Osteoporosis

Osteoporosis involves the gradual weakening of your bones over time, making them fragile and more likely to break (fracture). As this condition develops slowly over the years, you may only get a diagnosis after having a fall that causes you to break a bone.

Your bones are made of a hard material (minerals) and tough, elastic fibres (collagen fibres). Bone is a living tissue containing cells that make bone as well as cells that absorb bone. When you are young and growing, bone is made faster than it is absorbed (resorbed). When you are older, bone is resorbed faster than it is made. 

If you have osteoporosis, your bones will have lost some of its minerals and will be less dense. You may hear this described as thinning of the bones, having brittle bones or having a reduced bone density.

Osteoporosis affects over three million people in the UK and mainly affects older people, but can affect younger adults too. Every year, more than 500,000 people with osteoporosis go to hospital to have treatment for fragility fractures — bones that break after a fall from standing height or less. 

Osteoporosis is a chronic (long-term) condition that can be managed through medication and preventing fractures.

There are no early symptoms of osteoporosis because you can't feel your bones getting weaker. It doesn’t cause aches or pains until you break a bone and then the pain is due solely to the fracture. 

In fact, osteoporosis is usually only detected when a bone fractures after a minor fall or sudden impact. In people without osteoporosis, a minor fall doesn’t usually cause a bone fracture, which is why these fractures in a person with osteoporosis are called fragility fractures. 

Bone fractures in older people can have lifelong consequences. Half of all people with a hip fracture stop being able to live independently due to resulting mobility problems. 

The most common injuries in people with osteoporosis are:

• Fractures of the spinal bones (backbones) 
• Hip fractures
• Wrist fractures

However, fractures can occur elsewhere eg: 

• Arms
• Pelvis
• Ribs — a cough or sneeze can break a rib or partially collapse a spinal bone 

Spinal bone fractures may cause persistent back pain, gradual loss of height and a hunched or stooped posture. This makes it difficult to support your body weight. These symptoms can occur if you fracture one or more spinal bones, which can happen even without a fall or sudden impact. 

After a fracture to your spinal bones, they can become squashed, which in severe cases, causes your posture to bend forward. This can affect your ability to carry out everyday tasks and can also make breathing difficult as your lungs have less room to expand in your chest. 

You should see your GP if you:

• • Are starting to develop a hunched or stooped posture
  • Have a history of fractures
  • Have hip pain
  • Have pain or discomfort in your neck or back

The density of your bone determines whether you have osteoporosis or osteopenia. Osteopenia is the stage before osteoporosis, where your bone density is lower than average for your age but not low enough for a diagnosis of osteoporosis. Osteopenia does not always develop into osteoporosis. 

If you have osteopenia, you can keep your bones healthy and therefore reduce your risk of developing osteoporosis by making certain lifestyle changes. Your GP may also prescribe a bone-strengthening treatment, which is usually given to people with osteoporosis.

There is no national screening programme for osteoporosis. However, if you have a risk factor for osteoporosis, your GP may assess you to determine if you have other risk factors. This will involve asking you questions. 

Your overall risk of developing osteoporosis will depend on how many risk factors you have, which your GP may calculate using a risk calculator. The two most common risk calculators used are FRAX® and Fracture. These calculators consider risk factors such as:

• Family history of hip fractures
• How much alcohol you drink
• If you have other medical conditions eg rheumatoid arthritis
• If you smoke
• Your age
• Your BMI (body mass index)

If your risk is high or uncertain, or your GP suspects you have osteoporosis, they may arrange for you to have a DEXA scan. This is a short, painless procedure that takes about five minutes, depending on the part of the body being scanned. It’s used to find out how much material your bones contain. This information is then used to determine whether you have osteoporosis.

If you've had a fragility fracture, you will usually have a DEXA scan to confirm whether you have osteoporosis. However, if you've had a fragility fracture and are a woman aged 75 or over, you may receive a diagnosis of osteoporosis without having a DEXA scan. This is because the condition is so common in women after age 75. Even after having a fragility fracture, it is still important to seek treatment as you can reduce your risk of future fractures. 

Other tests used to diagnose osteoporosis include: 

• An ultrasound scan — this can be used to screen people at risk 
• Digital X-ray radiogrammetry (DXR) — a newer test that needs less equipment than a DEXA scan and can also be used to screen people at risk

Your bones are at their most dense and strongest during your early adult years until your late 20s. Most people start losing bone density from age 35. In some people, this happens faster than usual, causing osteoporosis.

