Osteoporosis

	Topic Overview
	Health Tools
	Cause
	Symptoms
	What Happens
	What Increases Your Risk
	When To Call a Doctor
	Exams and Tests
	Treatment Overview
	Prevention
	Home Treatment
	Medications
	Surgery
	Other Treatment
	Other Places To Get Help
	Related Information
	References
	Credits

What is osteoporosis?

Osteoporosis is a progressive disease that causes bones to become thin and brittle, making them more likely to break. Osteoporosis may result in broken bones (fractures) in the spine and hip. Hip fractures often require hospitalization, and fractures of the bones in the spine (vertebrae) can cause loss of height and severe back pain. Both may lead to permanent disability.

Whether you develop osteoporosis depends on the thickness of your bones early in life, as well as health, diet, and physical activity later in life. See an illustration of healthy bone versus bone weakened by osteoporosis .

What causes osteoporosis?

During childhood and teenage years, new bone is added faster than existing bone is absorbed by the body. After age 30, this process begins to reverse. As a natural part of aging, bone dissolves and is absorbed faster than new bone is made, and bones become thinner. You are more apt to have osteoporosis if you did not reach your ideal bone thickness (bone mineral density) during your childhood and teenage years. Not getting enough calcium, vitamin D, and phosphorus may contribute to bone thinning.

After age 50, lower levels of estrogen in women and of testosterone in men may speed up bone loss.

If your mother, father, or a sibling has osteoporosis, your risk for the disease is higher.

You can use this tool to check your risk for osteoporosis:

Interactive Tool: Are You At Risk for Osteoporosis?

What are the symptoms?

Osteoporosis is a "silent disease" because typically you do not have symptoms in its early stages. As the disease progresses, you may develop symptoms related to weakened bones, including:

• Back pain.
• Loss of height and stooped posture.
• A curved backbone (dowager's hump).
• Fractures that may occur with a minor injury, especially of the hip, spine, or wrist.

How is osteoporosis diagnosed?

A diagnosis of osteoporosis is based on your medical history, physical examination, and a test to measure your bone thickness (bone density test). Early diagnosis of osteoporosis is very important in order to begin treatment that might prevent fractures.

The United States Preventive Services Task Force recommends that all women age 65 and older routinely have a bone mineral density test to screen for osteoporosis. If you have a higher risk for fractures, routine screening should begin at age 60.

How is it treated?

The process of bone thinning is a natural part of aging. However, you can slow or delay osteoporosis with healthy lifestyle habits, such as not smoking, getting enough calcium and vitamin D, and getting regular exercise, which helps build and strengthen your bones.

Treatment for osteoporosis includes eating a diet rich in calcium and vitamin D, getting regular exercise, and taking medication to reduce bone loss and increase bone thickness. It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis. Even small changes in diet, exercise, and medication can help prevent a broken bone.

My doctor says I have osteopenia. What is it?

Osteopenia means that your level of bone thickness falls somewhere between normal and the very low bone density of osteoporosis. If you are diagnosed with osteopenia, your health professional will probably recommend diet and lifestyle changes, vitamin D and calcium supplements, and possibly medication to prevent further bone thinning.

Frequently Asked Questions

Health tools help you make wise health decisions or take action to improve your health.

	Decision Points focus on key medical care decisions that are important to many health problems.
	Should I have a dual-energy X-ray absorptiometry (DEXA) test to diagnose osteoporosis?
	Should I take bisphosphonate medications for osteoporosis?
	Actionsets are designed to help people take an active role in managing a health condition.
	Making your home fall-proof
	Taking calcium for osteoporosis

During childhood and teen years, new bone grows faster than existing bone is absorbed by the body. After age 30, this process begins to reverse. As a natural part of aging, bone dissolves and is absorbed faster than new bone is made, and bones become thinner. You are more apt to have osteoporosis if you did not reach your ideal bone thickness (bone mineral density) during your childhood and teenage years.

