Osteoporosis

Osteoporosis is a condition where bones become weak and break more easily. It happens because bones lose mass and strength over time, especially as people get older. This is normal, but some people lose bone faster than others.

Bones can break even from small actions, like bending over or falling slightly. Common places for breaks are the spine, wrist, forearm, and hip. Often, there are no signs until a bone breaks.

Risk factors for osteoporosis include getting older, being female, and changes in body hormones. Certain diseases, medicines, smoking, and not being active can also increase the risk. To help prevent osteoporosis, it’s important to eat well, stay active, and avoid smoking or too much alcohol. Special medicines can help people who have already broken a bone because of weak bones.

Signs and symptoms

Osteoporosis usually does not show any signs or symptoms until a bone breaks. When a bone breaks easily from things like a small fall, lifting, bending, or even coughing, it is a sign of osteoporosis. Common places for these breaks include the spine, ribs, hip, and wrist.

Broken bones are a frequent problem with osteoporosis and can make it hard to move. The most common breaks happen in the wrist, spine, shoulder, and hip. When the spine breaks, it can cause sudden back pain and change how a person stands. Breaks in longer bones like the leg can also make it hard to walk and might need surgery. There are tools to help figure out how likely someone is to break a bone based on things like age, weight, and health habits. When a bone breaks because of osteoporosis, it is called established osteoporosis.

Risk factors

Osteoporosis is a condition where bones become weak and break more easily. It mainly affects older people and women, especially after menopause. Other risk factors include certain diseases, some medicines, and lifestyle choices like smoking or not getting enough sunlight.

Non-modifiable

Advanced age and being female are the biggest risk factors. Women lose hormones after menopause, which protects bones. Men also lose some bone strength as they age, but not as quickly. Family history and small body size can also increase risk.

Potentially modifiable

Drinking too much alcohol, smoking, and not getting enough vitamin D can weaken bones. Not eating enough calcium or being very underweight also helps. Some exercises, like heavy endurance training in women, can affect bone health. Certain metals in the environment and some soft drinks might play a role too. Long-term use of some stomach medicines can also affect bone strength.

Medical disorders

Many health problems can increase the risk of osteoporosis. These include diseases that limit movement, problems with hormone levels, and conditions that affect how the body uses nutrients. Some immune system diseases and blood disorders can also be linked to weaker bones.

Medication

Some medicines can increase the risk of osteoporosis. These include steroids, certain seizure medicines, and some drugs for thyroid problems. Other drugs that affect hormone levels or bone health can also play a role.

Pregnancy-associated osteoporosis

Rarely, osteoporosis can occur during pregnancy and breastfeeding, though the exact cause isn’t known.

Evolutionary

Humans naturally lose bone density as they age, more than other primates. This is thought to be linked to walking on two legs, which puts more stress on bones. Our diets today also often have less calcium than early human diets.

Fracture risk assessment

For women over 65, or younger women with risk factors, doctors often check bone density to see if osteoporosis might be present.

Mechanics

Osteoporosis happens when bones lose too much mass and become fragile. Bones break when the force on them is stronger than the bone can handle. Understanding how bone structure changes helps doctors find better ways to diagnose and treat osteoporosis.

Pathogenesis

Osteoporosis happens when the body breaks down bone faster than it can build it up. Bones are always changing, with some parts being broken down and new bone being made. But as people get older, especially women after menopause, the balance shifts, and more bone is broken down than built. This makes bones weaker and more likely to break.

The body needs certain things like estrogen, calcium, and vitamin D to keep bones strong. Without enough of these, bones can become weaker. Bones in the spine, hip, and wrist are especially at risk because they have more of the softer, spongy bone that changes more quickly. By the time people are in their 30s or 40s, they start losing this spongy bone, which can lead to fractures.

Diagnosis

Osteoporosis often doesn’t show clear signs early on, so it’s hard to notice without tests. As it gets worse, you might feel pain in your back, lose height, or notice you’re standing in a curved way. Doctors can find osteoporosis by looking at how strong your bones are using special X-ray machines.

One common way to check bone strength is with a test called DEXA scan. This helps doctors see if bones have become weaker. Sometimes, they also do blood tests to look for other health problems that might be linked to weaker bones.

Screening

The U.S. Preventive Services Task Force suggests that all women aged 65 or older should have a bone density scan. They also advise screening for younger women who have certain risk factors. However, there isn't enough information to say how often these scans should be repeated.

For men, it's not clear if screening for this condition is helpful. Prescrire mentions that testing men who haven’t had a bone fracture before might not be needed. Some groups recommend testing men aged 70 or older, or those at similar risk. There are tools to help decide who should get tested.

Prevention

To help prevent osteoporosis, it's important to make healthy choices in daily life. Avoiding smoking and drinking less alcohol can make a big difference. Eating well is also key. For example, people with certain conditions like coeliac disease should follow a gluten-free diet and make sure to get enough calcium and vitamin D.

Staying active through exercise is one of the best ways to keep bones strong. Activities that challenge the muscles and bones, like resistance training, are especially helpful. High-intensity exercises, such as jumping or skipping, are good for bone health too. It's also important to eat enough protein, calcium, and vitamin D. If someone is at higher risk for fractures, they might need extra help from a doctor.

