Discuss all medical advice, diagnosis, and treatment with your healthcare provider.

The Basics

What is osteoporosis?

Osteoporosis is an illness that thins and weakens the bones to the extent of fragility and susceptibility to breakage. The word "osteoporosis" literally means "porous bone." People with osteoporosis are most likely to break bones in the hip, spine, and wrist.

Bones are living tissue. As the body ages, old bone breaks down and is replaced by new bone. As people age, more bone is broken down than is replaced. This process is called bone remodeling.

The inside of healthy bones looks like a honeycomb. However, when a person develops osteoporosis, the spaces in the bone's structure become larger and the bones thus become weaker, with lower mass and density. In the early stages of this condition, known as osteopenia, bone strength is reduced but not to level expected with osteoporosis.

Osteoporosis is sometimes referred to as a silent illness because there are no outward symptoms in the early stages. People are often diagnosed with osteoporosis only after a fall or bump causes a bone to break or fracture. As the illness progresses, symptoms may include:

• Back pain, which can be severe if you have a fractured or collapsed vertebra
• Loss of height over time, with an accompanying stooped posture
• Fracture of the vertebra, wrists, hips, or other bones

Around the age of 30, bone mass stops increasing. At this point, peak bone mass is reached and the goal becomes to maintain the level of bone mass. The rate of bone loss in women increases for several years after menopause. Thereafter, the depletion of bone slows down but does not stop completely.

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What causes osteoporosis?

Osteoporosis is a condition of significantly reduced strength in bone. The strength of your bones is dependent on various factors, including their size, density, and amount of bone remodeling. When your bones do not have a significant amount of calcium, vitamin D, and other minerals, they become weaker and their internal structure deteriorates.

The leading cause of osteoporosis in women is the drop in estrogen levels that occurs during menopause, leading to rapid bone loss. Bone density levels can be compared with a savings account: accumulate as much bone mass as possible early on to generate highest levels of peak bone mass, so you will have more bone density to "spend" as your bones regenerate more slowly with age.

Risk factors:

• Female gender. Women are twice as likely as men to suffer fractures due to osteoporosis. Women have lower bone mass than men and they tend also to live longer. The sudden drop in estrogen levels that occurs at menopause accelerates bone loss. Small-framed women are particularly at high risk. Men who have low levels of testosterone are also at an increased risk. Beginning at age 75, osteoporosis is as common in men as it is in women.


• Age. The older you become, the higher your risk of osteoporosis, because your bones become weaker with age.


• Race. White and Southeast Asian people have a greater risk of osteoporosis. African-American and Hispanic men and women have a lower but still significant risk.


• Family history. Osteoporosis is hereditary. If you have a parent or sibling with osteoporosis and, especially if you also have a family history of fractures, you are at greater risk.


• Frame. Men and women who are exceptionally thin or who have small body frames tend to have a higher risk because they may have less bone mass to draw from as they age.


• Tobacco use. The role tobacco plays in the development of osteoporosis is unclear, but researchers know that tobacco use contributes to weak bones.


• Chronic alcoholism. Excess consumption of alcohol reduces bone formation and interferes with the body's ability to absorb calcium.


• Low calcium intake. People who have never consumed sufficient calcium have an increased risk for osteoporosis. Low calcium intake contributes to low bone mineral density, early bone loss, and an increased risk of fractures.


• Medical conditions that decrease calcium absorption. Stomach surgery (gastrectomy) can affect your body's ability to absorb calcium. Conditions such as Crohn's disease, Cushing's disease, hyperparathyroidism, and anorexia nervosa, can also inhibit your body's ability to absorb calcium.


• Inactivity. Bone health begins in childhood. Children who are physically active and take in sufficient amounts of calcium have the greatest bone density. Any weightbearing exercise is beneficial and can increase your bone density at any age.


• Lifetime exposure to estrogen. The greater a woman's lifetime exposure to estrogen, the lower her risk of osteoporosis. For example, if a woman enters menopause later or if she begins menstruating at an earlier than average age, she has a lower risk of developing osteoporosis. The risk for osteoporosis includes the following:
  
  
  • A history of abnormal menstrual periods
  • Menopause that begins earlier than one's late 40s
  • Ovaries that have been surgically removed before age 45 and you don't receive hormone therapy


• Corticosteroid medications. Long-term use of corticosteroid (oral steroid) medications, such as prednisone, cortisone, prednisolone, and dexamethasone, damage the bones. These medications are common treatments for chronic conditions such as asthma, rheumatoid arthritis, and psoriasis. If you need to take a steroid medication for long periods, your healthcare professional will monitor your bone mineral density.


• Thyroid hormone. An excess of thyroid hormone produced by a hyperactive thyroid or an excessive amount of thyroid hormone medication to treat an underactive thyroid (hypothyroidism) can cause bone loss.


• Eating disorders. Women and men with anorexia nervosa or bulimia are at higher risk of lower bone density in their lower backs and hips.


• Some diuretics. Drugs that prevent buildup of fluids in your body—diuretics—cause the kidneys to remove more calcium, leading to weakened bones. Diuretics that cause calcium loss include furosemide (Lasix®), bumetanide (Bumex®), ethacrynic acid (Edecrin®), and torsemide (Demadex®). If you currently use one of these diuretics, talk to your healthcare professional about monitoring your bones and blood calcium level.


• Other medications. Long-term use of the blood-thinning medication heparin, the drug methotrexate, some antiseizure medications, and aluminum-containing antacids also can cause bone loss.


• Breast cancer. Postmenopausal women who have had breast cancer are at increased risk of osteoporosis, especially if they were treated with chemotherapy or aromatase inhibitors to suppress estrogen. This isn't true for women treated with tamoxifen, which may reduce the risk of fractures.


• Excess soda consumption. The link between osteoporosis and caffeinated sodas isn't clear, but caffeine may interfere with calcium absorption and its diuretic effect may increase mineral loss. In addition, the phosphoric acid in soda may contribute to bone loss by changing the acid balance in the blood. If you do drink caffeinated soda, be sure to get adequate calcium and vitamin D from other sources in your diet or from supplements.


• Depression. People who experience serious depression have higher rates of bone loss.

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Osteoporosis and women: the statistics

• In the US, 10 million people have osteoporosis.
• Millions more have low bone mass, which puts them at a higher risk of developing osteoporosis.
• Of the 10 million people affected with osteoporosis, 80% are women.
• One in every two women will suffer from a bone-related fracture in their lifetime.
• In the US, osteoporosis is responsible for more than 1.5 million fractures annually.
• Annually, 700,000 of fractures are in the vertebrae.
• The estimated cost of fractures due to osteoporosis is more than $14 billion each year.
• Girls ages 9-18 need 1300 mg of calcium per day.
• Women ages 19-50 need 1000 mg of calcium per day.
• Women ages 51 and older need 1200 mg of calcium per day.
• Hip fractures are the most devastating type of bone fracture and account for almost 300,000 hospitalizations each year. Of hip fracture patients:
  • 20% die within a year of the fracture.
  • 20% move to a nursing home within a year.
  • Many become isolated, depressed, or afraid to leave home because they fear falling.

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How does osteoporosis affect women differently?

Menstruation
The longer that a woman is menstruating, the less likely she is to develop osteoporosis. Therefore, if you started menstruating early, you have a lower risk. The later menopause begins, the less likely you are to develop osteoporosis. If you have a history of irregular periods, you are at a greater risk.

Pregnancy
There is a rare condition called pregnancy-associated osteoporosis. It usually occurs during the third trimester of a woman's first pregnancy and usually goes away after the pregnancy. During this time, women may suffer from severe back pain and experience a loss of height; they are also at risk of vertebral fractures.

