Overview
Osteoporosis is a condition in which bone density decreases and bone tissue deteriorates, making bones fragile. It is known as the "silent disease" because it usually does not cause symptoms until a fracture occurs.
It is present in 20% of women and 5% of men over age 50. The incidence in postmenopausal women is very high.
Symptoms
Osteoporosis is silent in early stages. As it progresses:
- Back pain (due to vertebral fractures)
- Loss of height (4-5 cm over time)
- Stooped posture
- Easily occurring fractures (even from simple falls)
- Most commonly hip, spine, wrist fractures
- Back or low back pain
Causes
Disruption of the balance of bone turnover:
- Increased breakdown
- Decreased formation
- Net bone loss occurs
Estrogen loss in menopause causes rapid bone loss.
Risk Factors
Non-modifiable:
- Sex: Being female (4 times more common)
- Age: Over 50
- Ethnicity: White, Asian
- Family history
- Body type: Thin, small build
- Hormonal conditions:
- Menopause, early menopause
- Low testosterone
- Hyperthyroidism
- Hyperparathyroidism
- Cushing's syndrome
Modifiable:
- Inadequate calcium intake
- Vitamin D deficiency
- Sedentary lifestyle
- Smoking
- Excessive alcohol
- Excessive caffeine
- Low body weight
- Some medications (long-term steroid use, some anticonvulsants, chemotherapy)
- Eating disorders
- Some diseases (celiac, rheumatoid arthritis, kidney disease)
Complications
- Fractures (especially hip, spine, wrist)
- Chronic pain
- Disability
- Height loss, stooped posture
- Significant decrease in quality of life
- High mortality after hip fracture (20% in the first year)
- Loss of independence
- Depression
When to See a Doctor
- Early menopause or surgical menopause
- Family history
- For bone density measurement if risk factors are present
- Women over 65 (routine screening)
- Men over 70
- Simple fractures from a fall
- Height loss, back pain
- Long-term steroid use
Diagnosis and Treatment
Diagnosis:
- DEXA (Bone density measurement) - gold standard
- T-score: -2.5 and below = osteoporosis
- T-score: between -1 and -2.5 = osteopenia
- Blood tests: calcium, vitamin D, PTH, thyroid, kidney
- 24-hour urine calcium
- FRAX score (10-year fracture risk)
- Imaging (for vertebral fractures)
Treatment:
1. Bisphosphonates (mainstay treatment):
- Alendronate (weekly)
- Risedronate
- Ibandronate
- Zoledronic acid (annual IV)
- Should be taken on empty stomach, upright position
2. Other medications:
- Denosumab (subcutaneous injection every 6 months)
- Romosozumab (new)
- Selective estrogen receptor modulators: Raloxifene
- Hormone replacement therapy (in special cases)
- Anabolic agents: Teriparatide, abaloparatide (in severe cases)
- Calcitonin
3. Supplements:
- Calcium: 1000-1200 mg/day
- Vitamin D: 800-2000 IU/day
Prevention (Lifelong)
Nutrition:
- Adequate calcium (dairy, dark green vegetables, almonds)
- Vitamin D (sunlight, fatty fish, supplements)
- Protein
- Vitamin K (leafy greens)
- Magnesium, zinc
- Avoid excessive salt and caffeine
Exercise:
- Weight-bearing exercises: Walking, running, dancing, stair climbing
- Strength training: 2-3 times a week
- Balance exercises (prevent falls)
- Tai chi, yoga
- Increases bone density in childhood and youth
Lifestyle:
- Quit smoking
- Do not drink excessive alcohol
- Maintain a healthy weight (do not be too thin)
- Prevent falls (home safety)
Fall prevention (in the elderly):
- Adequate lighting
- Anti-slip rugs
- Bathroom grab bars
- Appropriate footwear
- Eye examinations
- Review medications
Screening:
- Annual DEXA for women over 65
- DEXA in early menopause
- Earlier if risk factors present