Osteoporosis: The Silent Bone Loss Until the First Fracture
Osteoporosis causes no symptoms until a bone breaks. By then substantial bone has already been lost. It is diagnosable before that point, and treatment reduces fracture risk substantially, yet most people are never assessed.
What it is
Bone is living tissue, constantly removed and rebuilt. Bone mass peaks around age 25 to 30, then declines. In osteoporosis, removal outpaces formation and the internal architecture of bone thins and perforates, so bones break with minor force.
Osteopenia is reduced bone density not yet meeting the osteoporosis threshold.
Why it matters
Typical osteoporotic fractures occur at the hip, spine and wrist. Hip fracture after 70 carries a mortality of roughly 20 to 30 percent in the following year, and many survivors never regain independence.
Spinal fractures are the most common and the most missed. They often occur without a fall, causing sudden back pain, or none at all, and show up as loss of height, a stooped posture and a protruding abdomen. Losing more than 3 to 4 cm of height is a reason to be assessed.
Risk factors
Cannot change:
- Age
- Female sex, with accelerated loss in the five to ten years after menopause as oestrogen falls
- Family history, particularly a parent with hip fracture
- Previous fragility fracture, meaning a break from a fall from standing height or less. This is the single strongest predictor
- Small body frame, low body weight
- South Asian ethnicity, with generally lower peak bone mass
Can change or treat:
- Low calcium and vitamin D intake
- Physical inactivity and prolonged bed rest
- Smoking
- Excess alcohol
- Low body weight and eating disorders
- Early menopause or surgical removal of ovaries
- Low testosterone in men
- Long-term oral steroids, a major cause, where preventive treatment should be started alongside the steroid
- Hyperthyroidism, including over-treatment with levothyroxine
- Hyperparathyroidism
- Coeliac disease, inflammatory bowel disease and other malabsorption
- Chronic kidney disease
- Rheumatoid arthritis
- Some medications: certain antiepileptics, long-term heparin, some diabetes drugs, aromatase inhibitors, androgen deprivation therapy, and long-term proton pump inhibitors
Who should be scanned
A DEXA scan is appropriate for:
- Women 65 and over, men 70 and over
- Postmenopausal women under 65 with risk factors
- Anyone with a fragility fracture after age 50
- Anyone on oral steroids for three months or more
- Height loss above 3 to 4 cm, or new stooping
- Early menopause
- Conditions and medications listed above
Unlock More Content
Watch a short ad to continue reading the rest of this article for free.
Preparing your free unlock…
The FRAX tool estimates ten-year fracture probability using clinical factors with or without a DEXA result and helps decide who needs treatment.
Reading a DEXA report
The T-score compares your density with a healthy young adult:
- Normal: above -1.0
- Osteopenia: between -1.0 and -2.5
- Osteoporosis: -2.5 or below
- Severe osteoporosis: -2.5 or below with a fracture
The Z-score compares with people of your own age and is used in younger adults and children; a low Z-score prompts a search for a secondary cause.
Blood tests usually accompany the scan: calcium, phosphate, vitamin D, parathyroid hormone, kidney and liver function, thyroid function, and in men, testosterone.
Treatment
Calcium, around 1000 to 1200 mg daily, preferably from food: milk, curd, paneer, ragi, sesame, almonds, green leafy vegetables, small fish eaten with bones. Supplements are used when diet falls short, taken in divided doses with food.
Vitamin D, corrected and maintained, since calcium cannot be absorbed without it.
Bisphosphonates — alendronate, risedronate, zoledronic acid. First-line, well-evidenced, reducing vertebral and hip fractures. Oral forms must be taken on an empty stomach with a full glass of plain water, remaining upright for 30 to 60 minutes, which is essential to avoid oesophageal injury and is the main reason they fail.
Denosumab, a six-monthly injection. Effective, but must not be stopped abruptly, since rapid rebound bone loss and vertebral fractures can follow; another agent is needed if it is discontinued.
Teriparatide and romosozumab, anabolic agents that build bone, for severe disease.
Hormone therapy in selected younger postmenopausal women, and testosterone in hypogonadal men.
Two rare side effects of antiresorptive drugs are much discussed: osteonecrosis of the jaw and atypical femoral fracture. Both are uncommon, far less likely than the fractures being prevented, and the jaw risk is reduced by having dental work completed before starting treatment and maintaining oral hygiene.
Drug holidays are considered after three to five years of bisphosphonates in lower-risk patients, under medical guidance.
Exercise that builds and protects bone
- Weight-bearing impact: brisk walking, stair climbing, dancing, skipping or jogging where joints allow
- Resistance training, two to three times a week, which is the most effective component for bone and muscle together
- Balance training to prevent the falls that cause fractures
- Avoid forward bending with a rounded back, heavy twisting and sit-ups if vertebral fractures are present or suspected
Swimming and cycling are excellent for fitness but do not load bone meaningfully.
Habits that matter
Stop smoking. Limit alcohol. Maintain a healthy weight rather than being underweight. Get some sunlight. Treat the underlying conditions above. And treat fall prevention as part of fracture prevention, because most fractures need both weak bone and a fall.
This is general information. Osteoporosis treatment, calcium dosing and the timing of drug holidays should be decided with a doctor after proper assessment.