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Encyclopaedia


Osteoporosis

Introduction

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. It develops slowly over several years and is often only diagnosed when a minor fall or sudden impact causes a bone fracture.

The most common injuries in people with osteoporosis are:

However, they can also occur in other bones, such as in the arm or pelvis. Sometimes a cough or sneeze can cause a rib fracture or the partial collapse of one of the bones of the spine.

Osteoporosis isn't usually painful until a fracture occurs, but spinal fractures are a common cause of long-term (chronic) pain.

Although a fracture is the first sign of osteoporosis, some older people develop the characteristic stooped (bent forward) posture. It happens when the bones in the spine have fractured, making it difficult to support the weight of the body.

Who's affected?

Osteoporosis affects over three million people in the UK.

More than 500,000 people receive hospital treatment for fragility fractures (fractures that occur from standing height or less) every year as a result of osteoporosis.

Causes of osteoporosis

Losing bone is a normal part of the ageing process, but some people lose bone density much faster than normal. This can lead to osteoporosis and an increased risk of fractures.

Women also lose bone rapidly in the first few years after the menopause (when monthly periods stop and the ovaries stop producing an egg). Women are more at risk of osteoporosis than men, particularly if the menopause begins early (before the age of 45).

Many other factors can also increase the risk of developing osteoporosis, including:

  • long-term use of high-dose oral corticosteroids
  • other medical conditions – such as inflammatory conditions, hormone-related conditions, or malabsorption problems
  • a family history of osteoporosis – particularly history of a hip fracture in a parent
  • long-term use of certain medications which can affect bone strength or hormone levels
  • having a low body mass index (BMI)
  • heavy drinking and smoking

Read more about the causes of osteoporosis.

Diagnosing osteoporosis

Risk assessment tools

If your doctor suspects you have osteoporosis, they can make an assessment using an online programme, such as FRAX or Q-Fracture.

These tools help to predict a person's risk of fracture between the ages of 40 and 90. The algorithms used give a 10-year probability of hip fracture and a 10-year probability of a major fracture in the spine, hip, shoulder or forearm.

DEXA scan

They may also refer you for a DEXA (DXA) scan to measure your bone mineral density. It's a short, painless procedure that takes about five minutes, depending on the part of the body being scanned.

Your bone mineral density can be compared to the bone mineral density of a healthy young adult and someone who's the same age and sex as you. The difference is calculated as a standard deviation (SD) and is called a T score.

Standard deviation is a measure of variability based on an average or expected value. A T score of:

  • above -1 SD is normal
  • between -1 and -2.5 SD is defined as decreased bone mineral density compared with peak bone mass
  • below -2.5 is defined as osteoporosis

Osteopenia

You may be diagnosed with osteopenia if bone density tests show you have decreased bone density, but not enough to be classed as osteoporosis.

Your doctor may still recommend some of the treatments described below, depending on your results and your risk of fracture.

Treating osteoporosis

Treatment for osteoporosis is based on treating and preventing fractures, and using medication to strengthen bones.

The decision about whether you need treatment depends on your risk of fracture. This will be based on a number of factors such as your age, sex and the results of your DEXA scan.

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

Read more about how osteoporosis is treated.

Preventing osteoporosis

If you're at risk of developing osteoporosis, you should take steps to help keep your bones healthy. This may include:

Read more about preventing osteoporosis.

Living with osteoporosis

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

To help you recover from a fracture, you can try using:

Speak to your GP or nurse if you're worried about living with a long-term condition. They may be able to answer any questions you have.

You may also find it helpful to talk to a trained counsellor or psychologist, or other people with the condition.

The National Osteoporosis Society can put you in touch with local support groups, and they also have an online discussion forum.

Read more about living with osteoporosis.

At-risk groups

Osteoporosis often affects women, particularly after the menopause (when monthly periods stop). However, it can also sometimes affect men, younger women and children.

