Primary Disease Name: Osteoporosis
A debilitating disease that can be prevented and treated.
Osteoporosis Information
Osteoporosis is a disease in which bones become fragile and more
likely to break. If not prevented or if left untreated, osteoporosis
can progress painlessly until a bone breaks. These broken bones,
also known as fractures, occur typically in the hip, spine, and
wrist.
Any bone can be affected, but of special concern are fractures of
the hip and spine. A hip fracture almost always requires hospitalization
and major surgery. It can impair a person's ability to walk unassisted
and may cause prolonged or permanent disability or even death. Spinal
or vertebral fractures also have serious consequences, including
loss of height, severe back pain, and deformity.
Millions of Americans are at risk. While women are four times more
likely than men to develop the disease, men also suffer from osteoporosis.
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Osteoporosis Definition
Osteoporosis, or porous bone, is a disease characterized by low
bone mass and structural deterioration of bone tissue, leading to
bone fragility and an increased susceptibility to fractures, especially
of the hip, spine and wrist, although any bone can be affected.
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Osteoporosis Facts and Figures
- Osteoporosis is a major public health threat for 28 million Americans,
80% of whom are women.
- In the U.S. today, 10 million individuals already have osteoporosis
and 18 million more have low bone mass, placing them at increased
risk for this disease.
- One out of every two women and one in eight men over 50 will
have an osteoporosis-related fracture in their lifetime.
- More than 2 million American men suffer from osteoporosis, and
millions more are at risk. Each year, 80,000 men suffer a hip fracture
and one-third of these men die within a year.
- Osteoporosis can strike at any age.
- Osteoporosis is responsible for more than 1.5 million fractures
annually, including 300,000 hip fractures, and approximately 700,000
vertebral fractures, 250,000 wrist fractures, and more than 300,000
fractures at other sites.
- Estimated national direct expenditures (hospitals and nursing
homes) for osteoporosis and related fractures is $14 billion each
year.
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What is Bone?
Bone is living, growing tissue. It is made mostly of collagen,
a protein that provides a soft framework, and calcium phosphate,
a mineral that adds strength and hardens the framework.This combination
of collagen and calcium makes bone strong yet flexible to withstand
stress. More than 99% of the body's calcium is contained in the
bones and teeth. The remaining 1% is found in the blood.
Throughout your lifetime, old bone is removed (resorption) and new
bone is added to the skeleton (formation). During childhood and
teenage years, new bone is added faster than old bone is removed.
As a result, bones become larger, heavier, and denser. Bone formationcontinues
at a pace faster than resorption until peak bone mass (maximum bone
density and strength) is reached around age 30. After age 30, bone
resorption slowly begins to exceed bone formation.
Bone loss is most rapid in the first few years after menopause but
persists into the postmenopausal years. Osteoporosis develops when
bone resorption occurs too quickly or if replacement occurs too
slowly. Osteoporosis is more likely to develop if you did not reach
optimal bone mass during your bone building years.
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Osteoporosis and Women
Eighty percent of those affected by osteoporosis are women. Five
percent of non-Hispanic black women over age 50 are estimated to
have osteoporosis; an estimated additional 35 percent have low bone
mass that puts them at risk of developing osteoporosis.
Ten percent of Hispanic women aged 50 and older are estimated to
have osteoporosis, and 49 percent are estimated to have low bone
mass. Twenty percent of non-Hispanic white and Asian women aged
50 and older are estimated to have osteoporosis, and 52 percent
are estimated to have low bone mass.
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Osteoporosis and Men
Twenty percent of those affected by osteoporosis are men. Seven
percent of non-Hispanic white and Asian men aged 50 and older are
estimated to have osteoporosis and 35 percent are estimated to have
low bone mass.
Four percent of non-Hispanic black men aged 50 and older are estimated
to have osteoporosis and 19 percent are estimated to have low bone
mass.
Three percent of Hispanic men aged 50 and older are estimated to
have osteoporosis and 23 percent are estimated to have low bone
mass.