In women, bone loss increases around menopause, when ovaries decrease production of estrogen, a hormone that protects against bone loss. Likewise, testosterone protects men from bone loss. Osteoporosis is typically seen in men older than 65, when production of this hormone declines. In both men and women, the older you get the more likely you are to have osteoporosis. See an illustration of healthy bone versus bone weakened by osteoporosis .

Not getting enough calcium, vitamin D, and phosphorus contributes to bone thinning. In addition, a tendency for lower bone mass may pass from parent to child.

In the early stages of osteoporosis, you usually do not have symptoms. As the disease progresses, you may develop symptoms related to weakened bones, including:

• Back pain.
• Loss of height and stooped posture.
• A curved upper back (dowager's hump).
• Broken bones (fractures) that might occur with a minor injury, especially in the hip, spine , and wrist.
• Compression fractures in the spine may cause severe back pain. But sometimes these fractures cause only minor symptoms or no symptoms at all.

In a normal, healthy adult, bone is continually absorbed into the body and then rebuilt. During childhood and the teen years, new bone tissue is added faster than existing bone is absorbed. As a result, your bones become larger and heavier until about age 30 when you reach peak bone mass (density). The more bone mass you developed early in life, the less likely you are to develop osteoporosis.

After age 30, both men and women lose a small amount (approximately 0.4%) of bone each year.¹ Because most men build greater bone mass than do women, they tend to get osteoporosis later in life. After age 40 to 50, the rate at which bone dissolves and is absorbed by the body increases, resulting in declining bone mass.

A person with thinning bones may be diagnosed with lower-than-normal bone mass (osteopenia). Osteopenia sometimes progresses to osteoporosis.

When bones thin, they lose strength and break more easily. The bones that break most often due to osteoporosis are:

• The spine. About half of broken bones caused by osteoporosis are bones in the spine.² Men and women who have a spinal fracture have a higher risk of future spinal fractures.³ Vertebrae that are weak because of osteoporosis may break and collapse on top of each other (compression fracture). Compression fractures of the spine can result in back pain, stooped posture, loss of height, and a curved upper back (dowager's hump).
• The hip. Hip fractures are most common in older women.⁴ Hip fractures are often caused by a fall. They can make it very hard for you to move around and they usually require major surgery. After a hip fracture, many older people have medical complications such as blood clots, pressure sores, or pneumonia.
• The wrist and forearm.

In women, bone loss increases when the ovaries reduce production of estrogen, a hormone that protects against bone loss. Studies show that on average, women lose 1% to 3% of their bone mass per year for about 3 to 5 years after menopause.⁵

In men, the hormone testosterone protects against bone loss. Osteoporosis develops most often in men older than 65.

See an illustration of healthy bone versus bone weakened by osteoporosis .

The risk of osteoporosis increases with age as bones naturally become thinner. After age 30, the rate at which your bone dissolves and is absorbed by the body slowly increases, while the rate of bone building decreases. Both men and women lose a small amount (approximately 0.4%) of bone each year after age 30.¹

In women, more rapid bone loss usually begins after monthly menstrual periods stop, when a woman's production of the hormone estrogen slows down (usually between the ages of 45 and 55). A man's bone thinning starts to develop gradually when production of the hormone testosterone slows down, at about 45 to 50 years of age. Women typically have smaller and lighter bones than men. As a result, women develop osteoporosis almost 4 times more often than men.² Osteoporosis usually does not have an effect on people until they are 60 or older.

Whether a person develops osteoporosis depends on the thickness of the bones (bone density) in early life, as well as health, diet, and physical activity later in life. Factors that increase the risk of osteoporosis in both men and women include:

• Having a family history of osteoporosis. If your mother, father, or a sibling has been diagnosed with osteoporosis or has experienced broken bones from a minor injury, you are more likely to develop osteoporosis.
• Lifestyle factors. These include:
  • Smoking. People who smoke lose bone thickness faster than nonsmokers.
  • Alcohol use. Heavy alcohol use can decrease bone growth and increase the risk of falling. However, moderate alcohol use is linked to higher bone thickness. Most doctors recommend limiting, but not eliminating, alcohol use.⁵
  • Getting little or no exercise. Weight-bearing exercises—such as walking, jogging, stair climbing, dancing, or lifting weights—keep bones strong and healthy by working the muscles and bones against gravity. Exercise may improve your balance and decrease your risk of falling.
  • Being small-framed or thin. People with small frames are more likely to develop osteoporosis because they have smaller bones and less bone mass. Thin people are more likely to develop osteoporosis because they have less body fat. Fat cells make estrogen, which may protect women from bone loss after menopause. However, being overweight puts a woman at risk for other serious medical conditions, including type 2 diabetes, high blood pressure, and coronary artery disease (CAD).
  • A diet low in foods containing calcium, phosphorus, and vitamin D.
  • Drinking cola soft drinks. Cola, but not other carbonated soft drinks, may be linked to low bone mineral density in women.⁶
• Having certain medical conditions, such as hyperthyroidism or rheumatoid arthritis, that put you at greater risk for osteoporosis.
• Taking certain medications. Several medications cause bone thinning, such as:
  • Corticosteroids, used to treat conditions such as asthma and chronic obstructive pulmonary disease (COPD). If used for a period of 6 months or longer, corticosteroids can lead to steroid-induced osteoporosis.⁷
  • Medications used to treat endometriosis.
  • Aromatase inhibitors, used to treat breast cancer.
  • Thyroid replacement medication, if the dose is more than the body needs. This should be monitored by checking the level of thyroid stimulating hormone (TSH) every year.
  • Depo-Provera, a birth control medication given by injection. Longtime use may thin bones.
  • Antacids that contain aluminum, if they are overused. Aluminum-containing antacids remove phosphorus and calcium from your body.
  • Anticonvulsant medications such as carbamazepine.⁸
• Having certain surgeries, such as having your ovaries removed before menopause.

Other risk factors for osteoporosis may include:

• Being of European and Asian ancestry, the people most likely to have osteoporosis. People of African ancestry are least likely.
• Being inactive or bedridden for long periods of time.
• Dieting excessively or having an eating disorder, such as anorexia nervosa.
• Being a female athlete, if you have few or irregular menstrual cycles due to low body fat.

Women who have completed menopause have the greatest risk of osteoporosis, because their levels of the estrogen hormone drop. Estrogen protects women from bone loss. Likewise, women who no longer have menstrual periods—either because their ovaries are not working properly, or because their ovaries have been surgically removed—also can have decreased estrogen levels.

To check your risk for osteoporosis, use the Interactive Tool: Are You at Risk for Osteoporosis? or use this osteoporosis risk questionnaire.

Call your health professional immediately if you:

• Think you have a broken bone, notice a deformity after a fall, or cannot move a part of your body.
• Have sudden, severe pain when bearing weight.

Call your health professional for an appointment if you:

• Want to discuss your risk of developing osteoporosis.
• Have symptoms of menopause or have completed menopause and want to discuss whether you should take medication to prevent osteoporosis.
• Have been treated for a fracture caused by a minor injury, such as a simple fall, and want to discuss your risk of osteoporosis.

If you are nearing age 65, have osteopenia, or think that you are at high risk for osteoporosis, talk with your health professional about your concerns.

Watchful Waiting

If you do not have any risk factors for osteoporosis and you are already taking preventive measures, such as taking adequate calcium and vitamin D, you may only need routine screening.

Who To See

Health professionals who can evaluate your symptoms and risk of osteoporosis include:

• Nurse practitioners.
• Physician assistants.
• Family medicine doctors.
• Internists.
• Rheumatologists.
• Endocrinologists.
• Gynecologists.

To prepare for your appointment, see the topic Making the Most of Your Appointment

A diagnosis of osteoporosis is based on your medical history, physical examination, and a test to measure your bone thickness (density). During a physical exam, your health professional will:

• Measure your height and compare the results with past measurements.
• Examine your body for evidence of previous broken bones, such as changes in the shape of your long bones and spine . See an illustration of a compression fracture of the spine .

A bone mineral density test measures the mineral density (such as calcium) in your bones using a special X-ray, computed tomography (CT) scan, or ultrasound. From this information, your health professional can estimate the strength of your bones. See an illustration of a bone mineral density test .

