old bone tissue than necessary (both processes can be observed). Two essential minerals needed for normal bone formation are calcium and phosphorus. In a young body, these minerals are used to build bones.
However, calcium is also necessary for the normal functioning of the heart, brain, and other organs. To maintain the functions of vital organs and provide the necessary level of calcium in the blood, the body absorbs the required calcium from the bone tissue, which serves as a reservoir. When the level of calcium in the blood decreases or does not receive enough from the diet, conditions are created for disrupting the process of bone tissue regeneration.
Usually, bone loss occurs over a long period of time. Osteoporosis is often only diagnosed after the occurrence of bone fractures. Late diagnosis of the disease, in an advanced state, can cause serious health impairments.
The main cause of osteoporosis is usually a lack of sufficient amounts of certain hormones, especially estrogen in women and androgens in men. Osteoporosis is particularly observed in women, especially after the age of 60. Menopause is accompanied by a decrease in estrogen levels, which increases the risk of developing osteoporosis in women.
Other factors that can lead to bone loss in this age group include insufficient intake of calcium and vitamin D, lack of physical activity, and other age-related changes in the endocrine system (in addition to the lack of estrogen). Other causes that can contribute to osteoporosis include prolonged use of corticosteroids (Cushing’s syndrome), thyroid disorders, poor muscle development, bone tumors, certain genetic disorders, complications from certain medications, and low dietary calcium intake.
Other risk factors associated with the development of osteoporosis include:
Therefore, if a woman in the postmenopausal period experiences back pain, it is necessary to consult a physician for examination and initiation of treatment. Additionally, it is important to investigate the presence of osteoporosis in the presence of other risk factors, such as fractures or muscle and bone pain. In such cases, assessing bone density is necessary.
Diagnostic process:
Initially, the physician will inquire about the presence of any medical conditions, lifestyle factors, and history of fractures. Laboratory tests are used to determine levels of calcium, phosphorus, vitamin D, and hormones (estrogen, testosterone), as well as analyses to assess kidney excretory function.
Based on the medical evaluation, the physician may recommend determining the mineral density of the bone tissue, known as densitometry. This diagnostic method allows for the diagnosis of osteoporosis before the bone tissue starts to deteriorate and predicts the likelihood of future fractures. Furthermore, assessing bone density enables monitoring the effectiveness of treatment and the progression of osteoporosis over time.
This is why densitometry should be performed regularly (annually). There are several types of devices that can determine bone density. All densitometry methods are painless, non-invasive, and safe. Comprehensive examination devices can measure bone density in the hip, spine, and the entire body. Peripheral devices can measure density in the finger, wrist, knee, ankle, and heel.
Densitometers, such as DXA (dual-energy X-ray absorptiometry), measure bone density in the spine, hip, or the entire body. The measurement of density is based on the differential absorption of X-rays depending on the density of the bone tissue. The X-ray radiation used in such densitometers is very low, making the procedure almost harmless for the patient and medical staff.
Additionally, ultrasound densitometry can be used for screening purposes. Typically, the ankle is examined using this method. If the screening detects certain abnormalities, confirmation with DXA densitometry is necessary. The mineral density of the bone tissue is determined by comparing it to the density of a healthy individual of the same age and sex. Significant decrease in density indicates the presence of osteoporosis and a high risk of fractures. Depending on the results of densitometry, the physician prescribes the necessary treatment.
For patients with borderline results, the new method called FRAX (fracture risk assessment tool) is particularly useful in determining the 10-year risk of fractures. This calculation method takes into account all risk factors for the individual and determines their personal risk of fractures and the need for treatment.
Treatment of osteoporosis aims to slow down or halt mineral loss, increase bone density, prevent bone fractures, and reduce associated pain. Almost 40% of women with osteoporosis can experience bone fractures in their lifetime. Patients who have experienced a compression fracture have nearly a one in five chance of a new vertebral fracture after a certain period of time. In such cases, cascade fractures are discussed, where each new fracture triggers additional fractures. Therefore, the main goal of osteoporosis treatment is fracture prevention.
