Osteoporosis can occur without any symptoms Figure 03. You may not realize that your bones are becoming brittle until you get a fracture. Even regular x-rays cannot detect osteoporosis until you have lost more than 20% of your bone density.
There are, however, some late signs of osteoporosis. A collapsed bone in your back (vertebra), for example, may cause severe back pain, loss of height, or a stooped posture (kyphosis) Figure 03. If you have lost more than 1½ inches of height since the age of 35, you are at increased risk for osteoporosis.
Figure 03. Stooped posture (kyphosis)
Women are at a greater risk for osteoporosis than men Table 01. One out of two women and one out of eight men will break a bone because of osteoporosis after the age of 50. Women have a greater risk of osteoporosis because they have bones that are smaller and less dense than those of men. In addition, women tend to participate in fewer weight-bearing activities, and also tend to lose more bone mass than men. Women who have irregular menstrual cycles or no menstrual periods (amenorrhea) and women who have gone through menopause have a greater risk of osteoporosis. During the years just before and after menopause, women can lose about 20% of their bone mass.
Low estrogen levels contribute to brittle bones. Estrogen helps prevent bone breakdown, but doesn't build bone. Therefore, if you have low estrogen levels, you may experience bone loss that is not replaced, even if your estrogen levels return to normal. Estrogen-related bone loss usually tends to occur earliest in the spine, with the hip and wrist losing bone somewhat later on.
Some female athletes stop having their periods (amenorrhea) because the physical exertion changes their levels of reproductive hormones. These women are at risk for osteoporosis because their lack of estrogen causes them to lose bone mass. They may experience stress fractures that are very difficult to treat. This risk does not decrease if they exercise less or take calcium supplements.
Osteoporosis isn't just a disease of the very old. Some women may lose half their bone mass by age 65 because of prematurely low estrogen levels.
Young women with eating disorders (such as anorexia nervosa) are at risk for dramatic bone loss and stress fractures.
If you are close to or have reached menopause, you are at an increased risk for having osteoporosis. During the time around menopause, some women lose bone as they begin to skip periods and have other menopausal symptoms. Some may have as much as 50% bone loss during the five to seven years before their periods stop and true menopause begins. Women who have reached menopause are at a particular risk for osteoporosis as their estrogen levels further decline.
If you are a woman who has had her uterus removed (hysterectomy), you have a greater risk of osteoporosis.
A total hysterectomy at any age results in rapid bone loss. Even when both ovaries remain following a partial hysterectomy, there is usually a significant decline in estrogen production following removal of the uterus that results in menopause and increased bone loss in about five to eight years.
Osteoporosis from hormone loss also happens to men. Men who have low testosterone levels have a much higher risk for osteoporosis than other men. Osteoporosis related to low testosterone levels has a similar pattern to osteoporosis in women, and can cause significant bone loss in the spine and hip. Low testosterone levels can occur in men at any age; a decrease in sexual function and hair loss are the most common symptoms. All men over the age of 60 experience a decline in testosterone levels. Men who are treated for prostate cancer have a particularly high risk of osteoporosis.
Of the men who have osteoporosis, 20% have a type known as "idiopathic," a type that has no cause. Idiopathic osteoporosis can occur at any age. As a result, men who have major fractures or fractures with very little trauma, or who have curvature of the upper spine (kyphosis) or unexplained height loss should be screened for osteoporosis.
Insufficient vitamin D intake increases your risk of osteoporosis and decreases response to any osteoporosis treatment plan. Adequate levels of vitamin D are required in order to absorb calcium and to build bone. It is estimated that more than 70% of the population in the northern half of the U.S. are vitamin D-deficient. This significant bone loss is directly related to inadequate levels of vitamin D and sun exposure. This is true for all age groups, but is even more severe in the elderly. In addition, after age 50, there is a progressive decline in the absorption, metabolism, and effectiveness of vitamin D in both men and women. After about age 50 it is essentially impossible to get enough vitamin D from sun exposure alone. Vitamin D is not readily available in the diet, so supplements are usually required.
Insufficient calcium intake increases your risk of osteoporosis and decreases your response to any osteoporosis treatment plan. Calcium is required to build and maintain bone density at all ages. After the age of about 50, your ability to absorb calcium decreases, which is often made worse if you don't get enough vitamin D. As a result, you should increase your intake of calcium after age 50. However, you should take your calcium in several smaller doses to optimize absorption.
Having a small-boned frame or being tall increases your risk for osteoporosis. There is a direct relationship between increased height combined with low body weight and osteoporosis in both men and women. In women, body weight of less than 128 lbs has been shown to significantly increase risk of osteoporosis. Low body mass index (BMI) in men or women dramatically increases osteoporosis and fracture risk, as well as increasing risk of falls. In addition, small-boned women have an increased risk of fracture irrespective of bone density due to the decrease in bone mass.