While there are no clear underlying causes of osteoporosis, some people have a greater chance of developing the condition than others. It affects men and women, both old and young, but postmenopausal women are at greater risk of osteoporosis than men. 

This is because women are known to lose bone rapidly in the first few years after the menopause due to hormonal changes that affect bone density — specifically decreased oestrogen levels, a female sex hormone that is essential for healthy bones. 

Women are at an increased risk of osteoporosis if they: 

• Have a hysterectomy (womb removal) before age 45 — this risk is further increased if the ovaries are also removed
• Have missed their periods for six months or more due to excessive dieting or overexercising
• Start the menopause before age 45

In England and Wales, over two million women have osteoporosis. At age 50, around one in 50 women have osteoporosis, which rises to one in four at age 80. Over a third of women in the UK will have one or more bone fractures in their lifetime due to osteoporosis.

Your risk of osteoporosis, therefore, increases with age. Risk is higher in women aged over 65 and in men aged over 75. 

The cause of osteoporosis in men is usually unknown. However, the male sex hormone testosterone may be involved. Men continue to make testosterone throughout their lifetime but in men with low testosterone levels, the risk of osteoporosis is higher. In around half of all men with low testosterone levels, the cause is unknown. However, several causes have been identified for low testosterone levels, including: 

• Alcohol misuse
• Hypogonadism — this condition causes low testosterone levels
• Taking certain medications eg steroids

One in five men in the UK has one or more bone fractures in their lifetime due to osteoporosis.

Other risk factors include:

• Being underweight (a BMI of less than 21) or having an eating disorder eg anorexia or bulimia
• Having a family history of hip fractures or osteoporosis
• Having rheumatoid arthritis
• Having had a hysterectomy or early menopause without hormone replacement therapy
• Lifestyle factors — this includes: 
• Drinking excessive amounts of alcohol
• Low exposure to sunlight causing a vitamin D deficiency
• Poor diet causing a calcium deficiency
• Smoking heavily 
• Taking certain medications or having certain treatments for specific conditions — this includes: 
• Getting breast cancer treatment that uses aromatase inhibitors
• Hormone deprivation therapy for prostate cancer
• Taking anticoagulants eg heparin or warfarin 
• Taking steroid tablets for over three months

Your risk of developing osteoporosis is also higher if: 

• You have a condition that permanently reduces your mobility 
• You have or have had certain medical conditions — this includes: 
• Gastrointestinal conditions that cause poor absorption eg coeliac disease or Crohn's disease
• Chronic kidney disease
• Chronic liver disease
• Type 1 diabetes
• You have had gastrointestinal surgery to reduce the size of your stomach or remove part of your intestine — this reduces the surface area available to absorb nutrients such as calcium; these surgeries include weight loss surgery and surgery to treat gastrointestinal disorders, including:
• Inflammatory bowel disease
• Lupus
• Multiple myeloma
• Your bones fracture easily eg from a slight bump

Hormone-related disorders can also cause osteoporosis; these include:

• Adrenal gland disorders eg Cushing's syndrome
• An overactive thyroid gland
• Overactive parathyroid glands
• Pituitary gland disorders
• Reduced levels of sex hormones eg oestrogen or testosterone

Your doctor will consider a number of factors before deciding on the most appropriate osteoporosis treatment for you. They’ll assess your risk for bone fractures and whether you’ve had bone fractures in the past. They'll also consider your age, sex and the results of your DEXA scan before prescribing medication or recommending lifestyle changes, such as:

• Avoiding smoking and alcohol
• Exercising regularly
• Increasing your dietary intake of calcium
• Taking vitamin D supplements

If you received your diagnosis of osteoporosis after breaking a bone, you will still receive treatment to reduce your risk of future bone fractures. If you don’t want or need to take osteoporosis medication, it is still important to make sure you get enough calcium and vitamin D. Your doctor may therefore ask about your diet and may recommend changes or dietary supplements.

Medications for osteoporosis prevent further break down of your bones or build up their strength. They are sometimes also used to treat osteopenia. There are several different osteoporosis medications, including: 

Bisphosphonates

Eg alendronic acid, ibandronic acid, risedronic acid and zoledronic acid. 

These slow down how quickly your bone is resorbed to help maintain your bone density. They can be taken as tablets or given as injections. If taking bisphosphonate tablets, make sure you: 

• Take your tablets on an empty stomach with a full glass of water
• Stand or sit up for at least 30 minutes after taking them
• Wait 30 minutes to two hours before eating or drinking

Bisphosphonates take around 6-12 months to work and you may need to take them for at least five years. Your doctor may also prescribe calcium and vitamin D tablets to take on a different day to your bisphosphonate tablets.