The reasons for this risk are inconclusive. Even though there is a stress on a pregnant women's calcium supply, and calcium leaves her body more often owing to frequent urination, there are other changes during pregnancy that probably help bone mass. For example, increased levels of estrogen and weight gain are positive things for bone mass.

Breast Feeding
Bone density tends to be diminished during breast feeding, but the decrease is temporary, and your levels will rise within 6 months of weaning.

Menopause
As discussed earlier, the drop in estrogen levels that occurs during menopause significantly increases your risk of getting osteoporosis.

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Diagnosis and Treatment

Diagnosis

Healthcare professionals can diagnose or confirm osteoporosis (significant bone loss) or osteopenia (mild bone loss which is a warning of impending osteoporosis) using various tests that can measure bone mineral density. Bone mineral density represents the strength of your bones and their resistance to fractures. As well as measuring bone mineral density, osteoporosis can also be confirmed by the presence or history of osteoporosis-related fracture.

Bone mineral density is measured using a dual energy X-ray absorptiometry (DEXA). DEXA, otherwise known as bone densitometry or bone mineral density testing. The test is quick, simple, noninvasive, and it simply involves your lying on a padded table while an X-ray is taken to measure the density of the bones either in your spine, hip, or wrist. Measuring bone density in healthy people, also known as screening, can also help to predict risk of fractures as well as to monitor response of bones to osteoporosis treatments.

Recommendations in the United States for bone density screening include all women 65 years and older as well as postmenopausal women younger than 65 years who have one or more risk factors. In addition, women who present with fractures and women who are considering therapy for osteoporosis should have a bone mineral density test. These two latter groups of women already have the condition of osteoporosis and, therefore, bone mineral density is no longer called screening—it is a necessity. Your bone mineral density test results will be in the form of two scores and your healthcare professional will be able to explain to you the significance of your scores. Here is a general explanation of the scores.

T-score—This is the amount of bone you have compared with a young adult of the same gender with peak bone mass. A score above -1 is considered normal. A score between -1 and -2.5 is classified as osteopenia, the first stage of bone loss. A score below -2.5 is defined as osteoporosis. The T-score is used to estimate your risk of developing a fracture. In other words, if your T-score indicates osteoporosis, then you have a high risk of developing a fracture.

Z-score—This is the amount of bone you have compared with other people in your age group and of the same size and gender. If this score is unusually high or low, it may indicate a need for further medical tests.

The purpose of bone mineral density testing includes the following:

• Detect low bone mineral density before a fracture occurs
• Confirm a diagnosis of osteoporosis if you already have had one or more fractures
• Predict your chances of fracturing in the future
• Determine your rate of bone loss, and/or monitor the effects of treatment if the test is conducted at intervals of a year or more

When you consult your healthcare professional about osteoporosis, he or she will ask you a series of questions, perform a physical examination, and even order some lab tests before referring you for bone mineral density testing. He or she may also refer you to a specialist, such as an endocrinologist, for further evaluation of your condition. Every woman approaching or who has reached menopause, as well as younger women with risk factors for developing osteoporosis, should see their healthcare professional for an osteoporosis assessment.

By detecting osteopenia or osteoporosis early, you can take action to stop the progression of bone loss before a fracture occurs. With lifestyle changes and appropriate treatment strategies, osteoporosis can be prevented and treated, so that the consequences of osteoporosis (including broken bones and disability) can be avoided.

Osteoporosis is a preventable condition if diagnosed and treated early; however, there are no warning signs until a fracture occurs. Osteoporosis is often called the "silent disease" because bone loss occurs without symptoms. Sometimes even a fracture may occur without warning signs. For example, fractures of the vertebra of the spine often do not cause pain and sometimes may be discovered only when a loss of height is noted or when an X-ray is performed for other conditions of the back and chest.

Osteoporosis is a dangerous condition because it puts people at risk of hip, wrist, and spine fractures, causing serious complications. Hip fractures in particular are associated with complications of immobility, such as pressure sores, pneumonia, blood clots, infections, and even death. Also, the majority of people after a hip fracture will not return to their previous level of mobility. Hip fractures usually require surgery in order to stabilize the joint so the joint heals correctly. Steps should be taken to prevent this disease, however, if you have been diagnosed with it, care should be taken to avoid suffering fractures.

Although osteoporosis is primarily a disease of postmenopausal women, younger women may be able to apply strategies to prevent developing it later on in life. Most importantly, younger women should try to optimize peak bone mass, which usually peaks by age 30. Regardless of a woman's age, osteoporosis; as well as cardiovascular disease; cervical, breast, and bowel cancers should be her preventative health goals.

If you have already been diagnosed with osteoporosis, you will be recommended certain nonmedication- and medication-based treatments to reduce further loss of bone, to build new bone, and to reduce your risk of developing fractures. You may not feel the medication working, but your healthcare professional can periodically monitor your progress with a bone mineral density testing (see explanation in section about "diagnosis"). If your bone density test does not show an improvement (meaning an increase in your T-score), then you may require a change in treatment and your healthcare professional will be able to advise you. For postmenopausal women, a bone mineral density test is usually done 2 years after treatment starts, but in some women it may need to be done earlier. Once bone density scores improve, your healthcare professional will recommend bone density monitoring less frequently.

The beneficial effects on your bones will usually remain as long as you keep taking medication. Should you decide to stop or to take a break from your medication, make sure you discuss it with your healthcare professional.

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Prevention of osteoporosis

The prevention of osteoporosis aims to maximize peak bone mass up to the age of about 30. Therefore, the aim is to minimize the rate of bone loss, with the goals of maintaining bone strength long-term and preventing fractures. The time of maximum peak bone mass is estimated in the third decade of life in most individuals. Bone loss is significantly increased after menopause (most women will loose about 1% of their bone mass per year after menopause), which is when your healthcare professional will start recommending regular screening with bone mineral density testing so the disease can be diagnosed as early as possible.

Ten steps follow for preventing osteoporosis: five steps to maximizing your peak bone mass during the bone forming years and five steps to minimizing your bone loss, especially after menopause. One step alone is not enough to prevent osteoporosis entirely, but addressing all steps together may certainly reduce your chances of developing it.

Five steps for maximizing your peak bone mass

These steps are most important for women who haven't reached their maximum peak bone mass, which usually occurs around the age of 30.

Step 1 Get your daily recommended amounts of calcium and vitamin D

Adequate amounts of calcium and vitamin D are necessary to build and maintain healthy bones. How much calcium you need depends of your stage of life (see table below). Experts recommend 800 International Units (IU) of vitamin D to be consumed each day.

Recommended Calcium Intakes (mg/day)
Ages	(milligrams) mg/day
Birth-6 months	210
6 months-1 year	270
1-3	500
4-8	800
9-13	1300
14-18	1300
19-30	1000
31-50	1000
51-70	1200
70 or older	1200
Pregnant or breastfeeding
14-18	1300
19-50	100

For most people, the best way to get enough calcium is by eating at least three servings of low-fat dairy foods per day. Low-fat dairy foods contain less saturated fat, which can contribute to increased cholesterol levels. The table below describes foods that you can eat to ensure adequate intake of calcium. Most people find it difficult to eat enough diary foods; however, it is worthwhile discussing this with your healthcare professional as he or she can give you tips on how to modify your dietary routine and advise you whether you may need to take a calcium supplement if dietary modification isn't achievable for you.

Foods and drinks with high levels of calcium
Food	Calcium, milligrams
Milk (skim, 2%, or whole, 8 oz)	300
Yogurt (6 oz)	250
Orange juice (with calcium, 8 oz)	300
Tofu with calcium (1/2 cup)	435
Cheese (1 oz)	195-335 (hard cheese = higher calcium)
Cottage cheese (1/2 cup)	130
Ice cream or frozen yogurt (1/2 cup)	100
Soy milk (1 cup)	100
Beans (1/2 cup cooked)	60-80
Dark, leafy green vegetables (1/2 cup cooked)	50-135
Almonds (24 whole)	70
Orange (1 medium)	60

To ensure adequate vitamin D levels, your healthcare professional can perform a blood test. The best way to ensure adequate vitamin D levels is from exposure of face, arms, hands, or back (without sunscreen) to sunlight for 10 to 15 minutes at least twice per week. If you are never outdoors in the sunlight, you may require a vitamin D supplement and you should discuss this with your healthcare professional.

