Osteoporosis is a condition that affects the bones, causing them to become thin and weak.
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Approximately three million people in the UK have osteoporosis, and there are over 230,000 fractures every year as a result.
Osteoporosis happens more commonly in old age when the body becomes less able to replace worn-out bone. Special cells within the bones, called living bone cells, are no longer able to break down old bone and renew it with healthy, dense new bone.
As you get older, you also lose a certain amount of bone, causing the bones to become thinner. The bones become fragile and more likely to break (fracture), particularly the bones of the spine, wrist and hips.
Bone is a living tissue that is constantly repairing itself. It is made of a hard outer shell, which contains a mesh of collagen (tough elastic fibres), minerals, blood vessels and bone marrow. This mesh looks a bit like a honeycomb, with spaces between the different parts. Healthy bones are very dense, and the spaces within bones are small. In bone affected by osteoporosis, the spaces are larger, making the bones weaker and less elastic.
Bones are repaired and reinforced by a range of proteins and minerals, which are absorbed from the bloodstream. They include calcium, phosphorus, proteins and amino acids. The growth of sex hormones controls the amount of mineral substance deposited in the bones. Changes in hormone levels can therefore affect the strength of the bones. For example, the female hormone oestrogen offers some protection against osteoporosis. After the menopause, oestrogen levels fall, often causing the bones to thin quickly.
Symptoms of osteoporosis
Osteoporosis is a condition that develops slowly over several years. The symptoms are not obvious in the early stages of the condition and can take months or years to appear. The early warning signs of osteoporosis can include joint pains and having difficulty standing or sitting up straight. You may have no warning before a minor fall or sudden impact causes a bone fracture.
When the bones are significantly thinned (a low bone mass), breakages of the wrist, hip or spinal bones (vertebrae) are most common. A cough or a sneeze may cause the fracture of a rib, or the partial collapse of one of the bones of the spine.
A fractured bone in an older person can be serious because the bone is no longer able to repair itself effectively. This can lead to arthritis and even disability, such as long-term problems with mobility. Some older people may be unable to live independently following an injury.
The characteristic stooping (bent forward) position that is common in older people is a visible sign of osteoporosis. It happens when the bones in the spine are fractured (cracked), making it difficult to support the weight of the body.
Is osteoporosis painful?
Osteoporosis usually doesn’t cause pain unless a bone is broken as a result of the condition. Although not always painful, spinal fractures are the most common cause of chronic pain associated with the condition.
Causes of osteoporosis
Bones are at their thickest and strongest in early adult life. From around the age of 35, more bone cells are lost than are replaced. This causes the bone to become thinner and weaker. People who exercise when they are young and who remain active into old age are less likely to get osteoporosis. This is because bones stay strong if they are used.
Women are at greater risk of developing osteoporosis than men. This is due to the decrease in the hormone oestrogen after the menopause, which is essential for healthy bones. Women are at greater risk of developing osteoporosis when they have:
- an early menopause (before the age of 45),
- a hysterectomy before the age of 45, particularly when the ovaries are also removed, or
- when their periods are absent for a long time (more than six months) as a result of over-exercising or over-dieting.
The male hormone testosterone also helps to keep the bones healthy. Men continue to produce this hormone into old age, but the risk of osteoporosis is increased in individuals with low levels of testosterone.
Diseases of the hormone-producing glands
Diseases of the hormone-producing glands may cause osteoporosis. The female hormone oestrogen and male hormone testosterone play an important role in keeping bones strong, by processing minerals such as calcium. Osteoporosis can be triggered by hormone-related diseases, including:
- hyperthyroidism (overactive thyroid gland),
- disorders of the adrenal glands, such as Cushing’s syndrome,
- reduced output of sex hormones (oestrogen and testosterone),
- disorders of the pituitary gland, and
Other factors that can increase the risk of osteoporosis include:
- a close family history of osteoporosis,
- long periods of inactivity, such as long-term bed rest,
- heavy drinking and smoking,
- malabsorbtion problems, as experienced in coeliac disease and Crohn’s disease,
- long-term use of high-dose corticosteroid treatment (widely used for conditions such as arthritis and asthma), which can affect bone strength,
- long-term use of a medicine known as enoxaparin, which is used to prevent blood clots,
- inadequate amounts of calcium,
- low vitamin D levels, and
- very low body mass (for example being very underweight - having a BMI of 19 or less - or having thin bones as a result of an eating disorder).
Osteoporosis is not often diagnosed until the weakening of the bones has led to a broken bone. An X-ray cannot reliably measure bone density but is useful to identify spinal fractures.
