Osteoporosis
What is Osteoporosis?
Osteoporosis is a bone condition that pertains to the loss of the normal density of bones making them fragile. In a layman’s words it refers to bones that are abnormally porous like sponge rather than dense like a brick. This disorder can lead to bone fracture even with the most minor injury.
Symptoms of Osteoporosis
Osteoporosis can be present in a person without showing any symptoms for decades till there is bone fracture. Some Osteoporosis fractures may escape detection until years later because the patients may not be aware of a hairline fracture.
The spine, the hips, feet and wrists are common areas of bone fractures from Osteoporosis. In Osteoporosis bone micro-architecture is disrupted due to calcium depletion and variation in bone proteins.
Diagnosis of Osteoporosis
There are various methods for detection and diagnoses of Osteoporosis:
1) Dual Energy X-ray Absorptiometry (DXA) checks the “Bone Mineral Density” (BMD). BMD is a standard deviation (SD) and is measured as a ’T-score’.
The guidelines for diagnosis are:
Normal bone: T-score of -1.0 or higher SD
Osteopenia: T-score of -1.0 to -2.5 SD (this indicates low bone mass)
Osteoporosis: T-score of -2.5 or below SD (porosity of bones, advanced stage)
2) Blood tests also have to be carried out to check for cancer with metastasis to the bone, multiple myeloma or Cushing’s disease.
3) X-rays for bone densitometry: This test is recommended by the U.S. Preventive Services Task Force (USPSTF) for all women of 65 years of age and above as a rule. USPSTF recommends screening for men in the age group 65 and above for those who are reported a fracture and 80 years and above for those who have never had a fractured bone.
Causes of Osteoporosis
Osteoporosis is an imbalance between bone resorption and new bone formation during remodeling. Bone resorption is the break down of bones and release of minerals resulting in a transfer of calcium from bone fluid to the blood. There are various factors that cause these imbalances:
1) Gender: It is more common in women during menopause or after hysterectomy because of the low levels of estrogen.
2) Race: It is more commonly found in Caucasians and Asians.
3) Body type: Thin and small body frames are more prone to this disease.
4) Heredity: Family histories of fractures will double a person’s chances of suffering from Osteoporosis.
5) Personal history: If a person has suffered a fractured bone as a child, as an adult chances of the disease are greater.
6) Poverty: Poverty can lead to low consumption of a balanced diet.
7) Calcium/Vit D: A diet low in foods containing calcium and Vitamin D over a long period of time would increase chances of Osteoporosis.
Bad habits: Smoking and consumption of alcohol can also increase chances of being afflicted by this disease.
9) Lack of exercise: Insufficient exercise could weaken the skeletal bones. Also immobility due to a stroke could lead to lack of exercise, with the same effect.
10) Malabsorption: Poor absorption of nutrients from the gastrointestinal system can also cause Osteoporosis.
11) Chemotherapy: In women with ovarian cancer, chemotherapy can cause early menopause and lead to Osteoporosis.
12) Anorexia: Obsessive dieting and lack of nutrition can cause this disease.
13) Chronic lives disease: Chronic problems with the liver functions can also be a cause.
14) Medications: Some medications like blood thinners (heparin), anti-seizure medications, steroids and anticonvulsants can cause Osteoporosis.
Types of Osteoporosis
The basic symptom of Osteoporosis is a fracture. Fractures can occur in various parts of the body:
1) Feet/Wrist: A low trauma-fracture or fragility fracture occurs as a result of a fall from a standing height. The person doesn’t need to fall from a height to fracture a bone and they occur during a normal day’s routine. Some examples are fractures of the feet and wrist. Those who have a history of falls or gait disorders are more prone to such fractures.
2) Spine: Vertebral fractures can cause severe pain that radiates from the back to the side of the body. Repeated spinal fractures can cause chronic lower back pain and vertebral collapse as also curving of the spine (hunched-back appearance) which is called a dowager hump.
3) Large bones: Fractures of large bones like hips typically occur as a result of a fall. Hip fractures are difficult to heal even with surgery. These surgeries are complicated and can cause other problems like deep vein thrombosis. They in fact increase the chances of mortality.