Routine urine and blood tests can rule out other medical conditions, such as hyperthyroidism or Cushing's syndrome, that can cause bone loss. In men, blood tests to measure testosterone levels can see whether low levels are causing bone loss.

If you have been diagnosed with osteoporosis, you may need to follow up regularly with your health professional to monitor your condition.

Early Detection

If you or your health professional thinks you may be at risk for developing osteoporosis, you may have a screening test to check your bone thickness. A screening test may be advisable if you have:

• A fracture in a minor injury that may have been caused by osteoporosis.
• Another medical condition that is known to cause bone thinning.
• Risk factors for or symptoms that suggest osteoporosis.

The United States Preventive Services Task Force recommends that all women age 65 and older routinely have a bone mineral density test to screen for osteoporosis. If you are at increased risk for fractures caused by osteoporosis, routine screening should begin at age 60.

Most experts recommend that the decision to screen women age 60 and younger be made on an individual basis, depending on the risk of developing osteoporosis and whether the test results will help with treatment decisions. To help you decide whether you should be tested for osteoporosis, see:

Should I have bone mineral testing to diagnose osteoporosis?

The process of bone thinning (osteoporosis) is a natural part of aging. However, if you receive treatment early, you may be able to stop or slow the progress of bone loss. Treatment is important to:⁹

• Prevent broken bones.
• Maintain or increase your bone thickness.
• Relieve pain caused by fractures and changes to bones.
• Maintain your ability to function physically.

Treatment for osteoporosis includes eating a diet rich in calcium and vitamin D, getting regular exercise, and taking medication to reduce bone loss and increase bone thickness. It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis. Even small changes in diet, exercise, and medication can help prevent spine and hip fractures. Adults who adopt healthy habits can slow the progress of osteoporosis.

See an illustration of healthy bone versus bone weakened by osteoporosis .

Initial treatment

If you have been diagnosed with osteoporosis, your health professional probably will recommend lifestyle and diet changes. Eat foods rich in calcium, vitamin D, and phosphorus, all necessary for maintaining healthy, strong bones. Take supplements if you think you are not getting enough of these nutrients in your diet. If you are diagnosed with osteoporosis, your recommended daily calcium and vitamin D intake is 1,200 mg of calcium plus 400 to 800 IU of vitamin D.

Your bones need vitamin D to absorb calcium. One study showed that vitamin D may reduce an older person's risk of falling by 22%.¹⁰ The best source of vitamin D is exposure to sunlight. Vitamin D is also added to milk, some calcium supplements, and many multivitamin supplements.

Research studies do not agree about whether calcium plus vitamin D supplements can prevent fractures. Some studies show that calcium and vitamin D supplements reduce the risk of fracture.¹¹ But other studies show little effect of supplements on fracture risk.¹² The greatest benefit of supplements appears to be for people who have osteoporosis. Calcium and vitamin D supplements are recommended if you have been diagnosed with osteoporosis.

For more information on taking calcium, see:

Taking calcium for osteoporosis

Exercises, including weight-bearing exercise (walking, jogging, stair climbing, dancing, or lifting weights), aerobics, and resistance exercises are all effective in increasing bone mineral density and strength of the spine. Start out at an exercise level that you are comfortable with and work up gradually. To be most effective, weight-bearing exercises should be done for 45 to 60 minutes at least 4 days a week. If you stop exercising, your bones weaken and may be more likely to break. Walking also increases bone mineral density of the hip.¹³

Along with exercise and diet, your health professional will recommend that you not smoke and limit alcohol to one drink per day.

In some cases, medications are prescribed to protect against bone loss. These medications include raloxifene (Evista), and bisphosphonates, such as risedronate (Actonel) and alendronate (Fosamax), and parathyroid hormone (Forteo). It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis. For more information on taking bisphosphonates, see:

Should I take bisphosphonate medications for osteoporosis?

If you take corticosteroids longer than 6 months for asthma or other conditions, you may be at greater risk for developing steroid-induced osteoporosis. If you begin to have bone loss, you may need to take osteoporosis medications, such as bisphosphonates, while you are taking steroids.