Step 2 Perform regular weightbearing exercises

Regular exercise is important for your overall health, and experts recommend that you perform 30 minutes of moderate intensity exercise on most days of the week. However, regular weightbearing and muscle-strengthening exercises are important in order to maximize your bone strength and reduce bone loss. Weightbearing exercises, for example, jogging, walking, dancing, and soccer force your bones and muscles to work against gravity. Swimming and bicycling are not weightbearing.

Step 3 Avoid smoking and excessive alcohol intake

Smoking and moderate-to-excessive alcohol consumption can cause bones to become weaker. Stopping smoking and reducing your alcohol consumption to recommended levels can reduce this risk.

Step 4 Talk to your healthcare professional about your risk factors

Risk factors for osteoporosis are listed in step 3 ("risk factor assessment"). Even if you are premenopausal, you need to be aware of your risk of developing osteoporosis. This is necessary in order for you to institute as many strategies as possible to maximize your peak bone mass and minimize loss before it is too late to prevent the disease.

Step 5 When appropriate, have a bone mineral density test and take medication

If you have any major risk factors for osteoporosis, such as a family history, if you are underweight, or if you have had a fracture as an adult, then you should be evaluated with a bone mineral density test to see if you need to take medication in order to preserve your bone strength.

Five steps to minimizing your bone loss especially after menopause

Women up to the age of about 30 should be following the five steps above for maximizing peak bone density. Women beyond the age of their peak bone mass should follow the five steps below, especially if they are postmenopausal. At this time, postmenopausal women are at the highest risk of bone loss and osteoporosis development.

Step 1 Commit to a balanced diet and regular exercise program

An adequate intake of calcium in your diet, as well as regular sunlight exposure, and a weightbearing exercise program are the three most important things that will help you minimize bone loss.

Step 2 Stop smoking and reduce your alcohol consumption

Smoking and moderate-to-excessive alcohol consumption can cause bones to become weaker. Stopping smoking and reducing your alcohol consumption can reduce this risk. Women should drink no more than 1 alcoholic beverage (standard alcoholic drink) on a single day of the week

Standard alcoholic drinks in the United States all contain the same amount of alcohol—about 0.6 fl. oz. A standard drink is a 12 ounce can or bottle of beer, a 4 ounce glass of dinner wine, or a 1.5 ounce drink of 40% distilled spirits (served either straight or in a mixed drink). Keep in mind that the alcohol content of different beers, wines, and distilled spirits can vary.

Step 3 Get a risk factor assessment and screening test

Your risk of developing osteoporosis is based on the results of your bone mineral density test and on your risk factors. Clinical risk factors, which will put you at higher risk of developing osteoporosis, are described in detail in the section above on "causes of osteoporosis," However, a list of the main risk factors follows (these have been adapted from www.nof.org):

• Female gender
• Advanced in age
• Family history of osteoporosis
• History of a fracture in a first degree relative
• Personal history of fracture particularly over age 50
• Cigarette smoking and/or excessive alcohol intake
• Thin or small body frame
• Caucasian or Asian race
• Low calcium intake over your lifetime
• Deficiency in vitamin D
• Low physical activity or being sedentary
• Early menopause (younger than 45 years of age) or surgically induced menopause
• Absence of menstrual periods for an extended period (more than 6 months)
• Use of oral corticosteroid therapy (oral steroids) for more than 3 months
• Use of certain other medications (such as anticonvulsants)

All women over the age of 65 years or younger postmenopausal women who have one or more risk factors (other than being white, postmenopausal, and female) should undergo screening for osteoporosis with risk factor assessment and bone mineral density testing. Your healthcare professional will be able to judge whether your risk is high enough to warrant commencing medications for osteoporosis prevention. Medications have potential side effects, so only people at the highest risk will usually be recommended to take them for prevention

Step 4 If required, take medication for osteoporosis prevention

Medications are available for prevention and will be recommended if you at high risk of developing osteoporosis. Medications can help to preserve bone density and improve bone density if it is lower than it should be compared with a younger person at their peak bone mass.

Experts recommend that medications for osteoporosis prevention be used in those who have the following indications:

• Bone mineral density test T-scores below -2 with no other risk factors
• Bone mineral density T-scores below -1.5 (but not below -2) with one or more major risk factors (see step 3 above)
• A previous fracture of the hip or vertebral bones in the spine

The US Food and Drug Administration (FDA) has approved several medications for the prevention of osteoporosis. Some of these medications can also be used to treat osteoporosis in women who have already developed the condition (see section on treatment). Medications approved for osteoporosis prevention follows. If you have been recommended to commence preventative treatment with any of these medications be sure to discuss the potential risks and benefits with your healthcare professional.

Bisphosphonates are probably the most commonly prescribed medication for preventing osteoporosis in those at high risk. Bisphosphonates are available in daily, weekly, or once-a-month tablets and any one of these options will give you similar protection against osteoporosis. Certain hormone therapy medications are FDA approved for osteoporosis prevention also, but they are less likely to be prescribed solely for the purpose of osteoporosis prevention and are usually prescribed when there are other menopausal symptoms such as hot flashes, that need managing. Hormone therapy and raloxafene (Evista®) are both less commonly prescribed than bisphosphonates. However, they may be prescribed if you are getting troublesome side effects, such as nausea, from oral bisphosphonates. Side effects of the oral bisphosphonates will be described below.

Bisphosphonates for osteoporosis prevention

Alendronate (Fosamax®) daily or once-a-week tablet

Risedronate (Actonel®) daily or once-a-week tablet

Ibandronate (Boniva®) once-a-month tablet

All bisphosphonates help reduce bone loss, increase bone density, and reduce your future risk of developing osteoporosis-related fractures. Bisphosphonates in tablet form (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 alendronate (Fosamax®) or risedronate (Actonel®) and 60 minutes after taking ibandronate (Boniva®). There are bisphosphonates that are available in injectable form, however, they are only FDA approved for the treatment, and not the prevention, of osteoporosis. This will be described in the section on osteoporosis treatment.

Side effects of oral bisphosphonates include:

• Abdominal discomfort
• Nausea, vomiting, diarrhea, or constipation
• Irritation or pain of the esophagus
• Muscle, bone, or joint soreness or aches
• Eye pain
• Rash
• Altered sense of taste
• Stomach ulcers may occur in rare instances
• Osteonecrosis of the jaw (a condition in which a section of jawbone deteriorates and dies) is rare and considered more of a risk in people who take very large doses of injected medications (intravenously) for diseases such as cancer (higher doses of bisphosphonates are required for cancer treatment than for osteoporosis).

Before you start taking a bisphosphonates (oral or injectable), make sure your teeth are healthy. There's no recommendation to stop the medication before having a dental procedure, notify your dentist that you're taking a bisphosphonate and follow his or her recommendations for good oral hygiene.

Selective Estrogen Receptor Modulator (SERM)

Raloxifene (Evista®)

Like bisphosphonates, these medications can help reduce bone loss and reduce the risk of certain future osteoporosis-based fractures. These drugs are not estrogens but can mimic some of the effects of estrogen on bone. Much remains unknown about these medications and more research is needed to determine how they affect breast and uterine tissue. Currently, SERMs (selective estrogen receptor modulators) are not thought to have the same potential adverse effects on breast and uterine tissue as estrogens have. Side effects of SERMs include hot flashes and possible blood clots in veins.

