Eliana Cardozo, D.O.Physiatrist and Assistant Professor
Rehabilitation and Physical Medicine at Mount Sinai Hospital
New York, NY
First, What Exactly Is Osteoporosis Again?
A breakdown of the word osteoporosis: Osteo relates to bones and porosis translates to porous. Put it all together and you’ve got porous bones. Osteoporosis is a condition that occurs when your bones lose their density and strength, potentially becoming so brittle, weak, and fragile, they break (the medical term is fracture) from very little pressure.
It’s estimated that 10 million Americans have osteoporosis and another 44 million have low bone density, which puts them at risk for getting the disease. If you’re doing the math, that means 54 million Americans ought to be thinking about their bone health, according to the National Osteoporosis Foundation (NOF).
The majority of your bone health is determined while you’re young. You reach your peak bone mass—that’s the strongest your bones are going to be—around age 30. Your peak bone mass is largely determined by your genetics, but other factors also affect how strong and healthy your bones will be:
Diet (particularly one that’s rich in calcium and vitamin D)
Exercise habits (weight-bearing exercises build bone)
Other lifestyle factors (not smoking, drinking heavily, etc.)
After you hit peak bone mass, you’ll continue to make new bone, and you’ll lose some mature bone (a.k.a. resorption of bone). Your bones are filled with cells called osteoblasts and osteoclasts, which boost bone formation and break down old bone respectively. With this on-going cycle of losing and gaining, your overall bone density should break even; it shouldn’t change much in the first two decades after you’ve hit peak bone mass.
When you reach middle age, however particularly if you’re a postmenopausal woman, you may start losing bone a little faster. If the rate of bone loss surpasses the rate at which you make new bone, you have what’s called bone demineralization, a loss of minerals that give bones their strength and stability. In MD speak, this is the pathophysiologic process that leads to osteoporosis. Huh? In layman’s terms: It’s the perfect storm for developing the brittle bone condition.
So, What Are the Symptoms of Osteoporosis?
Osteoporosis is a pretty cunning disease because it’s silent. There are no early symptoms. Some may find out they have it through a routine bone density scan, but the majority of people don’t know they have osteoporosis until they fracture a bone.
Specific bone breaks are associated with the condition , and if you have one of these, it’s like a big, blinking sign for your doctor that you’re dealing with bone loss and possibly osteoporosis. The most common types of fractures with osteoporosis are:
Bone doctors hear it all the time. “But I was just walking, how did I break a bone?” The answer: You had a brittle bone that had no strength or resiliency left and it just snapped. This is what doctors call a fragility fracture—when your bone breaks from a standing height or less. If you stumble and fall (which we’ve all done before), healthy bones should be able to take the hit. But if you have osteoporosis, a bone is likely to break.
Here are the spots fragility fractures tend to occur:
Wrist (most common), as you try to break your fall
If you experience any of these, get to the doctor for an X-ray.
Spinal Compression Fractures
Those little bones in your vertebrae that make up your spine can fracture easily when they’re weakened, and when they do, it’s called a spinal compression fracture. This type of fracture is extremely common with osteoporosis (it happens every 22 seconds in men and women over 50 worldwide), and it doesn’t always result from a fall. Brittle vertebrae can crack from nothing more than sneezing, coughing, or even twisting the wrong way.
So, how would you know if have a spinal compression fracture? At first, you may not have any symptoms. But over time, you may experience aching in your lower back that gets worse when you stand up after you’ve been sitting or resting for a while. If this happens, call your doctor rather than suck it up. He can identify the issue using one of the following tools:
Bone density scan
Over time, spinal fractures from osteoporosis can also cause other, more visible symptoms:
Shrinkage: It’s normal to lose some height as you age, thanks to the discs between the vertebrae flattening out, but shrinking more than an inch can signal osteoporosis of the spine. Height loss of two inches or more can also occur with hip fractures, one study in the Journal of Clinical Densitometry found.