In select cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.^{14, 15} Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.^{16, 17}

Ongoing treatment

Once you have been diagnosed with bone loss, whether it is mild or severe, you will need to have regular follow-up tests to monitor the disease. Osteoporosis is a progressive disease; both men and women lose approximately 0.4% of bone each year after age 30.¹ It is never too late to develop and then maintain healthy habits that can slow progression of the disease.

• Eat a nutritious diet that includes adequate amounts of calcium and vitamin D. Both are necessary for building healthy, strong bones. Take supplements if you think you are not getting enough of these nutrients in your diet. If you are diagnosed with osteoporosis, your recommended daily calcium and vitamin D intake is 1,200 mg of calcium plus 400 to 800 IU of vitamin D. Your bones need vitamin D to absorb calcium. One study showed that vitamin D may reduce an older person's risk of falling by 22%.¹⁰ The best source of vitamin D is exposure to sunlight. Vitamin D is also added to milk, some calcium supplements, and many multivitamin supplements.
• Get regular exercise. Weight-bearing exercises such as walking, jogging, stair climbing, dancing, or lifting weights keep bones healthy by working the muscles and bones against gravity.

When you have osteoporosis, it is especially important to protect yourself from falling. When bones lose mass and become more brittle, they lose strength and break more easily. Women of European and Asian ancestry are more likely to have osteoporosis than those with African ancestry. An estimated 17% of white women will break a hip sometime after age 50, as will 6% of white men.⁴ To reduce your chances of breaking bones, take steps to prevent falls, such as having your vision and hearing checked regularly and wearing slippers or shoes with a nonskid sole. Exercises that improve balance and coordination, such as tai chi, can also reduce your risk of falling.

If your tests indicate continuing bone loss, your health professional probably will recommend that you take medication to increase bone density and decrease your risk of spine and hip fractures. These medications include bisphosphonates, such as risedronate (Actonel) or alendronate (Fosamax). It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis. For more information about taking bisphosphonates, see:

Should I take bisphosphonate medications for osteoporosis?

Calcitonin may be prescribed for women who are more than 5 years beyond menopause and who cannot take bisphosphonate medications, or for men who are not receiving testosterone treatment. Calcitonin has the added advantage of helping reduce pain from spinal fractures. However, studies show that calcitonin is less effective than bisphosphonate medications at stopping bone loss.¹⁸

Raloxifene (Evista) may be prescribed for women, especially if you are 55 to 65 years old. Raloxifene has been proven to reduce the risk of spinal fractures, but not hip fractures.¹⁸ Raloxifene may also reduce the risk of breast cancer, although it is not approved for this purpose. Raloxifene can cause hot flashes, so it is not often used in early menopause (45 to 55 years) when hot flashes are frequent.

In select cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.^{14, 15} Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.^{16, 17}

Treatment if the condition gets worse

It is never too late to develop and then maintain healthy habits that can slow bone thinning.

• Eat a nutritious diet that includes adequate amounts of calcium and vitamin D. Both are necessary for building healthy, strong bones. Take supplements if you think you are not getting enough of these nutrients in your diet. If you are diagnosed with osteoporosis, your recommended daily calcium and vitamin D intake is 1,200 mg of calcium plus 400 to 800 IU of vitamin D. Your bones need vitamin D to absorb calcium. One study showed that vitamin D may reduce an older person's risk of falling by 22%.¹⁰ The best source of vitamin D is exposure to sunlight. Vitamin D is also added to milk, some calcium supplements, and many multivitamin supplements.
• Get regular exercise. Weight-bearing exercises, such as walking, jogging, stair climbing, dancing, or lifting weights, keep bones healthy by working the muscles and bones against gravity.

Medications called bisphosphonates, such as alendronate (Fosamax) and risedronate (Actonel), may be used to slow the rate of bone loss and increase bone thickness and strength. This will reduce the risk of broken bones. For more information on bisphosphonates, see:

Should I take bisphosphonate medications for osteoporosis?