Other groups who are at risk of developing osteoporosis include:

  • people who have been taking steroid medication for more than three months
  • women who have had their ovaries removed
  • people with a family history of osteoporosis
  • people with an eating disorder, such as anorexia or bulimia
  • people who don't exercise regularly
  • people who smoke or drink heavily
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Causes

Osteoporosis causes bones to become less dense and more fragile. Some people are more at risk than others.

Bones are at their thickest and strongest in your early adult life and their density increases until your late 20s. You gradually start losing bone density from around the age of 35.

This happens to everyone, but some people develop osteoporosis and lose bone density much faster than normal. This means they're at greater risk of a fracture.

Risk groups

Osteoporosis can affect men and women. It's more common in older people, but it can also affect younger people.

Women

Women are more at risk of developing osteoporosis than men because the hormone changes that occur in the menopause directly affect bone density.

The female hormone oestrogen is essential for healthy bones. After the menopause (when monthly periods stop), oestrogen levels fall. This can lead to a rapid decrease in bone density.

Women are at even greater risk of developing osteoporosis if they have:

  • an early menopause (before the age of 45)
  • hysterectomy (removal of the womb) before the age of 45, particularly when the ovaries are also removed
  • absent periods for more than six months as a result of overexercising or too much dieting

Men

In most cases, the cause of osteoporosis in men is unknown. However, there's a link to the male hormone testosterone, which helps keep the bones healthy.

Men continue producing testosterone into old age, but the risk of osteoporosis is increased in men with low levels of testosterone.

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

  • the use of certain medications, such as oral corticosteroids
  • alcohol misuse
  • hypogonadism (a condition that causes abnormally low testosterone levels)

Risk factors

Many hormones in the body can affect the process of bone turnover. If you have a condition of the hormone-producing glands, you may have a higher risk of developing osteoporosis.

Hormone-related conditions that can trigger osteoporosis include:

Other risk factors

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

You can read more about who's at risk of osteoporosis and broken bones on the National Osteoporosis Society website.

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Treatment

Treating osteoporosis involves treating and preventing fractures and using medication to strengthen bones.

An important objective for health service across Wales is to try to prevent falls and fractures, particularly in people with osteoporosis and those with risk factors for osteoporosis.

The key messages for older people and their family and carers are:

  • falls are a risk as you get older, but aren't inevitable – there are measures you can take to prevent falls or reduce the harm that might be caused by falling
  • staying active and healthy – for example, through exercise and diet – is likely to keep you independent and reduce your risk of falling
  • if you're unsteady on your feet or fall, speak to your GP so that possible causes of falls, such as poor eyesight, certain medications, and poor muscle strength and balance, can be identified and treated

Read more about the types of exercise you can do to prevent osteoporosis and lower your risk of falls.

Although a diagnosis of osteoporosis is based on the results of your bone mineral density scan (DEXA or DXA scan), the decision about what treatment you need – if any – is also based on a number of other factors. These include your:

  • age
  • sex
  • risk of fracture
  • previous injury history

If you've been diagnosed with osteoporosis because you've had a fracture, you should still receive treatment to try to reduce your risk of further fractures.

You may not need or want to take medication to treat osteoporosis. However, you should ensure you're maintaining sufficient levels of calcium and vitamin D. To achieve this, your healthcare team will ask you about your diet and may recommend making changes or taking supplements.

NICE recommendations

The National Institute for Health and Care Excellence (NICE) has made some recommendations about who should be treated with medication for osteoporosis.

A number of factors are taken into consideration before deciding which medication to use. These include your:

  • age
  • bone mineral density (measured by your T score)
  • risk factors for fracture

NICE has summarised its guidance for two groups of people:

  • postmenopausal women with osteoporosis who haven't had a fracture (primary prevention)
  • postmenopausal women with osteoporosis who have had a fracture (secondary prevention)

You can read the NICE guidance by clicking on the links below.

A number of different medications are used to treat osteoporosis. Your doctor will discuss the treatments available and make sure the medicines are right for you.

Bisphosphonates

Bisphosphonates slow down the rate at which bone is broken down in your body. This maintains bone density and reduces the risk of fracture.