Osteoporosis Related Fractures
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One in two women and one in four men over age 50 will have an osteoporosis-related
fracture in their remaining lifetime. Osteoporosis is responsible
for more than 1.5 million fractures annually, including:
- over 300,000 hip fractures; and approximately
- 700,000 vertebral fractures
- 250,000 wrist fractures
- 300,000 fractures at other sites
The most typical sites of fractures related to osteoporosis are
the hip, spine, wrist and ribs, although the disease can affect
any bone in the body.
The rate of hip fractures is two to three times higher in women
than men6; however the one year mortality following a hip fracture
is nearly twice as high for men as for women.
A woman's risk of hip fracture is equal to her combined risk of
breast, uterine and ovarian cancer.
In 1991, about 300,000 Americans age 45 and over were admitted to
hospitals with hip fractures. Osteoporosis was the underlying cause
of most of these injuries. An average of 24 percent of hip fracture
patients aged 50 and over die in the year following their fracture.
One-fourth of those who were ambulatory before their hip fracture
require long-term care afterward.
At six months after a hip fracture, only 15% of hip fracture patients
can walk across a room unaided.
White women 65 or older have twice the incidence of fractures as
African-American women.
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Osteoporosis Cost
The estimated national direct expenditures (hospitals and nursing
homes) for osteoporotic and associated fractures was $17 billion
in 2001 ($47 million each day) and the cost is rising.
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Osteoporosis Symptoms
Osteoporosis is often called the "silent disease" because
bone loss occurs without symptoms. People may not know that they
have osteoporosis until their bones become so weak that a sudden
strain, bump or fall causes a fracture or a vertebra to collapse.
Collapsed vertebrae may initially be felt or seen in the form of
severe back pain, loss of height, or spinal deformities such as
kyphosis or stooped posture.
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Osteoporosis Risk Factors
Certain people are more likely to develop osteoporosis than others.
Factors that increase the likelihood of developing osteoporosis
are called "risk factors." These Osteoporosis risk factors include:
Personal history of fracture after age 50 - Current low bone mass
- History of fracture in a 1° relative - Being female - Being thin
and/or having a small frame - Advanced age - A family history of
osteoporosis - Estrogen deficiency as a result of menopause, especially
early or surgically induced - Abnormal absence of menstrual periods
(amenorrhea) - Anorexia nervosa - Low lifetime calcium intake -
Vitamin D deficiency - Use of certain medications, such as corticosteroids
and anticonvulsants - Presence of certain chronic medical conditions
- Low testosterone levels in men - An inactive lifestyle - Current
cigarette smoking - Excessive use of alcohol - Being Caucasian or
Asian, although African Americans and Hispanic Americans are at
significant risk as well Women can lose up to 20 percent of their
bone mass in the five to seven years following menopause, making
them more susceptible to osteoporosis.
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Osteoporosis Detection
Specialized tests called bone density tests can measure bone density
in various sites of the body. A bone density test can: Detect osteoporosis
before a fracture occurs and predict your chances of fracturing
in the future.
DXA BMD can determine your rate of bone loss and/or monitor the
effects of treatment.
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Osteoporosis Prevention
By about age 20, the average woman has acquired 98 percent of her
skeletal mass. Building strong bones during childhood and adolescence
can be the best defense against developing osteoporosis later. There
are four steps, which together, can optimize bone health and help
prevent osteoporosis. They are: " 1.A balanced diet rich in calcium
and vitamin D
2.Weight-bearing exercise
3.A healthy lifestyle with no smoking or excessive alcohol intake
4.Bone density testing and medication when appropriate.
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Osteoporosis Medication and Treatment
Although there is no cure for osteoporosis, the following medications
are approved by the FDA for postmenopausal women to prevent and/or
treat osteoporosis:
Bisphosphonates
Alendronate (brand name Fosamax®)
Risedronate (brand name Actonel®)
Calcitonin (brand name Miacalcin®)
Estrogen/Hormone Therapy
Climara®
Estrace®
Estraderm®
Estratab®
Ogen®
Ortho-Est®
Premarin®
Vivelle®
Estrogens and Progestins
Activella™
FemHrt®
Premphase®
Prempro®
Parathyroid Hormone Teriparatide (PTH (1-34)
Fortéo® Selective Estrogen Receptor Modulators (SERMs)
Raloxifene (brand name Evista®)
Alendronate is approved as a treatment for osteoporosis in men and
is approved for treatment of glucocorticoid (steroid)-induced osteoporosis
in men and women. Risedronate is approved for prevention and treatment
of glucocorticoid-induced osteoporosis in men and women.