A bone density scan, called a dual energy X-ray absorptiometry (DEXA) scan, measures the density of bones and compares this to a normal range.
The difference between your bone density and this average is calculated and you are given what is called a ‘T score’. If your T score is between 0 and 1, you’re considered to be within the normal range. If it is between -1 and -2.5, you will be diagnosed with osteopenia, which is the name for the category of bone density between normal and osteoporosis.
You will be classed as having osteoporosis if your T score is below -2.5.
This test helps to measure the strength of bones and the risk of fracture.
Don’t panic if you’re diagnosed with low bone density
Although this is a useful warning, it may not necessarily mean you’re at high risk of fracture. Talk to your doctor about all your risk factors for osteoporosis and broken bones. This will help you take positive steps to improve your bone health.
There are a number of different treatments available for osteoporosis.
Hormone replacement therapy (HRT)
HRT is used for women going through the menopause as it helps to maintain bone density and reduce fracture rates during the treatment. However, HRT is not always recommended as the first treatment for osteoporosis specifically, because it can slightly increase the risk of stroke, heart disease and breast cancer. You should discuss the benefits and risks of HRT with your GP.
Testosterone treatment for men is useful in the relatively rare cases when osteoporosis is due to an insufficient production of male sex hormones.
Bisphosphonates are non-hormonal drugs that maintain bone density and reduce fracture rates. The rate at which cells called osteoclasts break down bone is slowed, and the production of new bone increases. Strontium ranelate can be used as an alternative, if bisphosphonates are found not to be suitable. Your GP will advise you of the best course of treatment.
Calcitonin is a hormone made by the thyroid gland. It inhibits the cells that break down bone.
Calcium and vitamin D supplements
Calcium and vitamin D supplements can be of benefit for older people, male and female, to reduce the risk of hip fracture. Having enough calcium in your diet when you are young is important in minimising the risk, especially for women. You should aim to eat or drink 700mg of calcium each day, which is roughly equivalent to one pint of milk (preferably semi-skimmed). If you are not getting enough calcium in your diet, ask your GP for advice about taking a calcium supplement. All people over the age of 65 should take a vitamin D supplement.
Selective estrogen receptor modulators (SERMs)
SERMs are drugs that have a similar effect on bone as the hormone oestrogen. They help to maintain bone density and reduce the risk of fracture, particularly at the spine.
The National Osteoporosis Society runs 120 support groups across the country for people with osteoporosis. The NOS also have a range of detailed information booklets and a national telephone helpline (0845 450 0230) offering advice and support on all aspects of osteoporosis
Complications of osteoporosis
Osteoporosis can cause a loss of height as a result of fractures in the spinal column. This means the spine is no longer able to support your body’s weight, and it causes the characteristic hunched posture. It is common for minor falls to cause breaks or fractures to the wrist, forearm, neck or hip bones.
Some people become disabled as a result of weakened bones. Hip replacements are often needed following hip fractures, and this can leave people unable to walk independently. The decrease in mobility is a common reason for admitting people to nursing homes, where full-time care can be given.
Your genes determine the potential height and strength of your skeleton. However, lifestyle factors such as diet and exercise can influence how healthy your bones are and the rate at which they repair themselves. Following a healthy lifestyle throughout life is the best way to delay the onset of osteoporosis, and slow the rate at which your bones become fragile.
Regular exercise is essential. Try to do at least 30 minutes of exercise, a minimum of three to four times a week. Two types of exercise are particularly important in improving bone density and helping prevent osteoporosis - weight-bearing exercise and resistance exercise.
Weight-bearing exercises are those where your feet and legs are supporting your own weight. High-impact weight-bearing exercises, such as running, skipping, dancing, aerobics and even jumping up and down on the spot, are all useful ways of strengthening your muscles, ligaments and joints. When exercising, make sure that you wear footwear that provides your ankles and feet with adequate support, such as trainers or walking boots.
Those over the age of 60 can also benefit from doing regular weight-bearing exercise. This can include brisk walking, keep-fit classes or a game of tennis. Swimming and cycling are not weight-bearing exercises.
Resistance exercises are those that use muscle strength, where the action of the tendons pulling on the bones boosts bone strength. Examples include press-ups, weight lifting, or using weight equipment at a gym. If you have recently joined a gym or you have not been for a while, it is likely your gym will give you an induction. This involves being shown how to use all the equipment and recommended exercise techniques. If you are unsure how to use a piece of equipment or how to do a type of exercise, ask for help from a gym instructor.