Diet: In young age, when bone mass is forming, a well-balanced diet with an adequate amount of calcium and vitamin D is necessary (dairy products, fish, etc.). Additionally, sufficient physical activity is required at this age for optimal growth of both muscle and bone tissue. A diet rich in calcium and vitamin D is also beneficial for individuals already diagnosed with osteoporosis.
Postoperative monitoring: In the presence of a history of bone fractures, careful monitoring by specialists (orthopaedic surgeon, rheumatologist, endocrinologist) and physiotherapists is necessary for meticulous rehabilitation, as the regeneration of bone tissue affected by osteoporosis occurs very slowly.
Physical exercises: Changing your lifestyle is also an integral part of treatment. Regular physical exercises can reduce the risk of bone fractures associated with osteoporosis. Studies show that exercises stimulate muscle action on bone tissue, promoting bone tissue growth and maintaining or increasing bone density.
Research has shown that women who walk 1-2 km daily gain a reserve of 4-7 years in maintaining bone density. Exercise can also include weight-bearing activities depending on the degree of osteoporosis, but the loads should be gentle. Coordination with the treating physician is important for any physical exertion.
Medication treatment: Medications are often prescribed to treat osteoporosis and reduce the risk of fractures. These medications may include bisphosphonates, hormone therapy, selective estrogen receptor modulators (SERMs), calcitonin, and denosumab. The choice of medication depends on various factors, including the individual’s medical history, risk profile, and response to treatment.
It is important for individuals with osteoporosis to follow their prescribed treatment plan, including medications, lifestyle modifications, and regular monitoring by healthcare professionals. Compliance with treatment and regular follow-up appointments can help manage the condition effectively and reduce the risk of complications.
Medication treatment
Estrogens: Immediately after the onset of menopause, the use of estrogens in women is one of the ways to prevent bone loss. Estrogen can slow down or halt bone loss. If estrogen treatment begins during menopause, it can reduce the risk of hip fracture by 50%. Estrogen can be administered in the form of tablets.
However, recent studies have raised concerns about the safety of prolonged estrogen therapy. Women taking estrogen have an increased risk of developing certain types of cancer. Although it was previously believed that estrogens had a protective effect on the heart and blood vessels, recent studies show that estrogens, on the contrary, increase the risk of ischemic heart disease, stroke, and venous thromboembolism.
Many women taking estrogens experience side effects such as breast tenderness, weight gain, and vaginal bleeding. The side effects of estrogens can be reduced through proper dosage and combination with other medications. However, if a hysterectomy has been performed, estrogens are recommended directly.
Selective estrogen receptor modulators (SERMs): For women who cannot or do not wish to take estrogens, selective estrogen receptor modulators (SERMs) such as raloxifene (Evista) may be prescribed. These medications are particularly suitable in the presence of a family history of breast cancer when estrogens are contraindicated.
The effects of raloxifene on bone tissue and cholesterol levels are comparable to estrogens. Additionally, raloxifene does not stimulate the uterus or breast tissue, which reduces the risk of hormonal therapy-related effects. Raloxifene may cause inflammation. The risks of thrombosis formation are similar to the risks associated with estrogen use.
Tamoxifen (Nolvadex), which is commonly used for the treatment of certain types of breast cancer, also inhibits bone breakdown and preserves bone mass.
It is important for individuals considering medication treatment for osteoporosis to discuss the potential benefits and risks with their healthcare provider. The choice of medication should be based on the individual’s medical history, risk factors, and preferences, taking into account the overall benefit-risk profile. Regular monitoring and follow-up appointments are essential to assess the effectiveness of the medication and make any necessary adjustments to the treatment plan.