Parathyroid hormone is approved for the treatment of osteoporosis
in men who are at high risk of fracture. Treatments under investigation
include sodium fluoride, vitamin D metabolites, and other bisphosphonates
and selective estrogen receptor modulators.
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How to Tell the Health of Your Bones
It is important to understand that bone is not a hard and lifeless
structure; it is, in fact, complex, living tissue. Our bones provide
structural support for muscles, protect vital organs, and store
the calcium essential for bone density and strength.
Because bones are constantly changing, they can heal and may be
affected by diet and exercise. Until the age of about 30, you build
and store bone efficiently. Then, as part of the natural aging process,
your bones begin to break down faster than new bone can be formed.
In women, bone loss accelerates after menopause, when your ovaries
stop producing estrogen - the hormone that protects against bone
loss.
Think of your bones as a savings account. There is only as much
bone mass in your account as you deposit. The critical years for
building bone mass are from prior to adolescence to about age 30.
Some experts believe that young women can increase their bone mass
by as much as 20 percent - a critical factor in protecting against
osteoporosis.
Assessing your bone health
To determine if you have osteoporosis or may be at risk for the
disease, your doctor will ask you a variety of questions about your
lifestyle and medical history. Your doctor will want to know if
anyone in your family has suffered from osteoporosis or if they
have fractured bones. Based on a comprehensive medical assessment,
your doctor may recommend that you have your bone mass measured.
A bone mass measurement is the only way to tell if you have osteoporosis.
Specialized tests called bone density tests can measure bone density
in various sites of the body. A bone density test can:
- Detect osteoporosis before a fracture occurs
- 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.
The only sure way to determine bone density and fracture risk for
osteoporosis is to have a bone mass measurement (also called bone
mineral density or BMD test). Your doctor can help you determine
whether you should have a BMD test.
NOF Guidelines indicate, BMD testing should be performed
on:
- All women aged 65 and older regardless of risk factors*
- Younger postmenopausal women with one or more risk factors (other
than being white, postmenopausal and female).
- Postmenopausal women who present with fractures (to confirm the
diagnosis and determine disease severity).
*Note: Medicare covers BMD testing for the following individuals
aged 65 and older:
- Estrogen deficient women at clinical risk for osteoporosis Individuals
with vertebral abnormalities
- Individuals receiving, or planning to receive, long-term glucocorticoid
(steoid) therapy
-Individuals with primary hyperparathyroidism
- Individuals being monitored to assess the response or efficacy
of an approved osteoporosis drug therapy.
Medicare permits individuals to repeat BMD testing every two years.
There are several ways to measure bone mineral density; all are
painless, noninvasive and safe and are becoming more readily available.
In many testing centers you don't even have to change into an examination
robe.
The tests measure bone density in your spine, hip and/or wrist,
the most common sites of fractures due to osteoporosis. Recently,
bone density tests have been approved by the FDA that measure bone
density in the middle finger and the heel or shinbone. Your bone
density is compared to two standards, or norms, known as "age matched"
and "young normal."
The age-matched reading compares your bone density to what is expected
in someone of your age, sex and size. The young normal reading compares
your density to the optimal peak bone density of a healthy young
adult of the same sex. The information from a bone density test
enables your doctor to identify where you stand within ranges of
normal and to determine whether you are at risk for fracture. In
general, the lower your bone density, the higher your risk for fracture.
Test results will help you and your doctor decide the best course
of action for your bone health.
Types of BMD Tests
There are several different machines that measure bone density.
Central machines measure density in the hip, spine and total body.
Peripheral machines measure density in the finger, wrist, kneecap,
shin bone and heel.