Poor posture: If you fracture bones in your upper spine, a.k.a. the thoracic spine, you can develop a hunched look as the spine starts to curve forward. Medically, this condition is called kyphosis, but you may hear it called a hunchback, a widow’s or dowager’s hump—all very un-PC ways to describe the disfiguring condition.
Are There Any Signs That I Might Develop Osteoporosis?
While fractures are the main symptoms, there are some signs you should be watched carefully, because they indicate you’re at greater risk for developing the condition. Keep in mind: These aren’t necessarily direct causes, but rather osteoporosis risk factors.
You’ve been diagnosed with low bone density. The medical term is osteopenia , and you can think of it as pre-osteoporosis. If you have osteopenia, your bone density is below average. Your bones are weaker and more likely to fracture than those of someone with normal bone density, but they aren’t quite as vulnerable someone with osteoporosis. By taking measures (lifestyle changes and in some cases, medication) to improve your bone density, or at least keep it stable, you can lower your risk of progressing to osteoporosis.
You’re a woman. Osteoporosis does occur in men, but it’s far more common in women. Roughly 80 percent of the 10 million people with osteoporosis are females. A woman’s bones are thinner and smaller than a man’s, which means her peak bone mass is lower to start with. Women start losing bone mass earlier than men, and lose at a faster rate, according to a review in the Journal of Clinical Medicine Research.
You’re very thin. Being a petite, thin woman puts you at a higher risk than other women, because your bones are thinner as well. So when you start losing bone mass naturally with age, there’s less to take from. Weighing less than 127lbs or having a BMI lower than 21 seems to increase your risk. Being overweight doesn’t help either. Obesity can lead to diseases and conditions such as diabetes, which can accelerate bone loss.
You’re postmenopausal. Estrogen and osteoporosis are tightly linked. Loss of estrogen, which gives you all those lovely menopausal symptoms (ugh, hot flashes!), can also cause loss of bone density. The female sex hormone is thought to help promote osteoblasts, the cells that are responsible for bone growth. When you go through menopause and your estrogen levels ebb, so do those bone-boosting cells, leaving you vulnerable to postmenopausal osteoporosis. A woman can lose up to 20 percent of her bone in the first five to seven years following menopause, research has shown.
You have a genetic predisposition to weak bones. Low bone mass and osteoporosis tend to run in families. Plus, those with roots in Northern Europe or Asia tend to carry a higher risk than other ethnicities. African Americans have lower rates of osteoporosis and higher peak bone mass.
You drink heavily or smoke. Another reason to temper your tippling and stub out the butts: Cigarette smoking and heavy chronic drinking can affect healthy bone development and accelerate bone loss.
You’ve had (or have) an eating disorder. Poor nutrition, low body fat, and loss of your menstrual cycle are all side effects of eating disorders such as anorexia nervosa or bulimia. If you suffered from one while you were young, your bones may not have reached their full bone mass potential. Struggling with an eating disorder as an older adult may accelerate bone loss and slow bone growth.
You have an underlying condition. You can develop bone atrophy, or bone loss, from other diseases or medications used to treat them. This is known as secondary osteoporosis.
Diseases linked to secondary osteoporosis include:
Medications that may lead to bone loss include:
What Do I Do If I Have Signs of Osteoporosis?
Your first step is a visit to your primary care doctor. If you have symptoms of a fracture, your doctor will order an X-ray, CT scan, or MRI to confirm whether you’re indeed dealing with a break.
At that point, you’ll likely be referred to a doctor who specializes in bones, such as an orthopedist. Osteoporotic fractures are usually in areas that you can’t exactly cast, like the spine or back. Instead, they typically require:
Occasionally a brace (in the case of the spine)
Surgery, in some cases, such as a hip replacement
Once your fracture is addressed, your doctor will likely treat your osteoporosis to prevent another fracture—a common occurrence. Research in the journal Bone put the risk of a repeat fracture at 86 percent. Which type of doctor should you see? While there is no singular specialist in osteoporosis, several types of doctors treat the condition. They include:
Geriatric medicine doctors
A fragility fracture alone is enough for an osteoporosis diagnosis, even without a bone density scan, or a dual-energy X-ray absorptiometry (known as DXA or DEXA scan). But your physician will likely order one to see the extent of your bone loss.
