What is osteoporosis?
Until recently, when I thought of osteoporosis nothing in particular came to mind. I knew it was “something” that “happened” to older people, women in particular. And I knew it had to do with bones becoming weaker, more fragile and prone to fracture.
What I did not at all appreciate is that osteoporosis is a disease process that can seriously affect not only the quality of one’s life, but it’s length as well.
Some statistics:
· About 10 million people in the U.S. age 50 years and older have osteoporosis, 80% of these are women. Just over 43 million more people have low bone mass, putting them at increased risk for osteoporosis. This includes 16 million men. (Osteoporosis Working Group, Healthy People 2030)
· “In the United States, approximately 20% of women over 50 years of age and 30% of women 65 years of age or older meet DXA [scan] criteria for osteoporosis.” (Walker & Shane, 2023)
· “An additional 40% of postmenopausal women have low bone mass (osteopenia).” (Walker & Shane, 2023, italics mine)
· “Fractures from osteoporosis and low bone mass lead to as many hospitalizations as strokes and heart attacks.” (Gunter, p.136)
· A Swedish study in 2000 found that the lifetime risk of an osteopathic fracture in the spine, hip, forearm or shoulder was 47% in women and 24% in men. The study also concluded that “fractures of the hip and spine carry higher risks than fractures at other sites, and that lifetime risks of fracture at the hip in particular have been underestimated.” (Kanis et al., 2000)
· Lifetime risk of breast cancer for a woman: 15%
· Lifetime risk of a hip fracture for a woman: 17% (Gunter, p.136)
(For a sobering description of the ramifications of severe osteoporosis, as well as some of the obstacles involved in treating it, see Dr. Jen Gunter’s story of her mother’s experience in The Menopause Manifesto, pp. 136-137.)
What we know at this point leads us to believe that white women are the demographic with the greatest risk of contracting osteoporosis and African American women are the group with the least risk. Please keep in mind, however, that while most of the studies done on osteoporosis have prioritized women’s experience of it, we have little research that includes enough diversity in the study populations to really understand the complexities of how osteoporosis affects women of color, intersex or trans people, and men.
The "Silent Disease"
Osteoporosis is often called “the silent disease” because there are no symptoms, no aches and pains, no limitations on movement, no mood swings, nausea, or sleep disturbances that point to low bone mineral density. The vast majority of people do not know that have osteoporosis until they incur what is called a “fragility fracture.”
This site has some interesting pictures and a brief synopsis of fragility fractures:
Hemant Sharma
A fragility fracture happens when a person fractures a bone in an accident that would not typically create a break in a healthy bone. Most of these fractures happen after a fall from standing height or lower, but can also happen from an even smaller trauma, for example, a sneeze, when a forearm bangs against a counter, or, in the case of Dr. Gunter’s mom, when she brushed her knee against a wall and broke her patella (kneecap).
Most of us are likely to consider hip fracture a not atypical, if unfortunate, side effect of aging. Many of us probably know someone who has broken a hip, typically an older woman who has taken a fall off a curb or over a throw rug.
Hip fractures are devastating for the elderly and those who care about and for them. According to Schnell et al (2010), “Hip fractures are associated with significant morbidity, mortality, loss of independence, and financial burden.”
Studies over the past twenty years show mortality rates within the year after one sustains a hip fracture ranging from 25% to over 50%, with the greatest risk of death coming in the first six months post-fracture.
The reasons for these percentages are still being explored.
· It’s possible there may be underlying disease conditions that are exacerbated or exposed by the stress of fracturing one’s hip and undergoing one or more surgeries to repair the damage.
· Older people may also be more prone to contracting iatrogenic illnesses, i.e. those illnesses one catches as a result of being hospitalized and medically treated.
· And of course, it takes longer as we age to bounce back from injury and recover our previous strength and mobility. Indeed, the majority of people who suffer a hip fracture will not regain their former mobility and are likely to become increasingly dependent on others, on walkers and motorized carts, and on medications, some of which may be used to treat mental health issues such as depression and anxiety resulting from the blow to their independence.