Hormone Therapy

A summary of the different types of hormone therapy preparations approved for preventing osteoporosis in postmenopausal women follows. Women with a uterus must not take estrogen alone and should take progestin either in a separate preparation or as an estrogen/progestin combination preparation.

• Oral estrogen
  
  • Premarin®
  • Estrace®
  • Estratab®
  • Ogen®
  • Ortho-Est®


• Estrogen skin patches (transdermal estrogen)
  
  • Alora®
  • Climara®
  • Estraderm®
  • Vivelle®
  • Vivelle-Dot®


• Oral progestin
  
  • Prometrium®
  • Provera®


• Combined oral estrogen/progestin
  
  • Femhrt®
  • Prefest®
  • Prempro®
  • Premphase®


• Combined estrogen and progestin skin patches
  
  • Climara Pro®

Currently, hormone therapy is prescribed mainly for the relief of menopausal symptoms such as hot flashes, night sweats, vaginal dryness, and urinary symptoms. The Food and Drug Administration (FDA) has also approved hormone therapy for the treatment and prevention of osteoporosis, although often there are other therapies that your healthcare professional may prescribe first.

Although the FDA has approved hormone therapy for the prevention of osteoporosis in postmenopausal women, findings from the Women's Health Initiative (WHI) study, which were first released in 2002, have caused some controversy concerning prescribing these medications.

The WHI research study commenced in 1991 and involved over 160,000 women, the majority of whom were over the age of 60 years (most women who take hormone therapy are 50 to 59 years old), Caucasian, and overweight or obese. Apart from being overweight, this was a relatively healthy group of women. The research aimed to determine the risks and benefits of hormone therapy in postmenopausal women with regard to effectiveness in treating menopausal symptoms and risk or benefit on breast cancer, colorectal cancer, heart disease, blood clots, stroke, and osteoporosis.

The WHI is the first randomized clinical research trial to provide significant evidence that hormone therapy in postmenopausal women can prevent osteoporosis-related hip fractures as well as fractures at other sites. The study results indicated that 10 of every 10,000 postmenopausal women taking estrogen plus progestin will have a hip fracture each year, compared with 15 of every 10,000 women taking placebo pills.

Apart from the findings concerning osteoporosis in postmenopausal women, the WHI study revealed other information regarding hormone therapy, breast cancer, blood clots, cardiovascular disease, and colorectal cancer. Findings emerged in the last 5 years that although hormone therapy can be beneficial for the treatment of osteoporosis, its use may increase the risk of heart disease and breast cancer in certain women.

More recently, new information about hormone therapy and the risk of heart disease has been published in scientific journals. In the WHI follow-up study published in April 2007, women 50 to 59 years old who used hormone therapy had much less risk of stroke, heart attacks, and breast cancer, and women who used hormone therapy within 10 years of menopause had no increased risk of heart attacks.

Hormone therapy should be prescribed for the shortest period of time possible. When used solely for the prevention of postmenopausal osteoporosis, hormone therapy should only be considered for women at high risk.

There is some research describing a lower risk of blood clots with estrogen skin patches as opposed to oral estrogen. However, there is still a lot we do not know about estrogen skin patches, therefore they should still be considered to carry the same risk.

Step 5 Avoid certain medications

Some medications should be avoided in those with a high risk of developing osteoporosis, as they have potential to accelerate bone loss. You should talk to your healthcare professional about the risk of bone loss if you take any of the following medications:

• Corticosteroid medications, for example, prednisone (Deltasone®)
• Heparin (Heparin®), a medication used to prevent and treat abnormal blood clotting
• Vitamin A
• Certain antiepileptic drugs (for example, phenytoin [dilantin], carbamazepine [Tegretol®], primidone [Mysoline®], phenobarbital [Nembutal®], and valproate [Depakene®])

Summary of Osteoporosis Prevention for All Women

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Treatment

Accepted treatment for osteoporosis

Women with established osteoporosis will be recommended to use both nonmedication-and medication-based treatments for their condition. The nonmedication-based treatments are similar to some of the steps or strategies needed to prevent osteoporosis (see section above).

Nonmedication-based treatment

Good nutrition

The foods we eat contain a variety of vitamins, minerals, and other important nutrients that in a balanced diet, help keep our bodies healthy. In particular, calcium and vitamin D are needed for strong bones. (See prevention section for recommended amounts of calcium and foods that are good sources of calcium.)

Regular exercise

Exercise, particularly weightbearing physical activity is an important part of an osteoporosis treatment program. Exercise not only improves your bone strength but it increases muscle strength, coordination, and balance, and leads to better overall health as well as a reduced risk of frailty and falls (a major problem in the elderly). Exercise has been associated with improvements in and maintenance of bone mineral density and a reduced risk of hip fractures.

Benefits of exercise are quickly lost if you stop exercising, therefore, choose an exercise regimen that you really enjoy to ensure long-term continuity of your program. Try different exercises to find out what you enjoy most. On the other hand, excessive exercise should be avoided because it can lead to weight loss and amenorrhea (loss of menstrual periods), which may in turn increase bone loss.

Sunlight exposure

Getting at least 15 minutes of sunlight exposure twice a week to your face, arms, or legs is one of the best ways to get vitamin D, which is important for making your bones as strong as possible; otherwise you may need to take a vitamin D supplement. Some medications for the treatment of osteoporosis are available fortified with vitamin D. Your healthcare professional will be able to check your vitamin D levels with a blood test and advise whether you should take a supplement.

Stop smoking

Smoking cigarettes accelerates bone loss, therefore, quitting is beneficial for keeping your bones as strong as possible.

Preventing falls

All women with osteoporosis should avoid the risk of falling. Falls can increase the likelihood of fracturing a bone in the hip, wrist, spine, or other part of the skeleton. Reducing falls involves maximizing certain physical attributes including your balance, flexibility, and strength, as well as minimizing internal and external factors that can increase your risk of falling.

Recurrent falls are particularly common in the elderly, a population at high risk of osteoporosis and fractures. If you or your relatives are experiencing recurrent falls, it is important that you discuss this with your healthcare professional. Sometimes an undiagnosed medical condition, such as cardiovascular or neurological disease, can be the underlying cause, and if treated, you may stop accidentally falling over.

Physical attributes that can decrease your risk of falls

• Good balance. You can improve your balance with activities like tai chi and yoga.
• Flexibility. You can improve your flexibility through tai chi, swimming, yoga, and gentle stretching exercises.
• Muscle strength. Lifting weights will certainly improve strength.

Internal factors to address for falls prevention

• Impaired vision. If you have poor vision, you should see an eye specialist for an assessment and for corrective lenses (glasses).
• Chronic diseases such as dementia and depression can affect mental or physical functioning significantly and, particularly in the elderly, can increase the risk of falls.
• Certain medications, such as sedatives and antidepressants, can affect balance and coordination and contribute to falls. In the elderly, certain combinations of these medications will further increase the risk; reviewing drug regimens on a regular basis is essential.

External factors to address for falls prevention

• Keep rooms and floors free of clutter
• Keep floor surfaces smooth but not slippery
• Wear supportive, low-heeled shoes, even at home
• Ask your health professional about wearing hip protectors to protect your hip bones in case you fall over.
• Avoid walking in socks, stockings, or slippers because they are slippery
• Be sure carpets and area rugs have skid-proof backing
• Keep stairwells well lit
• Put handrails on both sides in stairwells
• Install grab bars in bathroom
• Use a rubber bath mat in the shower or tub
• Keep a flashlight beside your bed
• Consider purchasing a cordless phone to avoid rushing to answer a phone call
• Ensure that there is adequate lighting in all areas
• Use a cane or walker if your balance is impaired
• Always walk in familiar areas when outside
• Walk on grass or sprinkle salt when sidewalks are slippery

Medication monitoring

If you have been diagnosed with osteoporosis, prolonged therapy with and/or high doses of certain medications can increase bone loss. A list of these medications can be found in the section above on osteoporosis prevention; these medications should be monitored closely by a healthcare professional.