If you’ve never had a fracture, you may get your osteoporosis diagnosis through a routine bone density scan from your primary care physician or gynecologist. A woman may get one shortly after going through menopause, especially if she has other risk factors, but the general recommendation is 65 years old. For men, routine scans are given around age 70.
Think of a bone density scan as an osteoporosis X-ray: With a low level of radiation, it measures how much calcium and other minerals are present in your bones—an indication of how weak or strong your bones are. The osteoporosis test gives you a T-score, which measures just how much bone density you have compared to a 30-year-old with peak bone mass.
A score of -2.5 or below means osteoporosis.
-1.0 to -2.4 is osteopenia.
How Is Osteoporosis Treated?
Once you have your osteoporosis test results, your physician can recommend treatment to strengthen or stabilize your bone density to prevent future fractures. A number of drugs—oral medication, injections, and IV infusions—can slow bone loss, promote new bone growth, or both. The most popular classes of osteoporosis drugs include:
Bisphosphonates: Drugs that slow bone loss, such as Binosto and Fosamax (Alendronate)
RANKL Inhibitors: Injections that block osteoclasts, the cells that break down bone, such as Prolia and Xgeva (Denosumab)
Anabolic agents: Injections that encourage new bone growth in severe cases, such as Evenity (Romosozumab-aqqg) and Forteo (Teriparatide)
What’s the Prognosis If I Have Prognosis?
With bone-healthy lifestyle changes and medications, people with osteoporosis typically do just fine. Osteoporosis drugs aren’t necessarily a lifetime commitment. You’ll have a repeat bone density scan in two years or so to track your progress.
If your bone density has improved or remained stable, you may be able to take a drug holiday from your meds. And injectables that build bone can only be used for one to two years, depending on the drug, due to their potential side effects.
The goal to prevent progressing to a more severe state of osteoporosis and suffering multiple fractures. If you’re holding steady, consider yourself a success story: Your doctor will!
Frequently Asked QuestionsOsteoporosis Signs and Symptoms
What are the early symptoms of osteoporosis?
Unlike many other conditions, there are no early signs. For most people, the first symptom is a bone break. You may have read about receding gums, brittle nails, and weak handgrips being early signs of osteoporosis. But our experts say they’re usually not indicative, and these can be symptoms of many other conditions.
What causes osteoporosis?
The root cause of osteoporosis is low bone density. So, how do you get that? Your bone density is mostly inherited (about 80 percent is due to genetics), but factors such as your gender, weight, diet, exercise habits, and lifestyle factors such as whether or not you smoke or drink can determine how strong and resilient your bones will be as you age.
What is the difference between osteoporosis and osteopenia?
Osteopenia is a precursor to osteoporosis. If you’re diagnosed with the condition, it means you have low bone density, but not low enough to be osteoporotic. A diagnosis doesn’t mean you’re destined for osteoporosis, especially if you know how to improve your bone density. Prevention of osteoporosis comes down to: weight-bearing exercise to boost bone formation; good nutrition (especially a diet rich in calcium and vitamin D or supplements); quitting smoking; drinking less; reducing your salt and caffeine intake (both can decrease calcium levels); and in some cases, meds. Doctors don’t routinely treat osteopenia, but if your bone density scan shows you’re dangerously close to osteoporosis and at high risk for fractures, you may be given a treatment plan.
Is a routine bone density test covered by insurance?
A screening for osteoporosis (that’s ICD-10 in insurance billing lingo) is covered under the Affordable Care Act (ACA) for women over 60 with risk factors. The United States Preventative Services Task Force (USPSTF), which makes guidelines that health insurance plans typically follow, recommends screenings at age 65. So if you’re under 60 and don’t have any risk factors, a baseline bone density scan may not be covered. Before you have a test, call your healthcare provider, and ask your physician about the out-of-pocket cost.