The first symptom of osteoporosis? Often, it’s a broken bone.

  • Post-menopausal women and elderly men, all of whom are hormonally deficient, are at increasingly high risk for bone density loss.  Getty Images

For the Gazette
Published: 5/13/2019 4:10:00 PM

May is National Osteoporosis Month, and organizations like the National Osteoporosis Foundation want to raise awareness of the condition. Osteoporosis affects 1 in 4 women — 25 percent — over age 65 (and 1 in 20 men), and tends to come as a shocking surprise to many people when diagnosed; unfortunately, the first symptom is often a broken bone.

Osteoporosis and osteopenia

Osteoporosis and osteopenia are conditions of low bone mass (bone density). These conditions weaken the bones and make a fracture more likely with even minor trauma. They are more common in women than men, especially women over age 50.

Osteoporosis is defined as having a bone mineral density which falls below the third percentile for healthy people in their mid-thirties, of the same sex and ethnicity as the patient. This is expressed as a “T-score,” which in good health should range from -1 to +1 (the middle two-thirds of a bell curve). Osteoporosis may also be diagnosed on simple clinical grounds such as the unexpected fracture of a bone which has not suffered major trauma.

When bone mass is in the 3rd to 16th percentiles, not as low as in osteoporosis, we diagnose osteopenia. People with osteopenia have a higher chance of fracture, but not as high as with osteoporosis. Untreated, osteopenia may progress to osteoporosis.

Bone metabolism & bone density

Bone metabolism is regulated by the sex hormones estradiol and testosterone, so bone density normally increases with age until the mid-thirties, then falls. Women have accelerated loss after menopause. Post-menopausal women and elderly men, all of whom are hormonally deficient, are at increasingly high risk for bone density loss. Women are five times more likely than men develop osteoporosis, a fact which often leads to overlooking the disease in men. One estimate is that 50 percent of American women and 10 percent of men over age 60 will suffer an osteoporotic fracture.

Osteoporosis has no early symptoms, so most people do not know that they have it until they break a bone. Since it is a systemic condition, a first fracture confers a very high risk of more bones breaking if the disease is not treated.

Improvements in diagnosis

The effects of osteoporosis have been publicized in recent decades, so it is worth noting some of the recent improvements in osteoporosis care. These include improved diagnosis, safer therapies and effective strategies to prevent secondary fractures. 

Diagnosis: The FRAX® calculator tool, introduced in 2008 by researchers at the University of Sheffield, England, is a computer-driven algorithm which allows a clinician to calculate a patient’s 10-year risk of suffering a major osteoporotic fracture (forearm, hip or shoulder). This requires only minimal historical data, height and weight for a rough calculation; a more refined estimate is made by including the patient’s bone mineral density results.

FRAX® is of incalculable value to clinicians. Prior to 2008, we counseled patients that their risk of a fracture was “increased” or “decreased” relative to the general population, without having actual data on the patient sitting in front of us. Using FRAX®, one can calculate a specific risk and can give the strongest therapies to the patients at highest risk. An overall risk of 20 percent, or a hip fracture risk of 5 percent, is generally considered reason to treat. FRAX® risk tool also reveals those patients for whom the risk of a fracture is so low as to require no therapy. In patients with no prior fractures, a FRAX® calculation is a reasonable prerequisite for treatment.

Improvements in treatment

Before 1995, the only effective therapies for osteoporosis were estrogens, androgens (testosterone), vitamin D in patients who were deficient, and fluoride. Each of these had serious side effects or concerns which limited their use. Alendronate (Fosamax), introduced in 1995, was a great improvement, as were the inevitable copycat drugs. Generic alendronate is widely prescribed but is fussy to take and has interactions with most other drugs. Zolendronate (Reclast), a sister drug, is a good alternative because it is effective for three years if given by IV infusion. Denosumab (Prolia) is safer than alendronate, more effective than either alendronate or zolendronate and requires only an injection every six months. All of these drugs reduce or halt bone loss, thus reducing fractures.

The most effective drugs for osteoporosis, the so-called “PTH analogues” teriparatide and abaloparatide, actually cause growth of new structural bone and improve the bone density. They are thus recommended for patients who have already suffered a fracture or who are at highest risk. They do not cause linear growth, only strengthening of bone structure — taking these will not make you taller nor give you bigger feet. 

A final and very important improvement in osteoporosis care is the recognition that vigorous therapy following an osteoporotic fracture can reduce the chance of further fractures. Prior to the era of therapy, a menopausal woman suffering a single fracture had more than a 60 percent chance of having another. This can be reduced by half by recognizing the index fracture as a warning of more trouble to come and starting therapy as soon as the fracture is healed. These observations have led us to create a protocol for the follow-up and treatment of patients seen at the Cooley Dickinson Hospital with osteoporotic fractures, using simple injections or infusions. Simple treatments are more likely to be carried out.

Patients with concerns about osteoporosis can consult with their primary care providers or seek specialty care with an endocrinologist. In addition to the author, local specialists including Drs. Stuart Chipkin and Matthew Spitzer at Valley Medical Group and John Nicasio at CDMG Endocrinology have particular experience with these disorders.

Robert Howe, MD, FACOG, is the Director of Reproductive Endocrinology at Cooley Dickinson Medical Group Women’s Health. He also specializes in gynecology and fertility services.

 

 

 

 


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