There are a number of different bisphosphonates, including

  • alendronate
  • etidronate
  • ibandronate
  • risedronate
  • zolendronic acid

They're given as a tablet or injection.

You should always take bisphosphonates on an empty stomach with a full glass of water. Stand or sit upright for 30 minutes after taking them. You'll also need to wait between 30 minutes and two hours before eating food or drinking any other fluids.

Bisphosphonates usually take 6 to 12 months to work and you may need to take them for five years or longer. You may also be prescribed calcium and vitamin D supplements to take at a different time to the bisphosphonate.

The main side effects associated with bisphosphonates include:

Not everyone will experience these side effects.

Osteonecrosis of the jaw is a rare side effect that's linked with the use of bisphosphonates, although most frequently with high-dose intravenous bisphosphonate treatment for cancer and not for osteoporosis.

In osteonecrosis, the cells in the jaw bone die, which can lead to problems with healing. If you have a history of dental problems, you may need a check-up before you start treatment with bisphosphonates. Speak to your doctor if you have any concerns.

Strontium ranelate

Strontium ranelate appears to have an effect on both the cells that break down bone and the cells that create new bone (osteoblasts).

It can be used as an alternative treatment if bisphosphonates are unsuitable. Strontium ranelate is taken as a powder dissolved in water.

The main side effects of strontium ranelate are nausea and diarrhoea. A few people have reported a rare severe allergic reaction to the treatment. If you develop a skin rash while taking strontium ralenate, stop taking it and speak to your doctor immediately.

Selective oestrogen receptor modulators (SERMs)

SERMs are medications that have a similar effect on bone as the hormone oestrogen. They help to maintain bone density and reduce the risk of fracture, particularly of the spine.

Raloxifene is the only type of SERM that's available for treating osteoporosis. It's taken as a tablet every day.

Side effects associated with raloxifene include:

Parathyroid hormone (teriparatide)

Parathyroid hormone is produced naturally in the body. It regulates the amount of calcium in bone.

Parathyroid hormone treatments (human recombinant parathyroid hormone or teriparatide) are used to stimulate cells that create new bone (osteoblasts). They're given by injection.

While other medication can only slow down the rate of bone thinning, parathyroid hormone can increase bone density. However, it's only used in a small number of people whose bone density is very low and when other treatments aren't working.

Nausea and vomiting are common side effects of the treatment. Parathyroid hormone treatments should only be prescribed by a specialist.

Calcium and vitamin D supplements

Calcium is the major mineral found in bone, and having enough calcium as part of a healthy, balanced diet is important for maintaining healthy bones.

For most healthy adults, the recommended amount of calcium is 700 milligrams (mg) of calcium a day, which most people should be able to get from a varied diet that contains good sources of calcium.

However, if you have osteoporosis you may need more calcium, which will usually be in the form of supplements. Ask your GP for advice about taking calcium supplements.

Vitamin D is needed to help the body absorb calcium.

It's difficult to get enough vitamin D from your diet alone because few foods contain vitamin D.  Between late March/April to the end of September, in Wales, the majority of people aged five years and above will probably obtain sufficient vitamin D from sunlight when they are outdoors.

However, some groups of people will not get enough vitamin D from sunlight because they have very little or no sunshine exposure. So it is recommended that people should take a daily supplement containing 10mcg of vitamin D throughout the year if they:

  • are not often outdoors, such as those who are frail or housebound
  • are in an institution such as a care home
  • usually wear clothes that cover up most of their skin when outdoors

People from minority ethnic groups with dark skin, such as those of African, African-Caribbean or South Asian origin, might not get enough vitamin D from sunlight – so they should consider taking a daily supplement containing 10mcg of vitamin D throughout the year.

If you're found to lack vitamin D, your GP may prescribe supplements at a higher dose than the above recommendation to correct the deficiency.

Hormone replacement therapy (HRT)

HRT is sometimes recommended for women who are experiencing the menopause, as it can help control symptoms.

HRT has also been shown to maintain bone density and reduce the risk of fracture during treatment.

However, HRT isn't specifically recommended for treating osteoporosis and it isn't often used for this purpose.