- DXA (Dual Energy X-ray Absorptiometry) measures
the spine, hip or total body
- pDXA (Peripheral Dual Energy X-ray Absorptiometry)
measures the wrist, heel or finger
- SXA (single Energy X-ray Absorptiometry) measures
the wrist or heel
- QUS (Quantitative Ultrasound) uses sound waves
to measure density at the heel, shin bone and kneecap.
- QCT (Quantitative Computed Tomography) most commonly
used to measure the spine, but can be used at other sites;
- pQCT (Peripheral Quantitative Computed Tomography)
measures the wrist
- RA (Radiographic Absorptiometry) uses an X-ray
of the hand and a small metal wedge to calculate bone density
- DPA (Dual Photon Absorptiometry) measures the
spine, hip or total body (used infrequently)
- SPA (Single Photon Absorptiometry) measures the
wrist (used infrequently)
With the information obtained from a BMD test, you and your doctor
can decide what prevention or treatment steps are right for you.
BMD tests cannot stand alone; they should always be a part of a
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Steps to Bone Health and Osteoporosis Prevention
1.Get your daily recommended amounts of calcium and vitamin D
2.Engage in regular weight-bearing exercise
3.Avoid smoking and excessive alcohol
4.Talk to your doctor about bone health
5.Have a bone density test and take medication when appropriate
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Osteoporosis Prevention - Calcium
Calcium is needed for the heart, muscles and nerves to function properly and for blood to clot. Inadequate calcium is thought to contribute to the development of osteoporosis. National nutrition surveys have shown that many women and young girls consume less than half the amount of calcium recommended to grow and maintain healthy bones.
Depending on your age, an appropriate calcium intake falls between 1000 and 1300 mg a day. If you have difficulty getting enough calcium from the foods you eat, you may take a calcium supplement to make up the difference.
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Osteoporosis Prevention - Vitamin D
Vitamin D is needed for the body to absorb calcium. Without enough vitamin D, you will be unable to absorb calcium from the foods you eat, and your body will have to take calcium from your bones. Vitamin D comes from two sources: through the skin following direct exposure to sunlight and from the diet. Experts recommend a daily intake between 400 and 800 IU per day, which also can be obtained from fortified dairy products, egg yolks, saltwater fish and liver.
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Osteoporosis Prevention - Exercise
Exercise is also important to good bone health. If you exercise regularly in childhood and adolescence, you are more likely to reach your peak bone density than those who are inactive. The best exercise for your bones is weight-bearing exercise such as walking, dancing, jogging, stair-climbing, racquet sports and hiking. If you have been sedentary most of your adult life, be sure to check with your healthcare provider before beginning any exercise program.
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Osteoporosis Prevention - No Smoking
Smoking is bad for your bones as well as for your heart and lungs. Women who smoke have lower levels of estrogen compared to nonsmokers and frequently go through menopause earlier. Postmenopausal women who smoke may require higher doses of hormone replacement therapy and may have more side effects. Smokers also may absorb less calcium from their diets.
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Osteoporosis Prevention - Alcohol
Regular consumption of 2 to 3 ounces a day of alcohol may be damaging
to the skeleton, even in young women and men. Those who drink heavily
are more prone to bone loss and fractures, both because of poor
nutrition as well as increased risk of falling.
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Questions and Answers on the Use of Hormones After Menopause for Osteoporosis and Recent Findings from the Women's Health Initiative
Source: National Institute of Arthritis and
Musculoskeletal and Skin Diseases
http://www.niams.nih.gov/hi/topics/osteoporosis/hormones.htm
What is the Women's Health Initiative?The Women's Health Initiative (WHI) is a long-term study of the risks and benefits of strategies that may reduce the occurrence of heart disease, breast and colorectal cancer, and bone fractures in postmenopausal women. More than 160,000 healthy postmenopausal women aged 50 to 79 were enrolled as WHI participants between 1993 and 1998. One part of the WHI is a clinical trial designed to study the long-term effects of postmenopausal hormone therapy on heart disease, osteoporosis, and colorectal and breast cancer risk. The hormone trial has two parts: one part has been looking at the effects of estrogen plus a progestin (a form of the hormone progesterone) in 16,608 postmenopausal women who have a uterus (that is, women who have not had a hysterectomy); the other part is looking at the effects of estrogen alone in 10,739 women who have had a hysterectomy. For women with an intact uterus, a progestin is given together with estrogen because estrogen alone has been shown to increase the risk of endometrial cancer (cancer of the lining of the uterus).