Medication-based treatment

Prevention and treatment of osteoporosis should always include a well-balanced diet, adequate intake of calcium and vitamin D, regular exercise, safety precautions for falls prevention, avoidance of tobacco products, and limited consumption of alcohol. If osteoporosis is diagnosed, you still must continue to make bone-healthy lifestyle choices. However, lifestyle modifications alone are often not enough and your medical professional will prescribe for you an osteoporosis medication to stop further bone loss and to reduce your risk for broken bones.

If you have been diagnosed with osteoporosis, you will be recommended to start medication to be taken on a regular basis together with many of the nonmedication-based treatments above. This medication will help build strength in your bones and reduce your chances of fracture. There are various medications available for treatment of osteoporosis and you can decide together with your healthcare professional which one is best for you. When deciding on your treatment, the following factors will need to be taken into consideration:

• Your age and past medical history:
  
  Older women are often at higher risk of side effects from certain medications, such as hormone therapy. Furthermore, if you have a past history gastrointestinal problems, you may not be able to take oral bisphosphonates.


• Your tolerance to side effects:
  
  Oral bisphosphonates commonly have gastrointestinal side effects, and if this occurs you may need a different medication. If you can't tolerate oral bisphosphonates, your doctor may recommend periodic intravenous infusions (slow injection into a vein) of a bisphosphonate. Intravenously administered bisphosphonates do not have the same side effects on the esophagus or stomach and there are no special instructions regarding eating, drinking, or positioning following their use.


• Whether you have a previous history or high risk of breast cancer and/or uterine cancer:
  
  Hormone therapy is usually not recommended for these women


• General safety and cost of medication
  
  Preparation of the medication:
  
  Medications for osteoporosis are available as tablets, patches, injectables, and nasal sprays. Tablets are often available in different sizes, with smaller tablets suitable for people with swallowing difficulties. Some medications may be taken as a once-daily or a once-weekly tablet, which may be convenient for some individuals. Some medications, including certain oral bisphosphonates, are fortified with calcium or vitamin D.
  
  Certain preparations will suit some people and not others, therefore, you need to choose a medication regimen that suits you so you do not fall behind with taking your medication. If you stop taking your treatment or take less than the fully prescribed amount, the therapeutic effective on your condition will be reduced.
  
  Before starting you on any medication, your healthcare professional will perform a bone mineral density test (dual energy X-ray absorptiometry or DEXA) as a baseline measure of your bone strength. During the course of treatment, repeat bone mineral density tests will be done approximately every year or two to monitor your response to medication.

Bisphosphonates

The different bisphosphonates that are approved for the treatment of osteoporosis are described below. There are specific circumstances when your healthcare professional may recommend an intravenous rather than an oral bisphosphonate. For example, if you find that oral bisphosphonates give you significant gastrointestinal side effects changing to an intravenous variety may improve your tolerance to the medication and maintain the similar benefit for your bones. Of course, there may be other side effects to be aware of if you are prescribed an injection.

Oral bisphosphonates

Alendronate (Fosamax®, Fosamax Plus D) daily or weekly tablet

Risedronate (Actonel®, Actonel® with calcium) daily or weekly tablet

Ibandronate (Boniva®) once daily or once monthly tablet

Side effects and instructions on how to take oral bisphosphonates are described in the section above on osteoporosis prevention. Intravenous (into a vein) bisphosphonates

Ibandronate (Boniva®) injection once every 3 months

Zoledronic acid (Reclast®) infusion once—yearly

Ibandronate (Boniva®) and zoledronic acid (Reclast®) should be administered to you by a healthcare professional.

The most common side effects associated with ibandronate (Boniva®) are fever; pain in the muscles, bones, or joints; flu-like symptoms; and headache. Side effects of zoledronic acid (Reclast®) can occur within the first few days after infusion and may take 1 to 2 weeks to disappear. Side effects of ibandronate (Boniva®) include flu-like symptoms, abdominal pain, and reactions at the injection site.

All bisphosphonates can potentially cause osteonecrosis of the jaw—a rare condition in which a section of jawbone deteriorates and dies. However, this side effect occurs primarily in people who take very large doses of the medication by vein (intravenously) for the treatment of cancer in bone, rather than for osteoporosis.

Before you start taking a bisphosphonate, make sure your teeth are healthy. There's no recommendation to stop the medication before having a dental procedure, but notify your dentist you're taking a bisphosphonate and follow his or her recommendations for good oral hygiene.

Selective estrogen receptor modulator (SERM)

Raloxifene (Evista®) tablet

This medication is prescribed less commonly than bisphosphonates.

It is approved for osteoporosis only in women, it is not currently approved for use in men.

Side effects of raloxifene include hot flashes and blood clots.

Teriparatide (Forteo®)

Teriparatide is a form of human parathyroid hormone, which is produced by the parathyroid glands—four small glands located next to the thyroid in the neck. Parathyroid hormone helps to balance calcium levels in the blood.

Teriparatide (Forteo®) is only available as a daily injection given just under the skin and, as with insulin, you too can learn to inject yourself.

Side effects of teriparatide include nausea, dizziness, and leg cramps. Teriparatide is approved for use for up to 24 months.

Salmon calcitonin

Miacalcin® nasal spray
Fortical® nasal spray
Miacalcin® injection given under the skin or into muscle

Salmon calcitonin is approved for the treatment of osteoporosis in women more than 5 years beyond menopause; however, it is less commonly prescribed compared with osteoporosis treatments. Salmon calcitonin can help maintain and increase bone mineral density.

Side effects of the nasal spray include nasal irritation, nose bleeding, headaches, and joint pain. Side effects of the injection include flushing of the face and hands, nausea, vomiting, and redness/pain/swelling at injection sites.

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Emerging therapies

There are several therapies under investigation for the treatment of osteoporosis.

• Denosumab
• Oral calcium-sensing receptor antagonists
• Sclerostin inhibitors
• Integrin antagonists
• Cathepsin-K inhibitors

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Empower Yourself

Dealing with osteoporosis

Osteoporosis can be a painful and even debilitating disease, but if you manage your illness, you can live an active lifestyle and prevent fractures. Some tips for managing your osteoporosis that you can easily practice at home include:

• Maintaining good posture
• Preventing falls
• Managing pain
• Ensuring adequate calcium in your diet
• 10-15 minutes sun exposure twice a week

It is never too late to start fortifying your diet with calcium-rich foods that will help improve your bone density. If you have been diagnosed with osteoporosis or osteopenia, or even if you have strong bones, beef up your diet too strengthen your bones. The chart below shows some examples of calcium-rich foods.

Food	Portion	Milligrams	Daily Value (%)
Plain low-fat yogurt	1 cup	450	45
American cheese	2 ounces	348	35
Milk (low fat)	1 cup	300	30
Orange juice w/calcium	1 cup	300	30
Broccoli	1 cup	90	10

Vitamin D can also keep your bones healthy. You can get it from the sun or from certain foods. If you spend 10 to 15 minutes exposed to sunlight particularly to your hands, arm, and face 2 or 3 times a week, you are soaking up sufficient vitamin D. If you are concerned about skin issues or don't have access to sunlight, you can take vitamin supplements or check the chart below to see what kinds of foods will provide you with vitamin D. (IU stands for International Units).

Food	Portion	IU	Daily Value (%)
Salmon, cooked	3.5 oz	360	90
Milk	1 cup	98	25
Egg (with yolk)	1 whole	25	6
Pudding	½ cup	50	10

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Frequently asked questions

How do you build strong bones?
You can build strong bones by getting enough calcium and weight-bearing physical activity during the tween and teen years, when bones are growing fastest. Young people in this age group have calcium needs that they can't make up for later in life.  In the years of peak skeletal growth, teenagers build more than 25% of adult bone. By the time teens finish their growth spurts around age 17, 90% of their adult bone mass is established. Maximum adult bone mass is usually established by the age of 30 years old.
 