This is because HRT slightly increases the risk of developing certain conditions, such as breast cancer, endometrial cancerovarian cancer, stroke and venous thromboembolism more than it lowers the risk of osteoporosis.

Discuss the benefits and risks of HRT with your GP.

Read more about the risks of HRT.

Testosterone treatment

In men, testosterone treatment can be useful when osteoporosis is caused by insufficient production of male sex hormones (hypogonadism).

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Prevention

Your genes are responsible for determining your height and the strength of your skeleton, but lifestyle factors such as diet and exercise influence how healthy your bones are.

Regular exercise

Regular exercise is essential. Adults aged 19 to 64 should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week.

Weight-bearing exercise and resistance exercise are particularly important for improving bone density and helping to prevent osteoporosis.

As well as aerobic exercise, adults aged 19 to 64 should also do muscle-strengthening activities on two or more days a week by working all the major muscle groups, including the legs, hips, back, abdomen, chest, shoulders and arms.

If you've been diagnosed with osteoporosis, it's a good idea to talk to your GP or health specialist before starting a new exercise programme to make sure it's right for you.

Weight-bearing exercises

Weight-bearing exercises are exercises where your feet and legs support your weight. High-impact weight-bearing exercises, such as running, skipping, dancing, aerobics, and even jumping up and down on the spot, are all useful ways to strengthen your muscles, ligaments and joints.

When exercising, wear footwear that provides your ankles and feet with adequate support, such as trainers or walking boots.

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

Resistance exercises

Resistance exercises use muscle strength, where the action of the tendons pulling on the bones boosts bone strength. Examples include press-ups, weightlifting or using weight equipment at a gym.

If you've recently joined a gym or haven't been for a while, your gym will probably offer you an induction. This involves being shown how to use the equipment and having exercise techniques recommended to you.

Always ask an instructor for help if you're not sure how to use a piece of gym equipment or how to do a particular exercise.

Healthy eating

Eating a healthy balanced diet is recommended for everyone. It can help prevent many serious health conditions, including heart disease, diabetes and many forms of cancer, as well as osteoporosis.

Calcium is important for maintaining strong bones. The recommended intake of calcium is at least 700mg a day. This is about the equivalent of one pint of milk.

Calcium can also be found in a number of different foods, including leafy green vegetables, dried fruit, tofu and yoghurt.

Vitamin D is also important for healthy bones and teeth because it helps your body absorb calcium. Vitamin D can be found in eggs, milk and oily fish.

It's difficult to get enough vitamin D from your diet alone because few foods contain vitamin D.  Between late March/April to the end of September, in Wales, the majority of people aged five years and above will probably obtain sufficient vitamin D from sunlight when they are outdoors.

Certain groups of people may be at risk of not getting enough vitamin D. These include:

  • people who have dark skin
  • people who are housebound or particularly frail
  • people with a poor diet
  • people who keep covered up in sunlight because they wear total sun block or adhere to a certain dress code
  • women who are pregnant or breastfeeding

If you're at risk of not getting enough vitamin D through your diet or lifestyle, you can take a vitamin D supplement. For adults, 10 micrograms a day of vitamin D is recommended.

The recommended amount for children is 7 micrograms for babies under six months, and 8.5 micrograms for children aged six months to three years. Talk to your GP for more information.

Other factors

Other lifestyle factors that can help prevent osteoporosis include:

  • quitting smoking – smoking is associated with an increased risk of osteoporosis
  • limiting your alcohol intake – the recommended weekly limit is 14 units of alcohol for men and women; it's also important to avoid binge drinking

Read more about healthy bones on the National Osteoporosis Society website.

Get some sun!

Between May and September, sunlight triggers the production of vitamin D, which helps your body absorb calcium.

This process helps strengthen teeth and bones, which in turn helps prevent conditions such as osteoporosis.

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Living with

Having osteoporosis doesn't mean you'll definitely have a fracture. There are measures you can take to reduce your risk of a fall or break.

Preventing falls

Making some simple changes at home can help reduce the risk of fracturing or breaking a bone in a fall.