Common side effects of bisphosphonates include:

• Irritation to your food pipe (gullet)
• Stomach pain
• Swallowing problems

In rare cases, you may develop osteonecrosis of your jaw, where your jawbone tissue dies. If you have a history of dental problems, see your dentist for a check-up before you start your treatment with bisphosphonates. This rare side effect is more common in people receiving high doses of bisphosphonates directly into a vein to treat cancer. 

Another very rare side effect is a fracture in the middle of your thighbone. 

If you have any concerns about taking bisphosphonates, speak to your doctor.

Denosumab

In postmenopausal women with osteoporosis who can't take bisphosphonates or do not tolerate them well, denosumab is an alternative. It is given by injection twice a year and slows down bone loss. 

In rare cases, osteonecrosis of the jawbone develops as a side effect. In very rare cases, a fracture in the middle of the thighbone occurs. 

You may have to take denosumab for the rest of your life as studies have shown that stopping this drug may cause a high risk of bone fractures in your spine.

Raloxifene

This is usually prescribed to women who have already had a fragility fracture. It belongs to a group of drugs called selective oestrogen receptor modulators (SERMs) and is taken once a day as a tablet.

It mimics the effects of oestrogen to reverse the rapid bone loss that occurs at menopause and make your bones stronger. This reduces your risk of bone fractures, especially spinal bone fractures. 

Side effects include hot flushes and leg cramps. Raloxifene may also cause a small increase in your risk of developing: 

• Breast cancer and endometrial cancer 
• Deep vein thrombosis  (DVT) — blood clots in a vein, usually in the leg
• Heart disease 

Raloxifene is therefore usually prescribed to younger women or menopausal women who also need treatment for their menopausal symptoms. 

Parathyroid hormone treatments

Parathyroid hormone is naturally made by your body and controls the amount of calcium in your bones. Parathyroid hormone treatments eg teriparatide are given as injections and stimulate the cells in your bones that make bone.

Most osteoporosis treatments only slow down bone density loss but parathyroid hormone treatment can increase your bone density. However, it is only prescribed when other treatments do not work and for people with very low bone density.

Common side effects include nausea and vomiting.

Calcium and vitamin D supplements

The main mineral in your bones is calcium, which is why it’s an important part of a healthy balanced diet. The recommended daily amount for people without osteoporosis is 700 milligrams, which you can get from your diet. However, if you have osteoporosis, you may need more calcium in the form of calcium supplements.

Vitamin D is needed to help your body absorb calcium. The recommended daily amount is 10 micrograms. During the spring and summer months (late March to September), you can get enough vitamin D from the sunlight on your skin. However, during the autumn and winter months, it is unlikely you will get enough vitamin D from sunlight alone. It is also hard to get enough vitamin D from your diet, which is why it is recommended that everyone takes daily vitamin D supplements of 10 micrograms during autumn and winter — this includes pregnant and breastfeeding women. 

Testosterone treatment

In men whose osteoporosis is caused by low testosterone levels, this treatment can help. 

If you have osteoporosis, it is not inevitable that you will have a fracture. You can reduce your risk of a fall and/or a fracture. 

To prevent falls: 

• Be aware of the side effects of medications you are taking — if a medication is making you drowsy or light-headed, speak to your doctor to see if you can be prescribed an alternative medication 
• Check your home for trip hazards eg loose carpets or rugs, and trailing wires
• Have regular eye tests and hearing tests
• If possible, avoid going out in icy weather
• Secure carpets and rugs to the floor 
• Use rubber mats around the sink and next to the bath to reduce your risk of slipping 

You may also want to consider wearing hip protectors to cushion your hip bones if you do fall. 

A healthy diet and regular exercise can help prevent many health conditions, including fragility fractures due to osteoporosis, heart disease and many types of cancer. Make sure your diet is balanced and includes a variety of nutritious foods from all five food groups.

Getting support

Your GP or nurse can provide advice and reassurance on living with osteoporosis. You can also try speaking to a trained counsellor or psychologist or calling a specialist helpline.

Recovering from a bone fracture

Bone fractures usually take six to eight weeks to heal. However, this varies depending on the type of fracture — some fractures need more medical interventions to heal. Osteoporosis does not affect your recovery time from a fracture. 

If you have a complicated fracture eg a broken hip or wrist you may need surgery to set the bone so it heals properly. Hip fractures often need hip replacement surgery and you may lose some mobility due to bone weakness. 

