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Encyclopaedia


Osteoporosis

Introduction

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break.

It's a fairly common condition that affects around three million people in the UK. More than 300,000 people receive hospital treatment for fragility fractures (fractures that occur from standing height or less) every year as a result of osteoporosis.

Wrist fractures, hip fractures and fractures of the vertebrae (bones in the spine) are the most common type of breaks that affect people with osteoporosis. However, they can also occur in other bones, such as in the arm, ribs or pelvis.

There are usually no warnings you've developed osteoporosis and it's often only diagnosed when a bone is fractured after even minor falls.

Read more about the symptoms of osteoporosis.

What causes osteoporosis?

During childhood, bones grow and repair very quickly, but this process slows as you get older.

Bones stop growing in length between the ages of 16 and 18, but continue to increase in density until you're in your late 20s.

You gradually start to lose bone density from about 35 years of age. Women lose bone rapidly in the first few years after the menopause (when monthly periods stop and the ovaries stop producing an egg).

Losing bone is a normal part of the ageing process, but for some people it can lead to osteoporosis and an increased risk of fractures.

Other factors that increase your risk of developing osteoporosis include:

Read more about the causes of osteoporosis.

Diagnosing osteoporosis

If your doctor suspects you have osteoporosis, they can make an assessment using an online programme, such as FRAX or Q-Fracture. They may also refer you for a scan to measure your bone mineral density.

This type of scan is known as a DEXA (DXA) scan. It's a short, painless procedure and your bone mineral density can then be used to assess your fracture risk.

Read more about diagnosing osteoporosis.

Treating osteoporosis

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

The decision about what treatment you have – if any – will depend on your risk of fracture. This will be based on a number of factors, such as your age and the results of your DXA scan.

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've been taking steroid medication for more than three months
  • women who've had their ovaries removed
  • people with a family history of osteoporosis
  • people who don't exercise regularly
  • people who smoke or drink heavily
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Symptoms

Osteoporosis develops slowly over several years.

There are often no warning signs or symptoms until a minor fall or a sudden impact causes a bone fracture.

Healthy bones should be able to withstand a fall from standing height, so a bone that breaks in these circumstances is known as a fragility fracture.

The most common injuries in people with osteoporosis are:

Sometimes a cough or sneeze can cause a rib fracture or the partial collapse of one of the bones of the spine.

In older people, a fractured bone can be serious and result in long-term disability. For example, a hip fracture may lead to long-term mobility problems.

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

Is osteoporosis painful?

Osteoporosis isn't usually painful until it causes a fracture.

Although not always painful, spinal fractures are the most common cause of long-term (chronic) pain associated with osteoporosis.

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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. But 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 are 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 45 years of age)
  • 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 glucocorticoids
  • 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:

  • hyperthyroidism (overactive thyroid gland)
  • disorders of the adrenal glands, such as Cushing's syndrome
  • reduced amounts of sex hormones (oestrogen and testosterone)
  • disorders of the pituitary gland
  • hyperparathyroidism (overactivity of the parathyroid glands)

Other risk factors

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

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

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Diagnosis

Osteoporosis is often diagnosed after weakened bones have led to a fracture.

If you're at risk of developing osteoporosis, your GP may refer you for a bone mineral density scan, known as a dual energy X-ray absorptiometry (DEXA, or DXA) scan.

Normal X-rays are a useful way of identifying fractures, but they aren't a reliable method of measuring bone density.

The FRAX tool

The World Health Organization (WHO) has developed a 10-year Fracture Risk Assessment Tool to help predict a person's risk of fracture between the ages of 40 and 90.

The tool is based on bone mineral density and other relevant risk factors, such as age and sex.

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 (DXA) scan

A DEXA scan can be used to help diagnose osteoporosis. It's a quick, safe and painless procedure that usually takes about five minutes, depending on the part of the body being scanned.

The scan measures your bone mineral density and compares it to the bone mineral density of a healthy young adult and someone who's the same age and sex as you.

The difference between the density of your bones and that of a healthy young adult 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

Although a bone density scan can help diagnose osteoporosis, your bone mineral density result isn't the only factor that determines your risk of fracturing a bone.

Your age, sex and any previous injuries will need to be taken into consideration before deciding whether you need treatment for osteoporosis.

Your doctor can help you take positive steps to improve your bone health. If you need treatment, they can also suggest the safest and most effective treatment plan for you.

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Treatment

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

Preventing falls and fractures

An important objective for health services across Wales is to try to prevent falls and fractures. This is of particular concern for people who've been diagnosed 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 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 – will also be 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 that you're maintaining sufficient levels of calcium and vitamin D. To achieve this, your healthcare team will ask you about your current 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've 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 and 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:

  • irritation to the oesophagus (the tube food passes through from the mouth to the stomach)
  • swallowing problems (dysphagia)
  • stomach pain

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)

Selective oestrogen receptor modulators (SERMs) are medications that have a similar effect on bone as the hormone oestrogen. They help 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 hot flushes, leg cramps and a potential increased risk of blood clots.

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 and vitamin D supplements can benefit older men and women and reduce their risk of hip fracture.

Having enough calcium as part of a healthy balanced diet is important for maintaining healthy bones. Aim to eat or drink 700mg of calcium each day. This is roughly equivalent to one pint of milk.

If you're not getting enough calcium in your diet, ask your GP for advice about taking a calcium supplement. You need to have 1.2g of calcium a day and 20 micrograms of vitamin D to have the right effect on your bones and help prevent falls or fractures or treat osteoporosis.

These doses only occur in a small number of branded formulations prescribed by doctors, so any pills you buy over the counter may not have enough calcium or vitamin D.

Hormone replacement therapy (HRT)

Hormone replacement therapy (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 and stroke, 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.

However, most vitamin D is made in the skin in response to sunlight. Short exposure to sunlight without wearing sunscreen (10 minutes twice a day) throughout the summer should provide you with enough vitamin D for the whole year.

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

  • people who 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 daily limit is 3-4 units of alcohol for men and 2-3 units for 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 also produced a leaflet called Living with broken bones (PDF, 1.15Mb).

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 0845 450 0230 or 01767 472 721. 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

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: 27/08/2014 14:00:09

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