Check your home for hazards you may trip over, such as trailing wires. Make sure rugs and carpets are secure, and keep rubber mats by the sink and in the bath to prevent slipping.

Have regular sight tests and hearing tests. Some older people may need to wear special protectors over their hips to cushion a fall. Your GP can offer help and advice about changes to your lifestyle.

Read more about preventing falls.

The National Institute for Health and Care Excellence (NICE) has also produced guidance called Falls: the assessment and prevention of falls in older people.

Healthy eating and exercise

Regular exercise and a healthy diet are important for everyone, not just people with osteoporosis. They can help prevent many serious conditions, including heart disease and many forms of cancer.

Try to have a balanced diet that contains all the food groups to give your body the nutrition it needs. Exercising regularly can increase the strength of the bones, relieve stress and reduce fatigue.

The National Osteoporosis Society has produced leaflets about Exercise and osteoporosis (PDF, 1.6Mb) and Healthy living for strong bones (PDF, 2.37Mb) that give further information and advice about diet and exercise.

Getting support

Your GP or nurse may be able to answer any questions you have about living with osteoporosis and can reassure you if you're worried.

You may also find it helpful to talk to a trained counsellor or psychologist, or to someone at a specialist helpline. Your GP surgery will have information about these.

Some people find it helpful to talk to others with osteoporosis, either at a local support group or in an internet chat room.

Osteoporosis support

The National Osteoporosis Society provide a helpline service run by nurses with specialist knowledge of osteoporosis and bone health.

Call 0808 800 0035. You can also email them at nurses@nos.org.uk.

They can provide you with details of local support groups and also have an online discussion forum.

Recovering from a broken bone

Broken bones usually take six to eight weeks to recover. Having osteoporosis doesn't affect how long this takes. Recovery depends on the type of fracture you have. Some fractures heal easily, but others may require more intervention.

If you have a complicated wrist fracture or hip fracture, you may need an operation to make sure the bone is set properly. Hip replacements are often needed after hip fractures, and some people may lose mobility as a result of weakened bones.

Osteoporosis can cause a loss of height as a result of fractures in the spinal column. This means the spine is no longer able to support your body's weight and causes a hunched posture.

This can be painful when it occurs, but it may also lead to long-term (chronic) pain. Your GP or nurse may be able to help with this.

During the healing process, you may need the help of a physiotherapist or occupational therapist so you can make as full a recovery as possible.

Read more about physiotherapy and occupational therapy.

Coping with pain

Everyone experiences pain differently, so what works for you may differ from what works for someone else.

There are a number of different ways of managing pain, including:

  • medication
  • heat treatment, such as warm baths or hot packs
  • cold treatment, such as cold packs
  • transcutaneous electrical nerve stimulation (TENS) – this is thought to reduce pain by stimulating the nerves
  • simple relaxation techniques, massage or hypnosis

You can use more than one of these techniques at the same time to manage your pain – for example, you could combine medication, a heat pack and relaxation techniques.

Working and money

You should be able to continue to work if you have osteoporosis. It's very important that you remain physically active and have a fulfilled lifestyle.

This will help keep your bones healthy and stop you focusing too much on your potential health problems. However, if your work involves the risk of falling or breaking a bone, seek advice from your employer, GP and the National Osteoporosis Society about how to limit your risk of having an accident or injury that could lead to a bone break.

If you can't continue working, you may be eligible for disability benefits, such as the Personal Independence Payment (PIP). People over 65 who are severely disabled may qualify for a disability benefit called Attendance Allowance.

Help for carers

You may also be entitled to certain benefits if you care for someone with osteoporosis.

More information

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Selected links

NHS Direct Wales links

Dexa (DXA) scan

Vitamins and minerals

External links

Bone Markers (Lab Tests Online UK)

Osteoporosis (Patient UK)

Menopause Matters (Menopause Matters)

Osteoporosis (Age UK)

You & Your Hormones: Osteoporosis

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The information on this page has been adapted by NHS Wales from original content supplied by NHS Choices.
Last Updated: 21/07/2016 13:10:24

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