4) Rib fractures: Fragility fractures of the ribs occur more in men, in the age group of 30-40 years. These are not diagnosed as signs of Osteoporosis because the fractures may be due to physical activity. But a test for testosterone levels subsequent to the diagnosis of the fracture would show if the person is at risk.
Treatment of Osteoporosis
In choosing a suitable treatment for Osteoporosis, a doctor has to consider all aspects of a patient’s medical history and the severity of the Osteoporosis. The methods of treatment would depend on the cause of Osteoporosis.
1) Hormone Replacement Therapy (HRT): HRT is also called Menopausal hormone therapy (MHT). The Estrogen hormone is prescribed to prevent bone loss, increase bone density, and prevent bone fractures. Estrogen is available as pills and patches. Biophosphonates are also used to strengthen bones but those who have any gastric ailments cannot consume these medications.
2) Selective Estrogen Receptor Modulator (SERM): SERMs are a type of medication that acts as the estrogen receptor throughout the body and augments the HRT.
3) Calcium supplements: Calcium is required for bone growth, bone healing and to maintain bone strength. In the treatment of Osteoporosis, About 1200mg of calcium carbonate supplements per day is essential. Consumption of calcium-rich foods is also necessary.
4) Vitamin D supplements: Vitamin D helps in the absorption of calcium; hence intake of Vitamin D is very necessary. Also, foods containing Vitamin D have to be consumed.
5) Teriparatide: This is a recombinant parathyroid hormone which is being used effectively nowadays for the treatment of Osteoporosis, especially in those patients who cannot be given Biophosphonates. It strengthens the bone mass and stimulates new bone formation.
6) Strontium ranelate: Oral strontium ranelate has been found to be effective in the treatment of vertebral fractures. It belongs to a class of drugs called Dual Action Bone Agents (DABA).
7) Exercises: Studies show that aerobics, weight bearing, and resistance exercises can increase BMD in postmenopausal women. This has to be done along with HRT.
Living with Osteoporosis
The bone fractures caused by Osteoporosis adversely affect the patient’s life in a major way. They experience considerable pain during movement. Their quality of life decreases. They may lose their jobs. It may not only cause restriction of movement for a while but cause permanent disability.
Hip fractures: Patients with a hip fracture will require long term hospitalization and nursing. The total immobilization and lack of exercise can lead to other ailments like pneumonia, bed sores and blood clots in the leg veins that can travel to the lungs. Hence, there is a high mortality rate in the case of hip fractures. The patient is more prone to fracture of proximal femur. Men and women in the age group of 80 and above are more at risk.
Vertebral fractures: Vertebral fractures may have a smaller impact on the mortality rate. But they are crippling, causing kyphosis (hump back). Kyphosis increases pressure on the internal organs and can cause breathing problems or digestive problems.
Rib fractures: Rib fractures are not necessarily crippling but should be treated early to prevent other complications.
Prevention of Osteoporosis 
The goal of preventing Osteoporosis would be to prevent fractures.
1) Fall prevention: Preventing a fall is the most effective way. To this end, obstacles and loose carpets need to be removed.
2) Lifestyle changes: Moderation or abstinence of alcohol and tobacco-based products can prevent falls and fractures.
3) Exercise: During childhood and adolescence itself, people who have a family history of Osteoporosis, need to undertake suitable exercises that encourage peak bone mass. Jogging and walking can also help to a large extent. These exercises would strengthen the bones and help the person to keep better balance.
Caution — in the case of persons who have other ailments like heart disease, obesity, diabetes mellitus, high blood pressure, etc, the exercises have to be monitored by a specialist to prevent complications other than Osteoporosis.
4) Medications: Long term use of steroids can also cause Osteoporosis so the patient may require calcium and vitamin D supplements along with the steroids.
The International Society for Clinical Densitometry believes that a diagnosis of Osteoporosis in men of 50 years and above and pre-menopausal women should not be made by densitometric testing alone. Other factors like family history, previous medical history for fractures (even hairline fractures), lifestyle, diet, medications taken, use of drugs/alcohol/cigarettes, sedentary habits, etc also need to be taken into consideration.
