Osteoporosis No Longer Just a Ladies’ Problem

Dr. Amir

Although a silent disease, osteoporosis has potentially lethal consequences.    Osteoporosis is a disease in which bones become fragile and more likely to break.  Because of its indolent course, osteoporosis is often left undiagnosed and progresses painlessly until a fracture occurs. Most commonly, osteoporotic fractures occur in the hip, spine, and wrist.  Despite awareness in the health care community, osteoporosis remains a public health problem now also recognized as a leading debility in men.

Osteoporosis, as defined by low bone density, occurs in about 44 million American men and women, accounting for 55 percent of the population age 50 and over.  By 2020, the US Surgeon General estimates that without an organized effort to reverse current trends, one of every two adults over the age of 50 will have or will be at high risk for developing osteoporosis.  With more than 1.3 million osteoporotic fractures yearly in the United States, osteoporosis is a major public health dilemma.  Early screening and diagnosis for bone loss can greatly reduce the risk of fractures

Causes of Osteoporosis

Aging and hormones play a key role in osteoporosis.  As we age, bones become more brittle.  Many hormonal causes attribute to bone loss in both men and women. In women, estrogen loss associated with menopause occurring during the first 10 years after menopause leads to an accelerated bone loss; therefore, making it crucial to screen all women of menopausal age. Affecting both sexes are two adjacent glands in the neck the thyroid and parathyroid glands.   An overactive thyroid in both sexes increases the turnover of bone and leads to premature bone loss.   Neighboring the thyroid is the parathyroid gland, serving as a calcium regulator.   When overactive, leads to osteoporosis.  In men, low testosterone is an increased risk for premature bone loss.   This may occur as part of the aging process or induced by drugs used to treat cancer, especially prostate cancer.

Other major risk factors that increase the risk of men in the same fashion as women are smoking alcohol abuse, vitamin D and calcium deficiency, malnutrition, malabsorption,  and long term steroid or medicines used to treat seizures.

Screening

Dual x-ray absorptiometry (DXA) — DXA testing is the most popular method for measuring Bone Mineral Density (BMD) because it provides precise measurements at important bone sites (eg, spine, hip, forearm) with minimal radiation.
National Osteoporosis Foundation (NOF) and International Society for Clinical Densitometry (ISCD) Guidelines for Screening with DXA

  • All women 65 years and older and men 70 and older regardless of risk factors
  • Postmenopausal women and men 50 to 70 years when risk factors are present
  • Adults who have a fracture after age 50
  • Adults with a condition or taking a medication associated with low bone mass or bone loss
  • Anyone being considered for pharmacologic therapy for osteoporosis
  • Anyone being treated for osteoporosis to monitor response to therapy
  • Postmenopausal women discontinuing estrogen should be considered for bone density testing

DXA results fall into 3 categories, comparing the results to age matched patients (also known as the T score): normal bone mineralization, osteopenia-low bone mineralization, or osteoporosis.  With a worsening T score, a patient’s risk of osteoporotic fracture increases.  However, because most patients are in the osteopenic state, further risk assessment is crucial to determine which patients required treatment

This has led to the development of the FRAX Risk Assesment —The FRAX fracture risk assessment tool developed by the World Health Organization (WHO)and incorporated into the National Osteoporosis Foundation (NOF)2008 updated guidelines can help clinicians better identify patients with low bone mass who are at high risk for osteoporosis related fracture and who would benefit from treatment. 

The tool is easily accessible at www.shef.ac.uk/FRAX/ uses a person’s risk factors with and without a bone density test. 

  • Besides height, weight, age and sex, the FRAX tool incorporates factors that independently predicts fracture risk in aging populations
  • A prior risk of fracture
  • A parent with a history of fracture
  • Use of glucocorticoids ( steroids)
  • Rheumatoid arthritis or another cause of secondary osteoporosis
  • Current smoking
  • Alcohol intake of 3 or more drinks daily
  • Bone Mineral Density if results are available

Treatment is indicated if the risk of Hip fracture is 3% or greater in the next 10 years or if any osteoporotic fracture risk is 20 % or greater

In Summary

  • Osteoporosis is a major public health problem
  • By 2020 one in two adults will be at high risk for or have osteoporosis
  • Fracture risk assessment should be part of adult preventative care
  • The principal BMD-independent risk factors to consider include: advanced age, previous fragility fracture, glucocorticoids, risk of falls, smoking, alcohol, family history of fracture.
  • All women over 65 should have a DXA scan
  • Post-menopausal women and men over 70 should be screened if one of risk factors is present.
  • Using NOF screening guidelines along with the FRAX score, will ensure vast screening and appropriate medical therapy for our aging adults. 
  • In a population that will be living longer, reducing fracture risk needs to be a part of your regular office visit.  Speak to your physician about your fracture risk and osteoporosis screening.