Osteoporosis Risk Factors,

Screening and Treatment

Although osteoporosis affects more than 26 million people in the United States alone, less than 10% of women with the disease and only 1% of men are diagnosed and receive treatment. Dr. Lynn Kohlmeier, of the Skeletal Health and Osteoporosis Center, calls it a "silent" disease.

Osteoporosis is loss of bone mass. It leads to increasingly fragile bones and the risk of fracture, particularly of the hip, spine, and wrist. Bone loss is painless: You may not know you have osteoporosis until a painful fracture unmistakably announces its presence.

There are things you can do to prevent osteoporosis. And even after it starts, you can slow it down. But first you have to know you are at risk.

Are You at Risk for Osteoporosis?

Osteoporosis is eight times more common among women than men. Being female is in itself the primary risk factor for this disease.

Estrogen seems to play a role here. Estrogen protects women from losing bone mass. But if you don't have enough estrogen--because of menopause, surgical removal of the ovaries, or irregular menstruation--your bone mass may decline and osteoporosis may result. After menopause, when estrogen production drops, a woman may lose from 30 to almost 50% of her bone mass.

Smoking cigarettes stimulates conversion of estrogen into an inactive form. That's why women who are heavy smokers may benefit less from estrogen replacement therapy.

Other risk factors include:

"Forty percent of males and 30% of females with hip fractures are vitamin D-deficient, and most individuals in the United States fail to meet the recommended daily allowance for calcium intake after age 10," says Dr. Kohlmeier. Our bodies need vitamin D so we can absorb calcium, and calcium has beneficial effects on bone mass.

Some drugs also make you more susceptible to osteoporosis. Steroids decrease how much calcium is absorbed by the body, especially when they are used for prolonged periods of time or by postmenopausal women. Thyroid hormone and thyroid replacement, both treatments for patients with thyroid cancer, also cause bone loss.

Finally, extended bed rest or immobility is a risk factor for osteoporosis. Exercise increases a person's bone density by 10-20%, so sedentary lifestyle can cause bone loss.

High-risk individuals include postmenopausal women not on hormone replacement therapy, both men and women treated with steroid medication, and patients with non-traumatic (fractures that occur "without good reason"--without an obvious external cause) fractures, hip fracture, or documented bone loss. If you fall into one of these categories, have your doctor test your bone mineral density. This test can establish how much bone has been lost and also show how well a woman is responding to therapy.

Those who have no risk factors may not need to be screened. But we all should be aware that exercise and good nutrition can play important roles in preventing this disease.

How Can You Prevent Osteoporosis?

Both vitamin D and calcium provide some protection from osteoporosis. Men and premenopausal women are commonly advised to ingest 1,000 milligrams (mg) per day of calcium. For postmenopausal women the suggestion is 1,500-2,000 mg a day. Foods high in calcium include milk, cheese, and yogurt. Vitamin D intake should begin at 400-800 international units (IU) a day; it is found in significant quantities in fatty fish, eggs, and fortified milk and is made by the body when it is exposed to sunlight.

Weight-bearing, impact-safe exercise is "key to achieving peak bone mass," according to Dr. Kohlmeier. Walking, "step work," and low-impact aerobics are good examples. You should exercise two to three times a week for 20-30 minutes at a time. Exercise of any sort helps the body in general: It improves muscle strength and balance, especially in the elderly, whose risk of fracture is great.

If you are taking drugs that may cause bone loss, talk with your doctor about possible alternatives. For instance, use inhaled steroids instead of prednisone (sold under many brand names), or azathioprine (Imuran) instead of cyclosporin A.

What Treatment Options Are Available?

For women past menopause, hormone replacement therapy (HRT) can both prevent and treat osteoporosis by increasing bone density and reducing the risk of fracture. HRT also reduces cardiovascular risk. Estrogen replacement therapy (ERT) slows bone loss. Although the risk of endometrial cancer increases after 5-10 years of ERT, estrogen can be administered with another drug, called progesterone (also called Progestin, among many other brand names), to reduce this risk.

Alendronate (Fosamax) is also used both to prevent and to treat osteoporosis. Alendronate greatly slows bone loss, and it increases bone mineral density more than any other drug available. Its possible side effects include gastrointestinal symptoms such as diarrhea, gas, and abdominal pain. Generally, however, patients with no previous symptoms will not have these problems.

Another possible side effect of alendronate is esophageal ulcers. This consequence can usually be avoided if you follow the manufacturer's instructions carefully--remaining upright for several hours after taking it. This side effect is a potential risk even for those who have never had gastrointestinal problems before.

Raloxifene (Evista) also reduces the loss of bone, and it increases bone mineral density in the process. Another point in its favor is that we don't think it increases the chances of getting endometrial or breast cancer: We think ERT does. Raloxifene's possible side effects include hot flashes, leg cramps, and blood clots in the legs or lungs.

Inhaled or injected calcitonin (Miacalcin, Calcimar) is another option for women who are 5 or more years past menopause. Calcitonin both reduces fracture risk and improves bone mineral density of the spine. There usually are no side effects.

As the baby boomers age, the number of people with osteoporosis will increase--and many will not even know they have it. The best strategy is to understand your risk factors and treatment options and discuss them with your doctor.

© 1999 by Medscape Inc. All rights reserved.

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