Spinal problems

Osteoporosis can cause spinal bone fractures, which makes it hard for you to support your weight. This can cause a stooped or hunched posture. The fracture can be painful when it occurs but can also cause chronic pain. 

During your recovery, you may need the help of a physiotherapist or occupational therapist.

Coping with pain

You can manage your pain by: 

• Applying heat packs or taking warm baths
• Applying ice packs
• Taking painkillers 
• Trying simple relaxation techniques eg hypnosis and massage
• Using transcutaneous electrical nerve stimulation (TENS) — this stimulates your nerves to help reduce pain

You can use several of these approaches together. 

Working 

You can work with osteoporosis. It is important to stay active to help your bones stay healthy. However, if your occupation has a high risk of falling and/or getting a bone fracture, speak to your employer, GP and the Royal Osteoporosis Society about how to reduce these risks. 

Although your genes control your health and bone strength, lifestyle factors eg your diet and exercise affect the health of your bones. You can therefore make changes to help reduce your risk of osteoporosis. 

Getting regular exercise

You can improve your bone density, which will help prevent osteoporosis, through weight-bearing and resistance exercise. 

Weight-bearing exercises use your feet and legs to support your body weight. High-impact weight-bearing exercises can strengthen your joints, muscles and ligaments. These exercises include:

• Aerobics
• Dancing
• Jumping up and down on the spot
• Running
• Skipping

Make sure you wear appropriate footwear, which supports your ankles and feet (eg trainers or walking boots) when performing these exercises. It is good for your health to perform regular weight-bearing exercises throughout your life but you can start at any age. If you are over 60, you can try brisk-walking, keep-fit classes or playing tennis. 

Resistance exercises use muscle strength but the action of your tendons (which connect your muscles to your bones) pulling on your bones also improves your bone strength. These exercises include press-ups, weightlifting or using weighted equipment at the gym. Resistance exercises can also improve the strength of supporting bones and muscles to improve your balance, which will reduce your risk of falling. 

In addition to aerobic exercise, which is good for your cardiovascular system, adults aged between 19-64 should perform muscle-strengthening activities at least twice a week to exercise all of the major muscle groups, which includes: 

• Abdomen
• Arms and legs
• Back
• Chest 
• Hips
• Shoulders

Eating a healthy diet and taking dietary supplements

A healthy, balanced diet can benefit everyone by preventing many serious health conditions, including many types of cancer, diabetes and heart disease, as well as osteoporosis.

Calcium is needed to maintain strong bones. It is recommended that adults get 700 milligrams a day — this should be possible through your diet alone.  Butter, cream, and soft cheeses contain little calcium but foods high in calcium include: 

• Dried fruit
• Green leafy vegetables
• Tofu
• Yoghurt

You can usually get 1,000 milligrams of calcium in a day by drinking a pint of skimmed or semi-skimmed milk and eating 50 grams of hard cheese (eg cheddar). Or you can substitute the hard cheese for one pot (125 grams) of yoghurt or 50 grams of sardines.

If you take calcium supplements and already have enough calcium in your diet, there is a risk that you can develop heart disease. So if you are considering calcium supplements, speak to your GP first. 

Vitamin D is also needed to maintain strong bones as it helps your body absorb calcium. It is recommended that adults get 10 micrograms a day. It can be difficult to get enough vitamin D through your diet alone as there are not many good food sources for vitamin D. Foods that are good sources of vitamin D include:

• Egg yolks
• Fortified foods eg some breakfast cereals and most fat spreads 
• Liver
• Oily fish eg herring, mackerel, salmon and sardines
• Red meat

To ensure you get enough vitamin D, consider taking a daily supplement containing 10 micrograms of vitamin D.

Stopping smoking and drinking less

Smoking is linked to an increased risk of osteoporosis as the chemicals from tobacco affect the bones. Excessive drinking of alcohol is also bad for your bones as it interferes with your calcium levels and vitamin D production. It is recommended that adults drink no more than 14 units of alcohol a week and that they avoid binge drinking. 

Spending time in the sun

When the days are longer and brighter during the spring and summer (late March to September), you can benefit from the sunlight. Sunlight causes your body to produce vitamin D, which helps your body absorb calcium to keep your teeth and bones strong.

However, it is important to note that too much exposure to sunlight can increase your risk of skin cancer. Consequently, if you are not using sun protection, limit your exposure to sunlight to 10-15 minutes, two to three times a week. In general, it is advised that you do use sun protection. Even when using a high SPF sunblock, some sunlight will penetrate into your skin, which is usually enough to trigger vitamin D production.

During autumn and winter, it is recommended that everyone takes vitamin D supplements.