Osteoporosis makes your bones weak and more likely to break. Anyone can develop osteoporosis, but it is common in older women. As many as half of all women and a quarter of men older than 50 will break a bone due to osteoporosis.

Risk factors include:

• Getting older

• Being small and thin

• Having a family history of osteoporosis

• Taking certain medicines

• Being a white or Asian woman

• Having osteopenia, which is low bone mass

Osteoporosis is a silent disease. You might not know you have it until you break a bone. A bone mineral density test is the best way to check your bone health. To keep bones strong, eat a diet rich in calcium and vitamin D, exercise and do not smoke. If needed, medicines can also help.

Osteoporosis: The Diagnosis

Osteoporosis is a condition of low bone density that can progress silently over a long period of time. If diagnosed early, the fractures associated with the disease can often be prevented. Unfortunately, osteoporosis frequently remains undiagnosed until a fracture occurs.

An examination to diagnose osteoporosis can involve several steps that predict your chances of future fracture, diagnose osteoporosis, or both. It might include:

• an initial physical exam

• various x rays that detect skeletal problems

• laboratory tests that reveal important information about the metabolic process of bone breakdown and formation

• a bone density test to detect low bone density.

Before performing any tests, your doctor will record information about your medical history and lifestyle and will ask questions related to:

• risk factors, including information about any fractures you have had

• your family history of disease, including osteoporosis

• medication history

• general intake of calcium and vitamin D

• exercise pattern

• for women, menstrual history.

In addition, the doctor will note medical problems and medications you may be taking that can contribute to bone loss (including glucocorticoids, such as cortisone). He or she will also check your height for changes and your posture to note any curvature of the spine from vertebral fractures, which is known as kyphosis.

Risk Factors for Osteoporotic Fracture Include:

• personal history of fracture as an adult

• history of fracture in a first-degree relative

• Caucasian or Asian race, although African Americans and Hispanic Americans are at significant risk as well

• advanced age

• being female

• dementia

• poor health, frailty, or both

• current cigarette smoking

• low body weight

• anorexia nervosa

• estrogen deficiency (past menopause, menopause before age 45, having both ovaries removed, or the absence of menstrual periods for a year or more prior to menopause)*

• low testosterone levels in men

• use of certain medications such as corticosteroids and anticonvulsants

• lifelong low calcium intake

• excessive alcohol intake

• impaired eyesight despite adequate correction

• recurrent falls

• inadequate physical activity.

*Women lose bone rapidly in the first 4-8 years following menopause, making them more susceptible to osteoporosis.

X Ray Tests

If you have back pain, your doctor may order an x ray of your spine to determine whether you have had a fracture. An x ray also may be appropriate if you have experienced a loss of height or a change in posture. However, since an x ray can detect bone loss only after 30 percent of the skeleton has been depleted, the presence of osteoporosis may be missed.

Bone Mineral Density Tests

A bone mineral density (BMD) test is the best way to determine your bone health. BMD tests can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized bone mineral density test is called a dual-energy x-ray absorptiometry or DXA test. It is painless: a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.

During a BMD test, an extremely low energy source is passed over part or all of the body. The information is evaluated by a computer program that allows the doctor to see how much bone mass you have. Since bone mass serves as an approximate measure of bone strength, this information also helps the doctor accurately detect low bone mass, make a definitive diagnosis of osteoporosis, and determine your risk of future fractures.

BMD tests provide doctors with a measurement called a T-score, a number value that results from comparing your bone density to optimal bone density. When a T-score appears as a negative number such as -1, -2 or -2.5, it indicates low bone mass. The more negative the number, the greater the risk of fracture.

Although no bone density test is 100 percent accurate, this type of test is the single most important predictor of whether a person will fracture in the future.

Bone Scans

For some people, a bone scan may be ordered. A bone scan is different from the BMD test just described, although the term “bone scan” often is used incorrectly to describe a bone density test. A bone scan can tell the doctor whether there are changes that may indicate cancer, bone lesions, inflammation, or new fractures. In a bone scan, the person being tested is injected with a dye that allows a scanner to identify differences in the conditions of various areas of bone tissue.

Lab Tests

A number of laboratory tests may be performed on blood and urine samples. The results of these tests can help your doctor identify conditions that may be contributing to your bone loss.

Treatment

In addition to diagnosing osteoporosis, results from BMD tests assist the doctor in deciding whether to begin a prevention or treatment program. Once you and your doctor have definitive information based on your history, physical examination, and diagnostic tests, a specific treatment program can be developed for you.

Recommendations for optimizing bone health include a comprehensive program that consists of a well-balanced diet rich in calcium and vitamin D, physical activity, and a healthy lifestyle (including not smoking, avoiding excessive alcohol use, and recognizing that some prescription medications and chronic diseases can cause bone loss). If you already have experienced a fracture, your doctor may refer you to a specialist in physical therapy or rehabilitation medicine to help you with daily activities, safe movement, and exercises to improve your strength and balance.