Having either a parent or sibling who has had osteoporosis, a spine or hip fracture, or another fragility fracture increases your risk of getting osteoporosis.
Smoking, drinking alcohol to excess, or leading an inactive lifestyle puts you at risk for osteoporosis. These modifiable risk factors are often major contributors to early osteoporosis in both men and women. In women, tobacco use causes menopause three years earlier than it would occur in a nonsmoking woman. In both men and women, tobacco inhibits normal bone metabolism. Alcohol abuse is a major contributor to osteoporosis (especially in men) because it results in abnormal bone metabolism and is associated with malnutrition. In addition, alcohol abuse carries with it an increased risk of injury and falls, which is dangerous for a person with weakened bones.
Some ethnic groups are more at risk than others. Although risk is higher among Caucasian and Asian women, African-Americans as well as Hispanic-Americans are also at risk for osteoporosis. Among African-American women, for example, 10% over the age of 50 have osteoporosis, and another 30% have low bone density.
Table 1. Risk Factors for Osteoporosis
Things you can't change Things you can change Age (women: over 50; men: over 60) Stop smoking Female gender Drink no more than 2 alcoholic drinks per day, and no more than 6 drinks per week Being tall, having a small frame, or a slender build (weight under 128 lbs or BMI below average) Get enough exercise, but not so much as to induce amenorrhea (women) Family history (mother, father, or sibling) of osteoporosis or hip or spine fracture Get adequate calcium and vitamin D Race (Caucasian or Asian ancestry at greater risk than Hispanic. African?American at lower risk than previous groups; however, all groups have elevated risk with increased age or other factors) Avoid certain medications (see Table 2) Menopause ? Certain diseases (see Table 3) History of previous fracture?especially after age 50 Confusion or dementia and/or unsteady gait and frequent falls that cannot be reversed with treatment.
Certain drugs increase your risk for osteoporosis by decreasing calcium absorption and vitamin D metabolism, and/or by directly affecting bone formation and breakdown Table 02.
Table 2. Drugs that Increase Your Risk for Osteoporosis
Major culprits Corticosteroids at all ages, and also inhaled corticosteroids in the elderly (Prednisone, Medrol, etc.) Phenytoin (Dilantin), Phenobarbitol (possibly other, newer anticonvulsants as well) Aluminum?containing antiacids (not the more common magnesium containing ones) Warfarin (Coumadin), Heparin Excessive thyroid hormone replacement (often taken to shrink a thyroid mass) Benzodiazipines (Valium, etc) Any treatment for prostate cancer. Most (possibly all) chemotherapy agents (including interferon, etc.) Methotrexate (possibly other, newer rheumatoid arthritis drugs as well) Other drugs/medications also associated with decreased bone density Insulin More than five years of continuous tetracycline use or excess vitamin A or use of oral vitamin A derivatives for acne treatment. Gonadatropin?releasing hormone treatment for endometriosis Caffeine (also contained in many headache medications) Certain diuretic medications (?loop diuretics? such as Lasix, Demidex, Bumex) Cholestyramine use for more than five years (used to lower cholesterol)
Some diseases increase your risk of osteoporosis by affecting bone metabolism Table 03.
Table 3. Diseases Associated with Decreased Bone Density
Overactive parathyroid glands Overactive thyroid gland Inflammatory bowel disease (Crohn's or other colitis; not irritable bowel) Severe chronic lung disease (emphysema, pulmonary fibrosis, etc.) Intestinal sprue, surgery to remove part of the stomach or small intestine, or other causes of malabsorption in the upper intestinal tract Cystic fibrosis Renal tubular acidosis or chronic renal dialysis Chronic immunosupression for any type of organ transplantation Osteogenesis imperfecta Insulin-dependent (type 1) diabetes Cushing's disease Grand mal seizure disorder Rheumatoid arthritis (not osteoarthritis) Dementia of any type Any disease resulting in muscle weakness or paralysis History of any previous fracture, especially after age 50 Dramatic increase in fracture risk with history fracture of either the spine or hip Scoliosis
There are some factors that have been shown to result in increased bone mass Table 04.
Table 4. Factors that Increase Bone Mass
Morbid obesity (weight over 250 lbs or significantly elevated BMI) without increased risk of falls Delayed menopause and/or continuous hormone replacement therapy More than three pregnancies combined with adequate calcium and vitamin D intake Lifetime high intake of milk products (average three or more servings per day) Use of thiazide diuretics for more than five years (decreases calcium excretion) Use of statin lipid-lowering medications (Zocor or Pravachol or Mevacor) for more than three years Lifetime history of extremely heavy weight-bearing activity (involving regular, continuous lifting of more than 40 lbs)
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