Hi. I’m Dr. Stephen Suhrer of Florida Woman Care of Jacksonville and I am going to take a few minutes to discuss two related problems that affect well over 40% of postmenopausal women – osteopenia and osteoporosis. Osteopenia is a disorder of weakening bone strength and is a precursor of osteoporosis which exists when a person’s bones have weakened to the point where they are brittle and are at signiﬁcant risk of fractures, especially at the hip, wrist, and spine.
Diagnosing Osteoporosis and Osteopenia
These disorders are exceptionally important to diagnose because of the difﬁculties created by fractured bones, especially hip fractures, which can be catastrophic. Why? Because hip fractures require surgical repair and because twenty to thirty percent of all people who suffer a hip fracture related to osteoporosis die within the ﬁrst year from a complication directly related to the hip fracture. Additionally, osteoporotic fractures of the spine can occur simply with the trauma of daily life and can result in postural changes creating severe back pain and changes in appearance such as this woman who suffers from a Dowager’s hump of the upper back which is irreversible. So, osteoporosis presents a very costly personal and societal problem.
In order to understand these disease processes, it is important to realize something that many people don’t understand…….that bone is a living tissue. Its structure is similar to that of a building with steel trusses inside of it that provide its support and strength. Within the trusses, there are two main populations of cells called osteoblasts and osteoclasts. Osteoblasts make new bone and create the trusses while osteoclasts tear down the aged and broken trusses, kind of like Pac-Men, so that new ones can be made to replace them.
The degree of activity of these two different bone cell types changes as we age creating several phases of bone health. In our younger years, more new bone is made than is destroyed. In our late 30’s to early 40’s, the activity of the osteoblasts and osteoclasts equilibrates resulting in a stable amount of bone. Then, in our mid to late 40’s, the rate of bone destruction exceeds the rate of bone production. This results in a slow and methodical breakdown of the bone which can lead to osteopenia and, eventually, osteoporosis, if nothing is done to counteract these effects.
This decline in bone production in the mid 40’s and after menopause is due to lower estrogen levels at these phases of life. It seems that this important hormone slows the activity of the bone-destroying cells, the osteoclasts. As the estrogen levels decline, bone destruction increases. This is why osteopenia and osteoporosis are so common after menopause.
Osteoporosis Risk Factors
In addition to the declining estrogen levels with older age, there are several other risk factors for the development of osteopenia and osteoporosis. These include any other states of low estrogen levels, such as in women who stop menstruating due to excessive exercise or those who have the eating disorder, anorexia nervosa.
Unchangeable risk factors include being white or Asian, having a family history of osteoporosis or having a small body frame. The behavioral risk factors include tobacco use, alcohol intake, and a lack of exercise. The medical risk factors include excessive thyroid hormone production, certain medications, such as steroids, low calcium intake, gastric bypass and removal of part of the intestine.
Recognizing osteopenia and osteoporosis before they result in a fracture is critically important. They are diagnosed by a simple low dose x-ray called a DEXA scan which determines the density or strength of bone in the spine and hip. This is typically ordered after menopause or when some of the above risk factors are present prior to menopause.
When the DEXA results indicate that a patient has osteopenia, the fracture risk is 2 to 4 times higher than average and the treatment usually involves calcium and Vitamin D supplementation along with recommendations for weight bearing exercise. For unknown reasons, weight bearing exercise stimulates the osteoblasts to make new bone. Occasionally, if patients have other risk factors for osteoporosis, medications may be used to treat osteopenia with the goal of reversing the problem.
If the DEXA scan indicates osteoporosis is present, the fracture risk is 4 to 8 times higher than average and treatment is necessary to reverse the problem. Treatment for osteoporosis includes the same as for osteopenia PLUS one of a variety of medications. These include medications that slow the bone-destroying activity of the osteoclasts, such as Reclast, Boniva, Fosamax, Actonel, Evista and Prolia. Another medication available to treat osteoporosis is Forteo which actually increases bone production rates. If possible, it is best to avoid ever developing osteopenia or osteoporosis. The risk can be signiﬁcantly lowered by making efforts to develop strong and healthy bones at a young age through exercise and healthy eating including adequate amounts of calcium and Vitamin D intake.
If you have any questions about these interesting problems, their treatment or their prevention, please ask your doctor and he or she will gladly discuss these topics with you. Schedule your consultation today!