Information every woman should know

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OsteoporosisWhat Is It? Osteoporosis is a disorder of the bones characterized by decreased bone mass (generalized thinning of the bones), which also decreases bone strength. Because weakened bones are more fragile and more likely to break, people with osteoporosis are at increased risk of fractures, especially fragility fractures (broken bones that happen with little or no trauma). It is not a form of arthritis, although it may cause fractures that, in turn, lead to arthritis.

In the United States, osteoporosis causes more than 1.3 million fractures annually and is much more common in women than in men. The most common first fracture is a wrist fracture, which typically occurs at age 50 to 70 in women. Hip fractures and fractures of the spine (compression fractures) may also occur and are most common in patients who are in their 70s. Particularly when it leads to hip fracture, osteoporosis can cause a great deal of suffering, including an increased risk of institutionalization or death. Symptoms Most people with osteoporosis have no symptoms and are totally unaware that they have the problem. One early sign can be a loss of height caused by curvature of the spine (Dowager's hump), which is caused by weakened vertebrae (spine bones). The weakened vertebrae undergo compression fractures -- tiny breaks that cause the spine bones to collapse vertically. When this happens, the height of the vertebrae is decreased, and the shape of each single vertebra goes from a normal rectangle to a more triangular form. Although the loss of height caused by compression fractures can sometimes be associated with back pain or aching, more typically it is asymptomatic (causes no symptoms).

Osteoporosis does not usually cause pain unless there has been a fracture. When there is no sign of a fracture, pain in the bones or joints is probably caused by another problem, such as arthritis (a disorder that affects the cartilage lining the joints), tendonitis (inflammation of the tendons), or a disorder of the muscles or connective tissues. In a similar way, although back pain can sometimes be caused by osteoporotic fractures, other common causes of back pain includes arthritis, a pulled muscle or problems in the disks between vertebrae. Diagnosis When taking your history, your doctor will look for factors that increase your risk of osteoporosis. These risk factors include:

Being female Being age 40 or older Being a postmenopausal woman who does not take estrogen replacement medication Having a diet low in calcium or an intestinal problem that impairs absorption Having an overactive thyroid Leading a sedentary lifestyle, with little or no routine exercise Being thin Taking certain medications, such as prednisone Having a certain ethnic background (white people and those of Asian descent are more at risk of osteoporosis than are African-Americans) Smoking Using alcohol to excess Having a family history of osteoporosis Having a history of at least one fragility fracture

On physical examination, your doctor may find that you are shorter than you thought you were. On X-rays, your bones may be less dense than expected, a sign of osteopenia (diminished bone on an X-ray). Although most cases of osteopenia are caused by osteoporosis, there are other causes such as osteomalacia (too little mineral in bone) as a result of inadequate intake or absorption of vitamin D.

The diagnosis of osteoporosis should be strongly suspected in any person who has a fragility fracture. It can also be established by a bone density test. There are several techniques available to measure bone density. The most complete and accurate method is DEXA (dual- energy X-ray absorptiometry), which is the best for both diagnosing osteoporosis and assessing response to treatment. DEXA is a quick (10 to 15 minutes) and painless test that uses minute amounts of radiation (less than dental X-rays) and is generally done on the spine and hip. A newer method, ultrasound bone density of the heel, is even quicker and less expensive, but it is generally accepted as only a screening tool. Usually, patients who are found to have osteoporosis by heel ultrasound eventually go on to have DEXA of the spine and hip.

Bone density tests can diagnose osteoporosis when the condition is asymptomatic and mild and can help lead to treatment that will prevent the condition from getting worse. In people with loss of height or suspicious fractures, bone density tests not only confirm the diagnosis of osteoporosis, they also serve as a baseline for treatment and can be used to follow the response to therapy. Expected Duration Although osteoporosis is a chronic (long-term) condition, proper treatment can result in significant improvements in bone mass and can decrease the likelihood that symptoms will appear. Even though bone mass does not generally return to normal, the risk of fracture is usually decreased by about 50 percent after several years of treatment. Prevention You can help prevent osteoporosis by having adequate calcium and vitamin D intake, by following a routine program of weight-bearing exercise, by not smoking and by avoiding excess alcohol consumption. Many physicians routinely recommend 500 to 1,000 milligrams daily of extra calcium intake (for example, in the form of calcium carbonate, as in Tums, and in many other inexpensive forms) or even more if your diet is particularly low in calcium or if you are nursing. Similarly, it may be appropriate to take a daily multivitamin that contains Vitamin D.

If you are a woman who has entered menopause, you should speak with your doctor about beginning a Food and Drug Administration (FDA)-approved treatment for osteoporosis, such as estrogen replacement therapy, raloxifene or alendronate. In postmenopausal women who are undecided about medication, a bone density test for osteoporosis may make the decision easier if it already shows signs of a problem. Because the loss of height caused by osteoporosis-related compression fractures is often asymptomatic, it is also a good idea to measure your height annually, especially if you are a woman older than age 40. Treatment Doctors treat osteoporosis by prescribing adequate intake of calcium and vitamin D and by beginning the patient on a program of routine weight-bearing exercise. In addition, several effective medications are available. For women, estrogen replacement therapy, alendronate (Fosamax), raloxifene (Evista) and nasal calcitonin (Miacalcin) are all effective FDA-approved treatments for osteoporosis. Although there are no FDA-approved treatments for men, alendronate and calcitonin are effective. Men who have abnormally low levels of testosterone (diagnosable by a simple blood test) can also be treated with testosterone to help their osteoporosis. For patients who experience problems or side effects with the standard treatments, there are non-FDA-approved treatments (for example, etidronate, pamidronate, risedronate) that may be better tolerated and effective.

Treatment progress is monitored by bone density measurements performed every one to two years. To allow for the most accurate comparison, all bone density measurements should be performed on the same machine in the same facility.

When an osteoporotic hip fracture does occur, minor or major surgery is often necessary; a wrist fracture may do well with casting alone, or surgery may be warranted. Other treatments for fracture include pain medication and rest for a short time. Calcitonin injections may reduce spine pain from a new compression fracture. When To Call A Professional Call your doctor about having a bone density test if you have several risk factors for osteoporosis, or if you have a fracture with minimal trauma (for example, a wrist fracture after minor trauma). If your medical insurance will not cover DEXA (typical cost $150 to $350) for screening for osteoporosis, it would be reasonable to have a heel ultrasound bone density (typical cost $25 to $35). If the heel ultrasound is abnormal, DEXA should be performed and may then be covered by your medical insurance. Prognosis Because the prognosis for osteoporosis is excellent with the drugs now available, it is never too late to start treatment. Bone density, even in severe osteoporosis, can generally be stabilized or improved, and the risk of fracture can be reduced by 50 percent after several years of treatment. Patients with mild or asymptomatic osteoporosis have an excellent prognosis, whereas those who have already experienced osteoporotic fractures can generally expect their bones to heal normally and pain to generally resolve within a week or two. The prognosis is best when the diagnosis and a treatment plan are established early or when a reversible cause (such as prednisone use) is identified and removed. If proper treatment is begun and tolerated, most patients can effectively prevent osteoporosis from developing or improve it once established. Additional Info NIH Osteoporosis and Related Bone Diseases - National Resource Center 1150 17th St., NW, Suite 500 Washington, DC 20036-4603 Telephone: (800) 624-BONE www.osteo.org

National Osteoporosis Foundation Department MQ P.O. Box 96616 Washington, DC 20077-7456 www.nof.org