How does calcium help build healthy bones?
Your body continually removes and replaces small amounts of calcium from your bones. If your body removes more calcium than it replaces, your bones will become weaker and have a greater chance of breaking. By getting plenty of calcium when you're young, you can make sure your body doesn't have to take too much from your bones.

Bones have their own "calcium bank account," so depositing as much calcium as possible during your teen years will help you reach your peak bone mass. After age 30 the account closes—so you can't add any more calcium to your bones. You can only maintain what is already stored to help your bones stay healthy.

What are good sources of calcium?
Calcium is found in a variety of foods. Low-fat and fat-free milk and other dairy products are the best sources of calcium because of they have so much of it.

Everyone can get most of their daily calcium from three cups of low-fat or fat-free milk, but they may need additional servings of calcium to get the 1300 mg necessary for strong bones because sometimes the calcium is not absorbed adequately in the gut. Caffeine, for example, may hinder the absorption of calcium.

Other advantages low-fat and fat-free milk and dairy products include:

• Low-fat and fat-free milk has lots of calcium with little or no fat.
• The calcium in low-fat and fat-free milk and dairy products is easy for the body to absorb and in a form that gives the body easy access to the calcium.
• Low-fat and fat-free milk has added vitamin D, which is also important for your bones.
• In addition to calcium, milk and dairy products provide other essential nutrients that are important for optimal bone health and development.

In addition to low-fat and fat-free milk and dairy products, there are other good sources of calcium, including:

• Dark green, leafy vegetables such as spinach, broccoli, and bok choy
• Foods with calcium added, such as calcium-fortified tofu, orange juice, soy beverages, and breakfast cereal or breads

Food labels can tell you how much calcium is in one serving of food. Look at the % Daily Value (% DV) next to the calcium number on the food label.

How does physical activity help build healthy bones?
Bones are living tissue. Weight-bearing physical activity causes new bone tissue to form, which makes bones stronger. This kind of physical activity also makes muscles stronger. When muscles push and tug against bones during physical activity, both bones and muscles become stronger.

How common is osteoporosis?
Over 10 million people in the United States have osteoporosis. About 18 million others have lost some bone mass and are likely to develop osteoporosis in the future. More than 80% of those affected are women.

Osteoporosis leads to over 12 million fractures each year in this country. One out of two women and one out of eight men over the age of 50 will suffer a fracture related to osteoporosis at some point during their lives.

Who is at risk of developing osteoporosis?
Anyone can develop osteoporosis, but women are at higher risk than men. In both men and women, the risk of osteoporosis increases with age, with bone loss usually starting slowly around age 30. For men, bone loss tends to occur over time, while women experience a period of heightened bone loss around menopause that then slows down again after a few years.

Thin people with small bones are at the highest risk of osteoporosis. And this relates to another reason women experience higher osteoporosis rates than men: they often simply begin with less bone mass.

Of all racial and ethnic groups, African Americans tend to be at the lowest risk, but all races and ethnicities suffer from osteoporosis.

Can osteoporosis be treated?
It is best to prevent osteoporosis before it starts, and there are many steps that everyone can take to decrease the risk of bone loss. If you are at high risk of osteoporosis or are already experiencing bone loss, talk to your doctor about available treatments. There are medications that can slow the rate of bone loss and even help rebuild bone.

How can you prevent osteoporosis?
There are steps you can take to reduce your risk of osteoporosis:

• Don't smoke
• Get regular weight-bearing exercise like dancing, walking, or climbing stairs
• Make sure you get enough calcium and vitamin D
• Eat green, leafy vegetables that contain vitamin K, like kale, spinach, broccoli, and cabbage
• Talk to your healthcare provider to see whether you need your bone density tested

Who should be screened?
There are no good screening tests to identify people who will incur bone loss and fractures. However, if you have osteoporosis risk factors or symptoms, your healthcare professional will most likely recommend a bone density scan to see whether you've had bone loss.

Can you explain how parathyroid hormone injections make bones stronger when excess parathyroid hormone made by the body weakens bones?

Parathyroid hormone (PTH) is produced by four small parathyroid glands in the neck that control how much calcium is in the blood and tissues. Calcium is necessary not only for bone health but also for normal heart, muscle, and nerve function and normal blood clotting. Every day, calcium lost in urine, feces, and sweat, or shed in skin, hair, and nails must be replaced by calcium from food and/or calcium supplements. When there is too little calcium to compensate for these normal losses, the body senses the low calcium level in the blood and tissues, and responds by releasing special hormones, including PTH. PTH breaks down or resorbs bone tissue to release calcium into the blood and tissues so that the body continues to function normally. Higher PTH levels bring the calcium level back to normal in one of three ways:

• By breaking down bone, which releases calcium into the blood and tissues
• By making it easier for calcium from calcium-rich foods or supplements to be absorbed from the intestines
• By slowing the loss of calcium through the kidneys and urine so more can be absorbed

When the calcium level in the blood and tissues returns to normal, parathyroid hormone levels drop again. Hyperparathyroidism is a medical condition that results when one or more of the four parathyroid glands becomes overactive. The overactivity leads to the constant release of too much PTH, which continues to break down bone and release calcium into the blood and tissues. Over time, excess bone breakdown can lead to osteoporosis and related fractures.

Although continuous exposure to parathyroid hormone causes bone loss, studies have shown that once-a-day injections of parathyroid hormone have the opposite effect and build new bone. The different effect on bone cells seems to be related to the rapid rise and fall of PTH in the blood when it is given as an osteoporosis treatment, as opposed to the constant high levels of parathyroid hormone in the blood when someone has hyperparathyroidism.

Parathyroid hormone injections (teriparatide) form new bone, increase bone mineral density and bone strength, and reduce risk for osteoporotic fractures. This is the first bone-building treatment for osteoporosis.

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Glossary of osteoporosis terms

Abdominal pain: Pain in the stomach or belly.

Absorb: 1. To take something in, as through the skin or the intestine. 2. To react with radiation and reduce it in intensity, as with a dose of radiation or transmitted light.

Aging: The process of becoming older, a process that is genetically determined and environmentally modulated.

Amenorrhea: Absence or cessation of menstruation. Amenorrhea is conventionally divided into primary and secondary amenorrhea.

Annorexia nervosa: Anorexia nervosa is an eating disorder characterized by low body weight, distorted body image, and an extreme fear of gaining weight. Individuals with anorexia often participate in voluntary starvation, purging, excessive exercise, and/or other measures, such as taking diet pills or diuretic drugs to help with weight loss.

Antiepileptic: Antiepileptics are a group of medications usually used to treat epilepsy and seizures.

Arthritis: Inflammation of a joint. When joints are inflamed they can develop stiffness, warmth, swelling, redness, and pain.

Back pain: Pain felt in the lower or upper back due to many causes of back pain.

Balance: A biological state that enables us to know where our bodies are in the environment and to maintain a desired position. Normal balance depends on information from the inner ear, other senses (such as sight and touch), and muscle movement.

Bisphosphonate: A class of drugs used to strengthen bone. Bone is in a constant state of remodeling, whereby new bone is formed by cells called osteoblasts while old bone is removed by cells called osteoclasts. Bisphosphonates inhibit bone removal (resorption) by the osteoclasts. Bisphosphonates are used to treat osteoporosis and the bone pain from diseases such as metastatic breast cancer, multiple myeloma, and Paget's disease. The bisphosphonates include Fosamax (alendronate) and Aredia (pamidronate).