Calcium: Calcium and vitamin D are necessary for increasing bone mass as an addition to estrogen replacement therapy. The recommended daily intake is 1200-1500 mg (through food and calcium supplements). Single doses should not exceed 600 mg as a large amount of calcium will not be absorbed simultaneously. It is better to divide the intake of calcium into two doses (for breakfast and dinner). It is also recommended to take vitamin D in a daily dose of 800-1000 IU, which is necessary for calcium absorption and thus increases bone mass.
Bisphosphonates: Bisphosphonates are medical drugs that can be taken orally (alendronate, risedronate, etidronate) or intravenously (zoledronic acid – Reclast, Aclasta). These medications slow down bone loss and, in some cases, increase bone mineral density. The intake of these medications and their effectiveness are monitored through periodic DXA scans.
When taking these medications orally, it is important to stand or sit upright for 30 minutes after swallowing the medication. This helps reduce the impact of the medication on the esophageal lining and prevents heartburn or ulcer formation. After taking bisphosphonates, you should wait for 30-40 minutes and avoid consuming food or other medications (only water is allowed). Prior to taking bisphosphonates, it is necessary to have a blood test to assess calcium levels and kidney function.
Alendronate (Fosamax): Clinical trials have shown that alendronate reduces the risk of vertebral and hip fractures by 50%. The most common side effects of this medication are nausea, heartburn, and difficulty swallowing. It is taken either daily or once weekly.
Risedronate (Actonel): This medication is used for the treatment and prevention of osteoporosis. The most common side effects of this medication are gastrointestinal disturbances. Women with severe kidney impairment should avoid taking this medication. Recent research results show that daily use of risedronate can lead to a significant reduction in new vertebral fractures (62%) in postmenopausal women with osteoporosis compared to a comparative group not taking this medication.
Etidronate (Didronel): This medication is approved in the United States for the treatment of Paget’s disease, but it has also demonstrated high efficacy in the treatment of osteoporosis in clinical trials.
Ibandronate (Boniva): This medication started to be used relatively recently and is used for the prevention and treatment of postmenopausal osteoporosis.
Zoledronic acid (Reclast): This is a potent intravenous bisphosphonate that is administered once a year. This medication is particularly beneficial for patients who cannot tolerate oral bisphosphonates or have difficulty adhering to the necessary regular doses of oral medications.
Other Hormones: These hormones are involved in the regulation of calcium and/or phosphate metabolism in the body, thus preventing bone loss.
Calcitonin (Miacalcin): Calcitonin is a hormone (derived from salmon) that slows down bone loss, and its administration can increase bone density. The medication can be administered through injections (two to three times per week) or as a nasal spray.
Teriparatide (Forteo): Teriparatide contains a portion of the human parathyroid hormone. It primarily regulates the metabolism of calcium and phosphate in the bones, stimulating the formation of new bone tissue and increasing bone density. This medication is administered through daily injections. When taking medications for the treatment of osteoporosis, dynamic monitoring is necessary (mammography and ultrasound of the pelvis for estrogen therapy, as well as blood and urine tests for other medications).
Prevention and Prognosis: Building strong bone tissue during childhood and adolescence can be the best protection against the development of osteoporosis later in life. Up to 98% of a woman’s skeletal mass is accumulated by the age of 30. Recommendations for osteoporosis prevention include:
With appropriate treatment, the progression of osteoporosis can be slowed down or halted. However, some individuals may become disabled due to decreased bone density. Nearly 26% of patients with osteoporosis experience fractures of the hip, pelvis, vertebrae, wrist, or shoulder. Hip fractures are quite common, and typically, 50% of patients are unable to walk independently following such fractures.
Additionally, there is a high risk of mortality associated with fractures of the hip, due to complications resulting from prolonged immobilization (up to 20%). In individuals aged 80 and above, 15% of women and 5% of men experience hip fractures. Therefore, osteoporosis is a serious condition that requires early diagnosis, prevention, and treatment.