Nutrition

Getting enough calcium and vitamin D is important for bone health, but studies show mixed results about whether supplements really help prevent fractures. Some research suggests that taking calcium and vitamin D together might help, but taking only vitamin D might not. There are also some possible side effects from too much calcium, like increased risk of certain health issues.

Vitamin K is another nutrient that may help with bone health. Foods like leafy greens, dairy products, legumes, and beans are good sources of calcium. Experts recommend certain amounts of calcium depending on age.

Physical exercise

Exercise, especially activities that put weight on the bones, can help keep bones strong as we age. Weight-bearing exercises, like walking or resistance training, are good for bone health. These exercises help bones stay strong and can lower the risk of fractures. Guidelines suggest a mix of different exercises, including balance training, resistance training, and posture exercises. Activities like cycling or swimming don’t put weight on the bones, so they aren’t as helpful for bone health.

For older people or those who have had fractures, exercise can improve physical performance and may reduce pain. Exercise programs that focus on strength and balance can help prevent falls and fractures.

Exercise prescription

For elderly people, exercises that build muscle strength and improve balance can help prevent falls and fractures. Activities like jumping, skipping, and other weight-bearing exercises are good choices. Resistance training should target major muscle groups. While aerobic exercise alone isn’t very effective for bone health, doing it with extra weight, like a weighted vest, might help — but this could also increase the risk of falls.

Physical therapy

People with osteoporosis may be more likely to fall due to balance issues or weak muscles. Physical therapy can help improve balance, posture, and muscle strength. Therapy may include exercises to strengthen muscles, improve posture, and increase activity levels. This can help regain normal spine shape, improve stability, and slow bone loss. Physical therapy also includes exercises that can help build bone strength without needing medicine.

Hormone therapy

Lower estrogen levels after menopause can increase the risk of osteoporosis. Hormone replacement therapy might help reduce this risk, but it also comes with risks, such as increased chances of certain cancers and blood clots. It is usually recommended only for younger women after menopause who are at high risk of fractures but have low risk of cancer and blood clots.

Management

Lifestyle changes

Doing exercises like walking and lifting light weights can help keep bones strong for people with osteoporosis. It’s also important to get enough calcium and vitamin D, especially for women after they go through menopause. Making sure you don’t fall can also help prevent problems from osteoporosis. Wearing special hip protectors might be useful for some people, especially those living in care homes.

Pharmacologic therapy

Doctors often suggest medicines for people who have broken a hip or spine because of osteoporosis, or for those whose bone density tests show they are at high risk. Bisphosphonates are a common type of medicine that can lower the chance of future fractures. They seem to work well for three to four years, but stopping after that might be okay. There are some rare side effects, like unusual bone breaks or jaw problems, but these don’t happen often.

The main goal of treating osteoporosis is to stop more fractures from happening. If someone has already broken a bone because of osteoporosis, it’s very important to prevent another break, since the risk goes up a lot after the first one. Different medicines work in different ways, and some are better for certain types of fractures. Not everyone gets the right medicine after a fracture happens.

For people who haven’t broken a bone yet, some medicines might help, but the proof isn’t strong for all of them. Alendronate can help stop spine fractures but doesn’t help with other kinds. Some other medicines, like Teriparatide and Denosumab, are also used to treat osteoporosis. However, some medicines have risks, like increasing the chance of blood clots or strokes, so they are used carefully.

Certain drugs can help prevent fractures in women after menopause. There is also some early evidence that certain traditional Chinese medicines might help with bone health, but more research is needed.

Prognosis

People with osteoporosis may face serious health challenges because of broken bones, though the breaks themselves are rarely deadly.

Hip fractures can make it hard to move and may lead to other health problems. For people aged 50 and above, about 13.5% may not survive six months after a hip fracture, and many need help to move around.

Broken backbone bones, while less likely to cause death, can cause lasting pain and change the body's shape. In rare cases, many backbone breaks can make breathing difficult.

Broken bones from osteoporosis affect many people each year, especially in the spine, hip, and wrist. Rib breaks are also common, especially in men.

Epidemiology

Osteoporosis becomes more common as people get older, especially after age 50. It happens more often in women than in men because of changes in their bodies after menopause. Worldwide, about 21% of women and 6% of men over 50 have osteoporosis, which means around 500 million people.

Women are also more likely to break bones because of osteoporosis. For example, a 60-year-old woman has a higher chance of breaking a bone in her life compared to a man of the same age. In 2019, many bone breaks linked to osteoporosis happened in people over 55. People living farther from the equator, where there is less sunlight, may have a higher risk of osteoporosis because they get less Vitamin D. Certain health conditions, like Celiac Disease, can also increase the risk of osteoporosis by affecting how the body absorbs important nutrients.

History

People have been studying how bones get weaker with age since the 1800s. A French doctor named Jean Lobstein was the first to use the word osteoporosis. Later, an American doctor named Fuller Albright discovered that this condition happens more often to women after they stop having periods.

Scientists who study old bones have found that some ancient people had bones that were weaker too. They think this was because these people didn’t get enough food and worked very hard farming. This hard work and lack of food may have caused their bones to become weak, just like people today can experience.

Anthropologists have looked at old bones and seen signs that these people didn’t get enough nutrients, which might have helped cause their bones to weaken.