Blood clots: Clumps of coagulated blood that form in a blood vessel or within the heart.

Bone: Bone is the substance that forms the skeleton of the body. Composed chiefly of calcium phosphate and calcium carbonate, it also serves as a storage area for calcium, playing a large role in calcium balance in the blood.

Bone density: Bone density is the amount of bone tissue in a certain volume of bone that can be measured using a special X-ray called a quantitative computed tomogram.

Bone mineral density (BMD): BDM, a measure of bone density, reflecting the amount of calcium in bones. The BDM test detects osteopenia (bone loss usually without symptoms) and osteoporosis (more severe bone loss which may cause symptoms).

Bone remodeling: A process of old bone being removed and new bone being generated.

Caffeine: A stimulant found naturally in coffee beans, tea leaves, cocoa beans (chocolate), and kola nuts (cola) and added to soft drinks, foods, and medicines. A cup of coffee has 100 to 250 milligrams of caffeine. Black tea brewed for 4 minutes has 40 to 100 milligrams. Green tea has one-third as much caffeine as black tea.

Calcitonin: A hormone produced by the thyroid gland that lowers the levels of calcium and phosphate in the blood and promotes the formation of bone.

Calcium: A mineral found mainly in the hard part of bones, where it is stored. Calcium is added to bones by cells called osteoblasts and is removed from bones by cells called osteoclasts. Calcium is essential for healthy bones. It is also important for muscle contraction, heart action, nervous system maintenance, and normal blood clotting. Food sources of calcium include dairy foods, some leafy, green vegetables, such as broccoli and collards, canned salmon, clams, oysters, calcium-fortified foods, and tofu. According to the National Academy of Sciences, adequate intake of calcium is 1200 milligrams a day (four glasses of milk) for men and women 51 and older, 1000 milligrams a day for adults 19 through 50, and 1300 milligrams a day for children 9 through 18. The upper limit for calcium intake is 2.5 grams daily.

Cardiovascular disease prevention: Involves disease of the heart and blood vessels. There are modifiable risk factors linked to its development including high blood pressure, smoking, and diabetes. Cardiovascular disease prevention refers to targeting these modifiable risk factors in order to reduce the chances of developing cardiovascular disease.

Chronic disease: A disease that is recurrent or lasting a long time such as more than 3 months.

Colorectal cancer: Also known as colon or bowel cancer

Compression: The act of pressing together, as in a compression fracture, nerve compression, or spinal cord compression.

Corticosteroids/oral steroid medications: Corticosteroids are a class of hormones that are produced in the adrenal gland. Corticosteroid medications are very similar to the hormones that our adrenal glands naturally produce.

Crohn's disease: A disorder whereby inflammation of the digestive or gastrointestinal tract can occur anywhere from the mouth to the anus. People tend to experience pain and diarrhea with this condition.

Cushing's disease: Cushing's disease is a hormonal disorder caused by high levels of cortisol in the blood due to a pituitary adenoma (pituitary gland tumor). The pituitary gland stimulates excessive release of cortisol from the adrenal gland as a result of a tumor.

Dairy products: Foodstuffs made from milk.

Depression: A psychiatric disease, characterized by symptoms including persistent low mood, loss of interest in usual activities, and reduced ability to experience pleasure.

DEXA: Dual energy X-ray absorptometry.

Diabetes: A disease characterized by high blood sugar resulting from either low levels of the hormone insulin or from insulin not working properly in the body.

Diuretic: A diuretic is any medication that increases the frequency and amount of urine excreted by the body.

Esophagus: The esophagus is a muscular tube through which food passes from the throat to the stomach.

Estrogen: Estrogen is a female hormone produced by the ovaries. Estrogen deficiency can lead to osteoporosis.

Family history: The family structure and relationships within the family, including information about diseases in family members.

FDA: The Food and Drug Administration, an agency within the US Public Health Service, which is a part of the Department of Health and Human Services.

Film: Slang for X-ray film, an X-ray, a radiograph.

Flu-like symptoms: Symptoms similar to flu including fever, muscle aches and pains, cough, and loss of appetite.

Fracture: A break in bone or cartilage. Although usually the result of trauma, a fracture can be caused by an acquired disease of bone, such as osteoporosis, or by abnormal formation of bone in a disease such as osteogenesis imperfecta ("brittle bone disease"). Fractures are classified according to their character and location as, for example, a greenstick fracture of the radius.

Gastrointestinal: The gastrointestinal tract is the organ that transports and digests food, and then expels the waste products.

Heart disease: Refers to different diseases affecting the heart.

Hip fracture: Broken bone in the hip, a key health problem among the elderly, usually due to a fall or other kind of trauma involving direct impact to the hip bone which has been weakened by osteoporosis. The part of the hip most often broken is the greater trochanter (the knobby end) of the femur (the thigh bone).

Hot flashes: Hot flashes are a sudden feeling of intense heat with sweating. It is a symptom of menopause.

Hormone: A chemical substance produced in the body that controls and regulates the activity of certain cells or organs.

Hormone therapy: A form of treatment that takes advantage of the fact that certain cancers depend on hormones to grow. Hormone therapy may include giving hormones to the patient or decreasing the level of hormones in the body.

Hyperparathyroidism: Indicative of overactive parathyroid glands, resulting in excess production of parathyroid hormone. The parathyroid hormone helps to balance calcium and phosphorus levels in the body.

Immunizations: Immunization (also known as vaccination) exposes the immune system to a disease or an infection in a controlled way in the hope that the body will respond by mounting an immune response to protect the body from real future exposures to that disease or infection.

Infusion: Slow injection into a vein.

Kidney: One of a pair of organs located in the right and left side of the abdomen that clear "poisons" from the blood, regulate acid concentration, and maintain water balance in the body by excreting urine. The kidneys are part of the urinary tract. The urine then passes through connecting tubes called "ureters" into the bladder. The bladder stores the urine until it is released during urination.

Magnesium: A mineral involved in many processes in the body including nerve signaling, the building of healthy bones, and normal muscle contraction. About 350 enzymes are known to depend on magnesium.

Malabsorption: The impaired absorption of nutrients from food by the intestines. Malabsorption can be specific and involve sugars, fats, proteins, or vitamins. Alternatively, malabsorption can be general and nonspecific.

Medication: 1. A drug or medicine. 2. The administration of a drug or medicine.

Menopause: The time in a woman's life when menstrual periods permanently stop; it is also called the "change of life." Menopause is the opposite of the menarche.

Neurological disease: Diseases that affect the brain, spinal cord, and/or rest of the nervous system.

Osteomalacia: Softening of bone, particularly in the sense of bone weakened by demineralization (the loss of mineral) and most notably by the depletion of calcium from bone.

Osteonecrosis: A breakdown of th ebone of the jaw. Symptoms include pain, swell of the gums, loosening of teeth, heaviness in the jaw, and gum infections.

Osteopenia: Mild thinning of the bone mass, but not as severe as osteoporosis. Osteopenia results when the formation of bone (osteoid synthesis) is not enough to offset normal bone loss (bone lysis). Osteopenia is generally considered the first step along the road to osteoporosis, a serious condition in which bone density is extremely low and bones are porous and prone to shatter. Diminished bone calcification, as seen on plain X-ray film, is referred to as osteopenia, whether or not osteoporosis is present. The diagnosis of osteopenia may also be made by a special X-ray machine for bone density testing.

Osteoporosis: Thinning of the bones with reduction in bone mass due to depletion of calcium and bone protein. Osteoporosis predisposes a person to fractures, which are often slow to heal and heal poorly. It is more common in older adults, particularly postmenopausal women; in patients on steroids; and in those who take steroidal drugs. Unchecked osteoporosis can lead to changes in posture , physical abnormality (particularly the form of hunched back known colloquially as " dowager's hump "), and decreased mobility.