In each part of the hormone trial, half of the women were randomly chosen to receive hormone pills, and the other half to receive placebo pills (inactive pills). Neither the study participants nor the researchers know who is taking hormones and who is taking a placebo. Medical studies with this design, known as randomized, controlled, double-blind clinical trials, are considered the "gold standard" for demonstrating a cause-and-effect connection between a particular treatment or behavior and a medical condition or result because they provide the most scientifically reliable information.
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Why were the women in the WHI estrogen plus progestin clinical trial told to stop taking the study medication in July 2002?An analysis by members of the independent Data Safety and Monitoring Board (DSMB) that monitors the health of participants during the study found that women taking the estrogen plus progestin combination had an increased risk of breast cancer compared to women taking placebo pills. The DSMB analysis also indicated that the overall health risks of taking estrogen plus progestin outweighed the benefits. In addition to an increased breast cancer risk, women in the estrogen plus progestin group had an increased risk of heart attacks, strokes, and blood clots in the lungs and legs.
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What are the effects of estrogen and menopause on bone health in women?
Estrogen is a hormone produced by the ovaries, and in small quantities by other body tissues. Estrogen plays a critical role in building and maintaining bone in adolescent and younger women. Throughout a person's lifetime, old bone is removed and new bone is added to the skeleton. In childhood and adolescence, new bone is added faster than old bone is removed, and the bones become larger, heavier, and denser. Women usually reach their maximum amount of bone, known as peak bone mass, between the ages of 20 and 30. After that, bone mass may remain stable or decline gradually, depending on a variety of lifestyle factors. Calcium and vitamin D and physical activity are also important for building bone and maintaining bone throughout life.
The reduction in estrogen production during menopause is the major cause of bone loss in women during later life. In the few years before menopause (defined as the completion of a full year without a menstrual period), the amount of estrogen produced by the ovaries starts to drop, resulting in a loss of bone mass. During menopause, the rate of bone loss increases as the amount of estrogen produced by the ovaries drops dramatically. Estrogen levels in postmenopausal women are about one-tenth the levels in pre-menopausal women. Bone loss is most rapid in the first few years after menopause but continues into the postmenopausal years.
Loss of bone mass due to low estrogen levels can also occur after a woman has had surgery to remove both her ovaries. This is sometimes called "surgical menopause." Surgical menopause can also result from failure of the ovaries following a hysterectomy, or following cancer therapy, such as chemotherapy or radiation treatments. Bone loss due to either natural or surgical menopause can lead to osteoporosis. But bone loss after menopause and with aging is natural and tolerable in many women and does not need to be treated unless the bone loss is so great that it leaves the bones fragile and prone to fracture.
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What is Osteoporosis?
Osteoporosis is a skeletal disorder marked by reduced bone strength that predisposes a person to an increased risk of fractures. Bone strength reflects two main features: bone density (which is related to bone mass) and bone quality.
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What Causes Osteoporosis?
Three main factors cause osteoporosis: (1) an increased rate of bone loss at menopause in women or as men and women age; (2) less than optimal bone growth during childhood and adolescence, resulting in failure to reach optimal peak bone mass; and (3) bone loss that is secondary to disease conditions, eating disorders, or certain medications and medical treatments. More than one factor may contribute to osteoporosis. For example, if a woman starts out with a relatively low peak bone mass, the loss of bone that occurs with menopause is more likely to result in osteoporosis.
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What is known about the effects of postmenopausal hormone therapy on bone
health?