As I read back over this post, I realize that the tone of it seems to be one of increasing anxiety, a piling up of all that is bad, and then worse, about osteoporosis. I think this is largely because most of us know so little and think infrequently about it. It is stark, unexpected, and not a little frightening to be confronted suddenly with so much unsettling data and to imagine that it might possibly apply to us. Dr. Gunter opens her chapter on bone health with the words “I am here to scare you about osteoporosis” because she wants to encourage us to pay attention and spread the word about this issue to other women.
Perhaps your experience has been different, but I have met a few women who told me they had been recently diagnosed with osteoporosis and they were panicking. They exercised regularly, didn’t smoke, drank alcohol in moderation, and ate conscientiously. They didn’t understand how they could have “gotten” fragile bones, and they didn’t really know what it meant for them or what they could or should do about it. They only knew enough about the implications of having osteoporosis to be scared.
Last August, just before my 53rd birthday, I had my first DXA (pronounced “dexa”) scan and was diagnosed with osteopenia, otherwise known as “mild bone loss” and a precursor to osteoporosis. I, too, freaked out. Just as I had rather blithely assumed that I would weather the menopause transition with minimal fuss, I took it for granted that I was active enough, ate well enough, and had challenged my bones enough that I had nothing to worry about. I assumed this in flagrant ignorance of the facts about osteoporosis.
What are the facts about osteoporosis?
One thing you probably have gleaned from the general scuttlebutt around osteoporosis is that it is a condition characterized by low bone mass, that is, a decrease in the amount of bone. However, in addition to the loss of bone, there are also changes in bone architecture—the bone’s structure and design—that leads to a loss of structural integrity. The trabecular or cancellous bone tissue that makes up the inner layer of bone comprises a network of thin plates and rods that are strong and lightweight, allowing us to withstand loads from activities like running and jumping.
Bone remodels frequently, with every bone in the body being completely reformed about every ten years. Osteoblasts create new bone, while osteoclasts break down old, unhealthy bone tissue. In osteoporosis, the osteoclasts get the upper hand.
What builds bone?
· Nutrients: Specifically, Calcium, Vitamin D, Vitamin K, and Magnesium
o These can be found in dairy products; dark green leafy vegetables like kale, spinach, and collards; salmon, sardines, and some nuts.
· Physical activity: Specifically, impact movements and the force created by muscular contraction pulling on the bone. The greater the force, the greater the contraction and the more stimulus there is on the bone to increase its strength.
What causes bone to deteriorate? What are the risk factors for osteoporosis?
· Genetics: A family history of osteoporosis can put a person at greater risk.
· Hormonal changes: Estradiol is protective against bone loss, so when estrogen declines in peri- and post-menopause, bone loss accelerates.
· A diet low in calcium or vitamin D
· Being underweight
· A sedentary lifestyle and/or exercise that does not include some impact exercises and strength building
· Chronic alcohol use
· Smoking
Secondary osteoporosis
Not all osteoporosis emerges due to the challenges of the menopause transition alone. There are medical conditions and medications that can predispose a person to contracting osteoporosis or cause bone loss. These contribute to what is called “secondary osteoporosis” because it is secondary to an underlying or exacerbating condition. For example,
· Anorexia, severe dieting, low protein intake, and/or extremely high levels of physical activity may cause a woman’s periods to stop or be intermittent. This happens because of hormonal fluctuations in which estrogen and progesterone are not being made at the same rates as when cycles are happening regularly. The fewer healthy cycles a woman has in her life, the less time she has the protection of estrogen in her body and the greater her vulnerability to the ailments of aging—osteoporosis, cardiovascular disease, metabolic issues, and dementia.
· Low levels of estrogen generally, other endocrine disorders, GI diseases, rheumatoid arthritis, certain cancers, and HIV/AIDS may contribute directly—or indirectly through the treatments used to address these illnesses—to the development of osteoporosis.