Other lifestyle factors that can help prevent osteoporosis include:
- eating a healthy diet that contains plenty of calcium - at least 700mg a day (equivalent to one pint of milk),
- quitting smoking - cigarette smoking is associated with an increased risk of osteoporosis, and
- limiting your alcohol intake - the recommended daily amount is three to four units for men and two to three units for women.
There are aspects of your home environment you can change to reduce the risk of fracturing or breaking a bone. It is a good idea to check your whole house for hazards that you may trip over, such as trailing wires. Make sure rugs and carpets are secure, and keep rubber mats by the sink and in the bath, to prevent slipping.
You should also make sure that you have regular sight and hearing tests. Some older people may need to wear special protectors over their hips to cushion any fall. Your GP will be able to offer you help and advice about changes to your lifestyle.
Get some sun!
Sunlight (in summer and spring) triggers the production of vitamin D, which then leads to more calcium being absorbed into your body. This process helps strengthen teeth and bones, which in turn helps to prevent conditions such as osteoporosis.
Can I still work?
You should be able to continue to work when you have osteoporosis. It’s very important that you remain physically active and sustain a fulfilled lifestyle to keep your bones healthy and avoid focusing too much of your attention on your potential health problems. However, if your work involves the risk of falling or breaking a bone, you should seek advice from your employer, doctor and the National Osteoporosis Society about how best to limit your risk of having an accident or injury that could lead to a bone break.
Osteoporosis expert Sarah Leyland on the questions to ask.
We asked Sarah Leyland, osteoporosis nurse and helpline supervisor for the National Osteoporosis Society, what she would want to know if she was diagnosed with osteoporosis.
How do I know what type of osteoporosis I have?
Ask your doctor to explain your diagnosis and what your X-rays are showing. If your X-ray is showing squashed bones in the spine, you may have ‘established osteoporosis’. Bones that look porous (spongy) may be an indication of low bone density and, if your bone density is significantly lower than normal, osteoporosis.
What sort of exercise can I do to strengthen my bones?
Do some weight-bearing exercise, such as brisk walking or climbing stairs, which pulls on your skeleton, stimulating your bone cells and improving bone strength. Choose exercise you enjoy, because you’ll need to do it throughout your life.
Why do I have to stop smoking?
Smoking slows down the activity of bone-building cells, which increases your risk of osteoporotic fractures (broken bones). Smoking and drinking excessive amounts of coffee and alcohol can also increase the calcium lost from the body. We need calcium for optimum bone strength.
Should I take vitamin supplements to strengthen my bones?
You’ll need to make sure you’re getting enough calcium and other minerals and vitamins, such as magnesium, B vitamins and vitamin K. You probably don’t need to take supplements to get all these nutrients. A well-balanced, calcium-rich diet with plenty of fruit and vegetables will give your bones all the goodness they need and can help to reduce the loss of calcium in the body caused by some foods. Calcium is easily available in dairy foods, and is also found in dark green leafy vegetables, nuts, pulses and bony fish.
Do I have to take medication?
Not everyone with osteoporosis needs a drug treatment. However, if you’re at high risk of bone breakages or fractures, your doctor will recommend the right treatment. You’ll usually need to have this treatment on a long-term basis.
What should I do if I experience side effects from my medication?
Talk to your doctor. Alendronic acid is the cheapest osteoporosis drug treatment, and probably as effective as any other, so it’s likely to be your doctor’s first choice. However, there are other options available.
If you have had a spinal fracture (compressed bones in the spine) caused by osteoporosis, Sarah has this advice.
- You won’t be paralysed, but you can be in a lot of pain. Remember, these fractures heal like any other broken bone, so the pain should ease after six to eight weeks. Talk to your doctor about the range of pain relieving drugs that can help. You may also want to consider other therapies, such as heat, transcutaneous electrical nerve stimulation (TENS), relaxation techniques and complementary therapies. Everyone recovers differently, so don’t be too hard on yourself if it takes a little longer to get back to normal.
- Bed rest is not going to help your spine to heal. Although you might need to rest in the first few days, gradually try to increase the amount of gentle exercise you do each day. Bed rest will, over time, increase your loss of bone density and reduce your muscle strength, so it’s best to avoid long periods of immobility.
- Long-term discomfort and pain is often caused by curvature and shortening of the spine. This can happen as your healed bones don’t return to their previous shape, leaving you with muscle spasm and ligament strain. Exercise to increase muscle strength, as well as supporting the spine, can help. Ask your doctor for a physiotherapy referral for specific advice. If the pain persists and is disabling, you could ask your doctor for a referral to a specialist pain clinic or pain-management course.
