Our expert is Nelson Watts, MD, FACP, MACE, CCD, Director, of Mercy Health Osteoporosis and Bone Health Services

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Mitzi Perdue

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FRACTURES FROM OSTEOPORIS ARE A COSTLY AND DEBILITATING PUBLIC HEALTH ISSUE

For postmenopausal women, osteoporotic fractures are more common than the following health issues combined:  stroke, myocardial infarction, and breast cancer.  Osteoporotic fractures frequently lead to pain, disability, and possible increased risk of death.

BONE LOSS IS BOTH AGE-RELATED AND MENOPAUSE-RELATED

With bones, there’s a constant process of old bone being removed and new bone taking its place. However, with age, the rate of bone loss is no longer matched by the rate of bone replacement.  Five years or so before menopause, the rate of bone loss accelerates and continues at a relatively high rate for another 5 years following the last menstrual period. During this ten-year period a typical woman may be losing as much as 2% of her bone mass per year. In later years, she’ll still be losing bone mass, but the rate is no longer as severe. By age 90, she may have the bone mass of a ten-year old girl.

DIFFERENT LOCATIONS FOR FRACTURES INDICATE DIFFERENT RISK FOR FUTURE FRACTURES

Fractures of the long bones (arms, legs), spine, and pelvis are associated with increased risk of future fractures, whereas fractures of fingers, toes, hands, feet, skull, or face (and possibly fractures of ribs, knees, elbows, and shoulders) are not. Other than fractures, there may be no signs or symptoms of osteoporosis. Because of this lack of signs, a fracture risk assessment is necessary to identify people at risk.

BONE LOSS HAS BOTH LIFESTYLE AND GENETICS FACTORS

There are hundreds of genes that influence bone loss, but even so, as much as 20% of osteoporosis is influenced by lifestyle.  Importantly, we know that in many cases having a healthy lifestyle can make the difference between having an incapacitating fracture or avoiding one altogether.  Lifestyle factors that can be modified and that can help slow bone loss include; getting enough calcium and vitamin D in the diet or through supplements, limiting alcohol and caffeine consumption, avoiding being underweight, and regularly engaging in weight-bearing exercise.  Walking, running, dancing or using an elliptical machine or treadmill are all excellent for weight-bearing exercise.  However, swimming is not as effective for preventing osteoporosis.  The buoyancy of water prevents the full force of gravity and thus diminishes the weight-bearing aspect of this exercise. Similarly, bicycling is less effective than walking because the seat of the bicycle means less weight bearing for the entire skeleton. Interestingly, weight lifting, the kind one might do at the gym, has not been shown to correlate strongly with preventing bone loss.

PRIMARY CARE PROVIDERS SHOULD EVALUATE RISK FOR OSTEOPOROSIS

Primary care providers should evaluate women at the time of menopause to determine if they are candidates for a risk reduction program.  The provider should look at such factors as: a familial history of osteoporosis; fractures that didn’t come about because of trauma; diet and exercise patterns; and being underweight. In addition, look for diseases that interfere with bone health such as rheumatoid arthritis, inflammatory bowel disease, or chronic obstructive pulmonary disease. Monitor drugs such as glucocorticoids, proton pump inhibitors, selective serotonin reuptake inhibitors, all of which are known to increase fracture risk. The presence of any of these factors would be reasons to order a bone density assessment.

PATIENTS MAY BE UNNECESSARILY FEARFUL OF PHARMACOLOGICAL INTERVENTIONS

We have medications that reduce risk by 50-70 percent within six to 12 months of initiating treatment. However, you may encounter patients who resist being on medications for preventing bone loss. They may feel that it’s just bad luck, as opposed to an underlying disease condition that caused their fracture. Perhaps they heard scary stories from their friends about bad things that happened because of medications for preventing bone loss or they start the medication and then quit it.

What’s needed in all these cases is education. These interventions are similar to interventions that prevent bad things from happening because of high blood pressure or high cholesterol. Your patients need to know that taking these medications can decrease the risk of a serious, debilitating, and at times, life-shortening fractures.

RECOMMEND A BONE DENSITY TEST BY AGE 65 IF NOT EARLIER

If a woman has had a fracture in the absence of a trauma that would explain it (for example, if she experienced a fracture with minimal trauma such as from stepping off the curb, as opposed to being hit by a car), or if she has had early menopause or any of the other risk factors, a bone density scan is in order.  Otherwise, all women should have a bone density test 15 years after their last menstrual period, most typically around age 65.