Ovaries: An ovary is an organ that forms part of the female reproductive system. It produces eggs and female hormones.

Parathyroid gland: A gland that regulates calcium, located behind the thyroid gland in the neck. The parathyroid gland secretes a hormone called parathormone (or parathyrin) that is critical to calcium and phosphorus metabolism. Although the number of parathyroid glands can vary, most people have four, one above the other on each side. They are located against the back of the thyroid and therefore at risk for being accidentally removed during thyroidectomy.

Peak bone mass: The maximum amount of bone accumulated during young adult life. Peak bone mass is usually reached around the age of 30.

Pill: A medicinal substance in a small round or oval mass meant to be swallowed. Pills often contain a filler and a plastic substance such as lactose that permits the pill to be rolled by hand or machine into the desired form. The pill may then be coated with a varnish-like substance.

Placebo: Placebo is a preparation that can be compared with an actual medication, and can have a therapeutic effect based solely on suggestion and the idea that it may have benefit.

Pneumonia: A lung infection caused often by a bacteria or virus.

Postmenopausal: After the menopause. Postmenopausal is defined formally as the time after which a woman has experienced 12 consecutive months of amenorrhea (lack of a menstrual period).

Pressure sores: Also known as bed sores. They are areas of damaged skin caused by staying in one position for too long. They commonly form where your bones are close to your skin, such as your back, heels, and hips. Pressure sores can cause serious infections, some of which are life-threatening.

Protein: A large molecule comprising one or more chains of amino acids in a specific order determined by the base sequence of nucleotides in the DNA coding for the protein.

Progesterone: A female hormone and the principal progestational hormone that is made mainly by the corpus luteum in the ovary and by the placenta. Progesterone prepares the lining (endometrium) of the uterus (the womb) to receive and sustain the fertilized egg and so allowing for pregnancy. Also refers to synthetic versions of the hormone.

Progestin: A progestin is a synthetic progestogen (a naturally occurring hormone in females) that has activity similar to naturally occuring progesterone. Hormone therapy for menopause is usually a combination of estrogen and progestin.

Psoriasis: A skin and/or joint disease that commonly causes red scaly patches, called psoriatic plaques, to appear on the skin.

Resorption: The process of losing substance. Bone, when it is remodeled (reshaped), undergoes both new formation and resorption. The cell responsible for the resorption of bone is called an osteoclast.

Rheumatoid arthritis: An autoimmune disease that causes chronic inflammation of the joints, the tissue around the joints, and other organs in the body. In autoimmune diseases, the body tissues are mistakenly attacked by their own immune system. The immune system is a complex organization of cells and antibodies designed normally to "seek and destroy" invaders of the body, particularly infections. Patients with these diseases have antibodies in their blood that target their own body tissues, where they can be associated with inflammation. Because it can affect multiple other organs of the body, rheumatoid arthritis is referred to as a systemic illness and is sometimes called rheumatoid disease. Although rheumatoid arthritis is a chronic illness (meaning it can last for years) patients may experience long periods without symptoms.

Screening: Refers to checkups that you need in the form of medical tests in order to prevent certain diseases.

SERM: Selective Estrogen-Receptor Modulator.

Skeletal: Pertaining to the skeleton, the bones of the body that collectively provide the framework for the body.

Spine: 1. The column of bone known as the vertebral column that surrounds and protects the spinal cord. The spine can be categorized according to level of the body: ie, cervical spine (neck), thoracic spine (upper and middle back), and lumbar spine (lower back). See also vertebral column. 2. Any short prominence of bone. The spines of the vertebrae protrude at the base of the back of the neck and in the middle of the back. These spines protect the spinal cord from injury.

Thyroid: 1. The thyroid gland. Also, pertaining to the thyroid gland. 2. A preparation of the thyroid gland used to treat hypothyroidism. 3. Shaped like a shield. (The thyroid gland was named by Thomas Wharton in 1656 because it was shaped like an ancient Greek shield.)

Tissue: A broad term that is applied to any group of cells that perform specific functions. A tissue in medicine need not form a layer. Thus,

• The bone marrow is a tissue.
• Connective tissue consists of cells that make up fibers in the framework supporting other body tissues.
• Lymphoid tissue is the part of the body's immune system that helps protect it from bacteria and other foreign entities.

T-score: This is the amount of bone you have compared with a young adult of the same gender with peak bone mass. The T-score is used to estimate your risk of developing a fracture.

Vertebra: A vertebra is one of 33 bony segments that form the spinal column of humans. There are seven cervical, 12 thoracic, five lumbar, five sacral (fused into one sacrum bone) and four coccygeal (fused into one coccyx bone).

Vitamin D: A steroid vitamin that promotes the intestinal absorption and metabolism of calcium and phosphorus.

Weightbearing exercises: Exercises that involve muscle pulling on bone. These exercises can help build stronger bones. The more bone mass you build before age 30, the better protected you will be in midlife, and especially after menopause, from the years of gradual bone loss.

These include weightlifting, jogging, hiking, aerobics, dancing, tennis, and other activities where muscles are working against gravity.

Weight loss: Weight loss is a decrease in body weight resulting from either circumstances that are voluntary (diet, exercise) or involuntary (illness). Most instances of weight loss arise owing to the loss of body fat, but in cases of extreme or severe weight loss, protein and other substances in the body can also be depleted.

Wrist:: The proximal segment (the near part) of the hand consisting of the carpal bones and the associated soft parts.

X-ray: High-energy radiation with waves shorter than those of visible light. X-rays possess the properties of penetrating most substances (to varying extents), of acting on a photographic film or plate (permitting radiography), and of causing a fluorescent screen to give off light (permitting fluoroscopy).

Z-score: This is the amount of bone you have compared with other people in your age group and of the same size and gender. If this score is unusually high or low, it may indicate a need for further medical tests.

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Osteoporosis Resources

Government Agencies

* Accepts Spanish calls

*Osteoporosis and Related Bone Diseases National Resource Center, NIH, HHS
2 AMS Circle
Bethesda, MD 20892-3676
Phone: (800) 624-2663
TTY: (202) 466-4315
Fax: (202) 293-2356
http://www.osteo.org

Office of Women's Health, CDC, HHS
Parklawn Building, Room 1561
5600 Fishers Lane
Rockville, MD 20857
Phone: (301) 827-0350
Fax: (301) 827-0926
http://www.fda.gov/womens/default.htm


Private Organizations

*National Osteoporosis Foundation (NOF)
1232 22nd Street, NW
Washington, DC 20037-1292
Phone: (800) 223-9994 (English) and (800) 624-2663 (Spanish)
http://www.nof.org

National Women's Health Network
514 10th Street, NW, Suite 400
Washington, DC 20004
Phone: (202) 628-7814
http://www.nwhn.org


Newsletters, Magazines, Reports

Healthy Women Today
The National Women's Health Information Center
http://www.womenshealth.gov/newsletter

National Osteoporosis Foundation
To sign up for the newsletter from the NOF, log on to this site.
http://www.nof.org/osteoporosis/osteoporosis_report_newsletter.htm


Tools

Harvard School of Public Health
Assess your risk with this online test.
http://www.yourdiseaserisk.harvard.edu/hccpquiz.pl?lang=english&func=home&quiz=osteoporosis

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References

1. Kanis JA, Borgstrom F, De Laet C, et al. Assessment of fracture risk. Oseoporosis Int. 2005;16;581-589 [Evidence Level C]

2. Ascott-Evans BH, Guanabens N, Kivinen S, et al. Alendronate prevents loss of bone desnsity associated with discontinuation of hormone replacement therapy: a randomized controlled trial. Arch Intern Med. 2003;163;789j-794. [Evidence Level A]

3. Rosen CJ. Clinical practice. Postmenopausal osteoporosis. N Engl J Med. 2005;353:595-603. [Evidence Level C]

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