One in three women will have an osteoporotic fracture which mainly involves the upper femur as a fractured hip, the vertebral bodies as crush fractures and with loss of height and deformity, and the Colles fracture. It is estimated that an osteoporotic fracture occurs every 3 minutes.
The Colles fracture is the least severe and occurs in the slightly younger age group of 60 plus but is a useful clinical marker to osteoporosis and the potential of more severe fractures elsewhere.
More than 60,000 women fracture the hip every year – about 20% die in the next year as a direct result of the fracture and of those who survive almost a half suffer the indignity of no longer being able to cope for themselves.
Multiple crush fractures of the spine lead to loss of height of up to 8 inches, compression of the heart and lungs in a smaller chest cavity and the gross curvature of the spine for which the term “Dowager’s Hump” does little justice to the severity of this disability. The tragedy with this condition is that it is preventable but not prevented.
Q. What is the best way of picking it up early ?
A. The secret is to try to pick up osteoporosis by the measurement of bone density before it becomes obvious through a life threatening and deforming fracture.
There are certain clinical risk factors which suggest the need for bone densitometry such as family history, early menopause, early hysterectomy and oophorectomy, prolonged steroid therapy, and anorexia with loss of periods. Mass population screening is not at the moment recommended as a way of picking up this condition.
Q. Why is it such a problem in older women ?
A. After the menopause, women lose about 2% of their bone density per year. Within 10 years many women who may have approached the menopause with a low bone mass are below the fracture threshold.
These fractures may occur with the most trivial trauma and should be remembered that menopausal women do have flushes, sweats which produce giddiness and encourage falls. It is odd that it is the thin women who break their bones not the overweight, apparently clumsy women because the oestrogen is made in the body fat offering the overweight women some protection.
On a practical level it does mean that the healthy, thin, post-menopausal women who thinks that she is protected because she walks her dog for half an hour per day is more at risk than the less active, stouter woman. Apart from loss of calcium, the mineral in bone, there is also a generalised loss of collagen in older women after the menopause.
This protein (colla means glue in most European languages) is an essential part of all body tissues and its loss produces the thin translucent skin in older women, brittle nails, loss of hair and diminution of the extensive collagenous matrix of the bone. It should be remembered that it is the collagen that gives bone its strength and calcium, although essential for strong bones, gives bone its brittleness.
Q. Which men are at risk?
A. Osteoporosis in men is less well understood. In perhaps half the cases there is no apparent clinical risk factor but the others have a history of steroid ingestion or hypogonadism with low testosterone levels.
Q. How does HRT help ?
A. Hormone replacement therapy by which we mostly mean oestrogen replacement stops resorption of bone allowing the formation of more new bone.
It also has a positive anabolic effect upon the skeleton allowing the bone density to markedly increase. This is an important concept because so many textbooks state that oestrogens do not increase bone density. That is not true. The same texts also say that osteoporotic bone or the bone in older women does not respond to oestrogens. That also is not true. We do know that the increase in bone density with oestrogen therapy is greater the more osteoporotic the bones or the older the woman. These are just the patients who need oestrogens.
There is also a clear correlation between the dose used, the plasma oestradiol levels and the incremental increase in bone density per year.
Oestrogens also prevent the giddiness of vasomotor instability hence the excess of falls in this age group. It also increases the collagen in the bone matrix as well as having a more demonstrable cosmetic benefit to the skin and the hair.
Q. Do calcium and vitamin D supplements have a role?
A. By far the best way of preventing or treating osteoporosis is by oestrogens but calcium and vitamin D supplements also have a role. It is important that older women who often have poor diets have supplementary calcium of 1500mgs each day and 400 units of vitamin D. This is most conveniently available in a single tablet of Calcichew D3 forte, one or two per day. Often women will not wish to take oestrogens with their side effects or bisphosphonates with their various side effects so supplementary calcium and vitamin D have a role. However, it should be stressed it is not first-choice therapy.
Q. How is it influenced by lifestyle?
A. Exercise and a sensible diet play an important role in general well being also specifically for the prevention of osteoporosis. Heavy weight bearing exercises do have a beneficial effect upon bone and it is wrong for women to think that brisk walks are an adequate alternative to oestrogens.
On the other hand a sedentary life-style, inadequate calcium, magnesium and vitamins etc in the diet as well as excessive smoking and alcohol plus a generally bad cardiovascular system can be damaging for the bones. A little known risk is the problem of fizzy drinks.
They contain purified sugar and caffeine and phosphate which all selectively remove calcium from the skeleton and excrete them in the urine. If the fizzy drink (without mentioning the obvious proprietary name) is canned then aluminium which also selectively removes calcium from the skeleton is present in ten times the concentration of that in bottles of the same drink. Milk is much better than cola for bones.
Q. How do the bisphosphonates (Didronel and Fosamax) work, and how long do they need to be taken for?
A. Bisphosphonates should be the second choice but are preferred by physicians who may be unhappy about using oestrogens and progestogens. It is easy to dissuade women from taking HRT if counselling overstates the problems of bleeding and the risks of breast cancer and deep vein thrombosis.
These drugs are often given to older women in the mistaken belief that the older skeleton does not respond adequately to oestrogens. Didronel is fairly free of side effects but for those taking Fosamax, care must be taken to avoid oesophageal and stomach ulceration.
Q. Are there any proven complementary or alternative treatments?
A. Osteoporosis is a slow process that is strongly influenced by factors including diet, lifestyle as well as changes in the hormonal environment.
The complementary therapies that are associated with increased bone mineral density are weight bearing exercise and correct nutritional and dietary patterns throughout life.
Regular exercise combined with maintaining adequate nutrition with regard to calcium, vitamin D, magnesium and other nutrients also required for bone health are essential for maximizing peak bone mass and for minimizing the rate of bone loss that occur with ageing. This would in turn reduce the risk of developing osteoporosis.
Calcium, magnesium and vitamin D have stolen most of the research limelight although we know of around 16 different vitamins and minerals that are important for optimal bone health. The avoidance of negative dietary influences is also crucial to maintaining healthy bone.
Complementary medicines are used more and more often for the pain of osteoporosis. These include calcium, vitamin D, various antioxidants and particularly acupuncture.
Q. Are there any exciting developments in the pipeline?
A. The modified oestrogen, SERMs, in the form of Raloxifene has been available for the last year. It has a licence for osteoporosis but its beneficial effects on the skeleton are much less than oestrogens. However, it does not cause bleeding and there seems convincing evidence that it reduces the risk of breast cancer. It does however produce flushes and sweats, so it is not very useful therapy for the menopause.
A new generation bisphosphonate called Residronate will have a licence by the end of the year. It is claimed that this has a better bone profile and fewer side effects than the current bisphosphonates.
Work is being done on the role of natural progesterone to confirm some of the apparently exaggerated claims made of its beneficial effect upon bone density. If it works it will be a major addition to osteoporosis prevention and therapy.