· Long-terms use of glucocorticoids, antiepileptic medications, certain cancer meds, proton pump inhibitors, or SSRIs (anti-depressants) can exacerbate or initiate osteoporosis.
o SSRIs are a particularly insidious class of drugs for women at risk of osteoporosis because they are regularly prescribed incorrectly and ineffectually to women going through perimenopause by doctors who do not understand the menopause transition. Rather than recognizing the symptoms women are describing as being triggered by normal hormonal fluctuation and decline, doctors tend to view women as being “mood disordered,” and offer them the contemporary female panacea, an anti-depressant.
Women and men both typically reach their peak bone mass in their mid-late twenties. However, unlike men who lose bone mass gradually and steadily over the course of their lives, women tend to plateau, holding on to their bone until they head into the menopause transition when they experience accelerated bone loss over the course of several years.
After my osteopenia diagnosis I opened Dr. Gunter’s chapter on bone health and mourned what I had not known:
· The time of most rapid bone loss in women “starts approximately one year before the final menstrual period” and lasts about three years.
· The average loss during this time is 6% total but could be 3-5% per year depending on the person.
· “After this period of rapid loss, bone is lost at a higher rate than before menopause—0.5% to 1% a year.” (Gunter, p.133)
It is not all bad news, though I understand if it feels that way at this point. There are, in fact, both pharmaceutical interventions and lifestyle choices that can help prevent and repair damage from osteoporosis. In fact, one study even showed a reversal of osteoporosis in a significant portion of a study group that started a regimen of strength training supervised by professional trainers. And if you are discouraged that it was only one study, remember that very few of these studies have been done. We need more research that prioritizes constructive, empowering, and non-pharmaceutical responses to osteoporosis.
Dr. Gunter raises an extremely important point when she says that it feels to her “as if there’s a cultural acceptance of osteoporosis.” Is osteoporosis, like menopause, simply considered a “woman’s illness”? Is it just normal for women to become frail and break bones? Is this why I—maybe we—haven’t thought and don’t know much about it?
Dr. Gunter also asserts that there is “a false belief among some that prevention is ineffective or medications to treat osteoporosis are too risky.” She contrasts the attention that breast cancer and contraception receive with that given to osteoporosis and feels that once again, “women are reduced to boobs and babies” (Gunter, p.136).
As with menopause, when it comes to osteoporosis, many women don’t know what they don’t know. We don’t know what our risk factors are, what we can do to prevent, delay, or reverse osteoporosis, and we don’t know if we may already have it.
In the next three posts we will explore how osteoporosis is diagnosed and what treatment options exist, both pharmaceutically and in terms of lifestyle modifications.
Resources:
Gunter, Jen. The Menopause Manifesto.
Kanis, J.A., Johnell, O., Oden, A., Sembo, I., Redlund-Johnell, I., Dawson, A., De Laet, C., Jonsson, B. (2000). Long-term risk of osteoporotic fracture in Malmö. Osteoporosis International, 11(8):669-74. DOI: 10.1007/s001980070064
Osteoporosis Working Group, Healthy People 2030: https://odphp.health.gov/healthypeople/about/workgroups/osteoporosis-workgroup#:~:text=In%20the%20United%20States%2C%20an,at%20increased%20risk%20for%20osteoporosis.
Schnell, S., Friedman, S.M., Mendelson, D.A., Bingham, K.W., Kates, S.L. (2010, September). The 1-year mortality of patients treated in a hip fracture program for elders. Geriatric Orthopaedic Surgery & Rehabilitation, 1(1), 6-14. DOI: 10.1177/2151458510378105
Walker, M.D., & Shane, E.S. (2023). Postmenopausal Osteoporosis. New England Journal of Medicine, 389: 1979-1991. DOI: 10.1056/NEJMcp23073
Images
Normal bone v. bone with osteoporosis:
Vertebral fragility fracture: https://www.europeanpharmaceuticalreview.com/news/42564/ucb-amgen-fda-osteoporosis-drug/