- Be as positive as you can. Most people recover well from these compression fractures in the spine and return to a good quality of life.
Ask your doctor
‘I was able to speak with at length with a nurse who gave me detailed information on diet, exercise and treatments’
Dorothy Borbas was diagnosed with osteoporosis at 75 years of age
“I discovered that I had osteoporosis in 1999, three days after I turned 75. I was in bed and had a cramp in my leg. When I got out of bed to stop the cramping I fell and fractured two vertebrae. Prior to my fractures, I hadn’t realised that I had osteoporosis, and it was some time before I received a firm diagnosis from the hospital. I then sought the help of the National Osteoporosis Society (NOS).
“The NOS provided me with an absolute lifeline. I was able to speak at length with a nurse who put my mind at ease and gave me detailed information on diet, exercise and treatments.
“I joined my local NOS support group. I am now an active member and enjoy helping to organise local fundraising activities.”
Bob Rees was diagnosed with osteoporosis after collapsing in pain on a family holiday
“I was 43 when I was diagnosed with osteoporosis. I was on a family holiday in the Dominican Republic in June 2002, when I collapsed in agony. In March 2003, nine months later and after extensive tests, I was diagnosed with severe spinal osteoporosis. I remember my relief at being told that I didn’t have bone cancer, as had been suspected, but my relief was short-lived when I was told that I had the bones of an 80-year-old.
“I turned to the National Osteoporosis Society (NOS) for support and I’m now an ambassador for the charity. I find that talking to other people with osteoporosis helps me deal with my own pain, and I advise anyone who has recently been diagnosed with osteoporosis to try to keep active. Don’t sit back and give in! Small lifestyle changes, such as walking or swimming, can help to keep your bones healthy.”
‘Even lying in bed was uncomfortable’
Phyllis Long, aged 60, was recently diagnosed with osteoporosis after months of experiencing upper back pain
“I had severe pain in the right side of my upper back for about one month, and decided I needed to see my GP. My back was so sore when anything touched it that even lying in bed was uncomfortable. It felt like my very bones were sore.
“I went to see my GP in January and he wondered if I was experiencing thinning of my bones because of my age, 60, and my medical history – I’d had a few breakages in the past 10 years. He referred me to a consultant orthopedic and spine surgeon, and he prescribed diclofenac 50ml painkillers to keep the pain at bay.
“The consultant suggested I have an MRI scan on my back and a bone density scan on my back and hips, which would measure the calcium in my bones. The MRI showed that I had arthritis in my lower three vertebrae, and the bone density scan gave me my T-score. I was told that the T-score baseline was 0 and that a score between one and three would be ‘normal’. Unfortunately, the scan revealed that my hips, at -1.3, were in the osteopenic level, and my spine, at -3, was in the osteoporotic level.
“The score meant that I definitely had osteoporosis, and that my back was worse than my hips. My doctor indicated that the emergency hysterectomy I had after the birth of my second child could be a factor in developing the osteoporosis. I was very taken aback, and had no idea that I would ever have such a thing. I’d led a healthy life, eating lots of fresh fruit and taking plenty of exercise. Plus, there was no history of osteoporosis in my family.
“My consultant told me that they would treat the condition with a tablet, called alendronic acid (70ml), which I now have to take once a week for the rest of my life. It’s from a group of non-hormonal medicines, known as eisphosphonates, which prevent bone loss from the body.
“I do walk regularly and am active in the garden, and the medical advice was to continue all activity as normal, as exercise would help to increase the amount of calcium in my bones.
“I had to provide a list of the foods I regularly ate, so the doctor could see if there were any gaps in my diet. As I don’t have a very large intake of calcium the doctor also prescribed chewable calcium tablets for me to take daily, two 1250mg tablets. I was given a list of high-calcium content foods, such as yoghurt, semi-skimmed milk, cheeses, whitebait, sardines and spinach, which I was advised to eat to boost my calcium intake.
“Within 24 months I’ll have another bone scan and my doctor is confident that my bone density will have increased significantly. For now, I’m waiting for an appointment with a rheumatologist, who I assume will help me further in dealing with the condition.”
NHS Choices links
- News: zoledronic acid
- News: alendronate risk
- Video: post-op. hip care
- Video: stay active
- Live Well: over-60s
- Live Well: strong bones
- Health A-Z: hip replacement