Medications to Prevent and Treat Osteoporosis

Although there is no cure for osteoporosis, several medications approved by the U.S. Food and Drug Administration (FDA) can help stop or slow bone loss, or help form new bone, and reduce the risk of fractures. Currently, alendronate, raloxifene, risedronate, and ibandronate are approved for preventing and treating postmenopausal osteoporosis. Teriparatide is approved for treating the disease in postmenopausal women and men at high risk for fracture. Estrogen/hormone therapy (ET/HT) is approved for preventing postmenopausal osteoporosis, and calcitonin is approved for treatment. In addition, alendronate is approved to treat bone loss that results from glucocorticoid medications like prednisone or cortisone. It is also approved for treating osteoporosis in men. Risedronate is approved to prevent and treat glucocorticoid-induced osteoporosis and to treat ostoeporosis in men.

Bisphosphonates

Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) are medications from the class of drugs called bisphosphonates.

Alendronate and risedronate have been shown to increase bone mass and reduce the incidence of spine, hip, and other fractures. Ibandronate has been shown to reduce the incidence of spine fractures.

Alendronate is available in daily and weekly doses. Risedronate is available in daily and weekly doses. Ibandronate is available in a monthly dose and as an intravenous injection administered once every three months.

Oral bisphosphonates should be taken on an empty stomach and with a full glass of water first thing in the morning. It is important to remain in an upright position and refrain from eating or drinking for at least 30 minutes after taking a bisphosphonate.

Side effects for bisphosphonates include gastrointestinal problems such as difficulty swallowing, inflammation of the esophagus, and gastric ulcer. There have been rare reports of osteonecrosis of the jaw and of visual disturbances in people taking bisphosphonates.

Some bisphosphonates are fortified with calcium and vitamin D. These nutrients are important for everyone, and people should include adequate amounts of them in their diets.

Raloxifene

Raloxifene (Evista) is approved for the prevention and treatment of postmenopausal osteoporosis. It is from a class of drugs called Selective Estrogen Receptor Modulators (SERMs) that appear to prevent bone loss in the spine, hip, and total body. Raloxifene has beneficial effects on bone mass and bone turnover and can reduce the risk of vertebral fractures. While side effects are not common with raloxifene, those reported include hot flashes and blood clots in the veins, the latter of which is also associated with estrogen therapy. Additional research studies on raloxifene will continue for several more years.

Calcitonin

Calcitonin (Miacalcin, Fortical) is a naturally occurring hormone involved in calcium regulation and bone metabolism. In women who are at least 5 years past menopause, calcitonin slows bone loss, increases spinal bone density, and according to anecdotal reports, relieves the pain associated with bone fractures. Calcitonin reduces the risk of spinal fractures and may reduce hip fracture risk as well. Studies on fracture reduction are ongoing. Calcitonin is currently available as an injection or nasal spray. While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, frequent urination, nausea, and skin rash. The only side effect reported with nasal calcitonin is a runny nose.

Teriparatide

Teriparatide (Forteo) is an injectable form of human parathyroid hormone. It is approved for postmenopausal women and men with osteoporosis who are at high risk for having a fracture. Teriparatide stimulates new bone formation in both the spine and the hip. It also reduces the risk of vertebral and nonvertebral fractures in postmenopausal women. In men, teriparatide reduces the risk of vertebral fractures. However, it is not known whether teriparatide reduces the risk of nonvertebral fractures. Side effects include nausea, dizziness, and leg cramps. Teriparatide is approved for use for up to 24 months.

Estrogen/Hormone Therapy

Estrogen/hormone therapy (ET/HT) has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spine fractures in postmenopausal women. ET/HT is approved for preventing postmenopausal osteoporosis and is most commonly administered in the form of a pill or skin patch. When estrogen – also known as estrogen therapy or ET – is taken alone, it can increase a woman’s risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin – also known as hormone therapy or HT – in combination with estrogen for those women who have not had a hysterectomy. Side effects of ET/HT include vaginal bleeding, breast tenderness, mood disturbances, blood clots in the veins, and gallbladder disease.

The Women’s Health Initiative (WHI), a large Government-funded research study, recently demonstrated that the drug Prempro, which is used in hormone therapy, is associated with a modest increase in the risk of breast cancer, stroke, and heart attack. The WHI also demonstrated that estrogen therapy is associated with an increase in the risk of stroke. It is unclear whether estrogen therapy is associated with an increased risk of breast cancer or cardiovascular events. A large study from the National Cancer Institute indicated that long-term use of estrogen therapy may be associated with an increased risk of ovarian cancer. It is unclear whether hormone therapy carries a similar risk.

Any estrogen therapy should be prescribed for the shortest period of time possible. When used solely for the prevention of postmenopausal osteoporosis, any ET/HT regimen should only be considered for women at significant risk of osteoporosis, and nonestrogen medications should be carefully considered first.