TStudies have shown that various forms of estrogen, including estrogen combined with progestin, can increase bone density or prevent bone loss in postmenopausal women. Results of some small clinical trials also indicated that estrogen reduces fractures in the spine. However, there were no large randomized clinical trials showing that estrogen prevents hip and other osteoporosis-related fractures. Research also indicates that women who take estrogen to maintain bone density must continue taking the hormone because its beneficial effects on bone health disappear after hormone use is discontinued.
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Did the WHI clinical trial of postmenopausal hormone therapy reveal any new
information on the effects of estrogen plus progestin on bone health?
Yes. The WHI is the first randomized clinical trial to provide definitive evidence that postmenopausal hormone therapy can prevent osteoporosis-related hip fractures as well as fractures at other sites. The WHI results show that estrogen plus progestin reduces the rate of hip and spine fractures by one third (34 percent) and reduces the rate of other osteoporosis-related fractures by 23 percent. Stated another way, the study results indicate that for every 10,000 postmenopausal women taking estrogen plus progestin, 10 will have a hip fracture each year, compared to 15 out of every 10,000 women taking placebo pills.
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What is known about the effects of postmenopausal hormone therapy on bone
health?
TStudies have shown that various forms of estrogen, including estrogen combined with progestin, can increase bone density or prevent bone loss in postmenopausal women. Results of some small clinical trials also indicated that estrogen reduces fractures in the spine. However, there were no large randomized clinical trials showing that estrogen prevents hip and other osteoporosis-related fractures. Research also indicates that women who take estrogen to maintain bone density must continue taking the hormone because its beneficial effects on bone health disappear after hormone use is discontinued.
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What do the WHI results tell us about the effects of estrogen alone on bone
health and other conditions?
The second part of the WHI hormone therapy trial is looking at the effects of estrogen alone on osteoporosis, heart disease, and breast and colorectal cancer in women who have had a hysterectomy. This part of the study is continuing, and results are not yet available. Members of the WHI Data Safety and Monitoring Board who reviewed the estrogen-progestin trial results are also regularly reviewing the results of the estrogen study to monitor the potential health risks of the study medication.
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Are there any other steps I can take to prevent osteoporosis and
fractures or keep osteoporosis from worsening?
Yes, there are many things you can do. Eat a healthy, balanced
diet that is high in fruits and vegetables and includes adequate
calcium, vitamin D, and vitamin K. Dietary sources of calcium and
vitamins are best, but they are also available as supplements. You
should also avoid smoking and, if you drink alcohol, do so in moderation.
Exercise can also help maintain bone health. Regular, weight-bearing
exercise (for example, walking, hiking, jogging, stair-climbing,
weight training, tennis, and dancing) may strengthen bone, and balancing
and muscle-strengthening exercises can reduce your risk of falling
and therefore lessen your chances of breaking a bone.
To reduce your risk of fracture, it's also important to take steps
to eliminate factors in your environment that can lead to falls.
Some of the many things you can do to avoid falls indoors include
keeping rooms free of clutter, keeping floors smooth but not slippery,
checking that all carpets and area rugs have skid-proof backing
or are tacked to the floor, installing grab bars and using a rubber
bath mat in your tub or shower, avoiding obstacles that you might
trip over, having your vision checked regularly, and using a nightlight
or flashlight if you get up at night. To avoid falls outdoors, use
a cane or walker if you need it for added stability, wear rubber-soled
shoes for traction, walk on grass when sidewalks are slippery, and
sprinkle salt or kitty litter on slippery sidewalks in winter.
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Are any other treatments for osteoporosis in development?
Yes. A new medication, parathyroid hormone (PTH), is pending approval by the FDA for treatment of osteoporosis. Unlike other osteoporosis drugs, which prevent or reduce bone loss, PTH has been shown to stimulate new bone formation. PTH is taken by injection. Researchers are studying other bisphosphonates and SERMs, and looking at the effectiveness of combination therapies for osteoporosis. They are also investigating new approaches for preventing and treating osteoporosis, including the role of statin (cholesterol-lowering) drugs, phytoestrogens (plant estrogens), nitric oxide (a medication often given to heart patients in the form of nitroglycerin), biophysical (vibrational) stimulation of bone, and gene therapy.
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