In select cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.^{14, 15} Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.^{16, 17}

If your osteoporosis is severe or you continue to have bone loss while taking a bisphosphonate:

• You may need to take both a bisphosphonate medication and hormone therapy. Studies show that taking both medications results in increased bone mass when compared to taking either alone.^{19, 20}
• Your health professional may prescribe teriparatide (Forteo). Forteo has been shown to slow bone loss and increase the rate of new bone growth.²¹ However, Forteo is expensive and requires daily self-injections.

It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis.

Compression fractures resulting from osteoporosis can cause significant back pain that lasts for several months. Treatments available to relieve your pain include:

• Nonprescription nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and aspirin.
• Nonprescription acetaminophen (such as Tylenol, Panadol, or Tempra).
• A pain reliever such as a narcotic, which may be prescribed on a short-term basis.
• Other medicines such as calcitonin (Calcimar or Miacalcin) to help decrease pain from spinal fractures.
• A back brace or corset to slow curvature of the spine.

One of two surgical treatments, vertebroplasty or kyphoplasty, may relieve pain from spinal compression fractures. In these procedures, a surgeon injects bone cement into the crushed spinal bones (vertebrae) through a needle.

If you experience a fractured bone related to osteoporosis, treatment to slow your bone thinning becomes very important. If you have had a spinal fracture, you are at risk of having another.³

What to think about

Although HRT and ERT have been used to prevent or slow bone loss, currently they are not recommended for women as the first choice for prevention or treatment of osteoporosis. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.^{14, 15} Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.^{16, 17} To learn more about the study, see WHI: Risks and benefits of taking HRT or ERT.

Because taking estrogen alone increases the risk of developing cancer of the lining of the uterus (endometrial cancer), ERT is only used if a woman has had her uterus removed.

Researchers are studying the effects of low-dose estrogen on women 65 and older. An early small study indicates that a low estrogen dose (one-quarter that of conventional ERT) may provide the same benefit—increased bone density and decreased fractures—as the higher dose. In the same study, about one-third of the women were given the low estrogen dose and progesterone (because these women had not had hysterectomies). This group of women also experienced increased bone density. However, the long-term risks of taking low-dose estrogen (and progesterone in one-third of the cases) were not studied and are unclear.²²

It's important to take calcium and vitamin D supplements along with any medications you take for osteoporosis. For more information on taking calcium, see:

Taking calcium for osteoporosis

After the age of about 30, bone thinning is a natural process and cannot be stopped completely. Whether you develop osteoporosis depends on the thickness of your bones early in life, as well as your health, diet, and physical activity later in life. The thicker your bones, the less likely the bones are to become thin enough to break. Young women in particular need to be aware of their risk for developing osteoporosis and take steps early to slow its progress and prevent complications. Plentiful physical activity during the preteen and teen years increases bone mass and greatly reduces the risk of osteoporosis in adulthood. If you eat a diet adequate in calcium and vitamin D and exercise regularly early in life and then continue with these healthy habits, you may be able to delay or avoid osteoporosis.

• Eat a nutritious diet that includes adequate amounts of calcium and vitamin D. Both are necessary for building healthy, strong bones. The recommended daily calcium intake for adults age 19 to 50 is 1,000 mg per day. Men and women age 50 and older need 1,200 mg of calcium each day. The recommended daily intake for vitamin D is 5 ug (200 IU) for adults age 19 to 50, 10 ug (400 IU) for adults age 51 to 70, and 15 ug (600 IU) for adults age 71 and older. The best source of vitamin D is exposure to sunlight. Vitamin D is vital for calcium absorption in bones and to improve muscle strength. One study showed that vitamin D may reduce an older person's risk of falling by 22%.¹⁰ If you are not getting enough calcium and vitamin D in your diet, take supplements.
• Get regular exercise. Weight-bearing exercises, such as walking, jogging, stair climbing, dancing, or weight lifting, keep bones healthy by working the muscles and bones against gravity.
• Don't drink more than one alcoholic drink per day. Drinking more than this puts you at higher risk for osteoporosis.
• Don't smoke. Smoking puts you at a higher risk for developing osteoporosis and increases the rate of bone thinning after it starts.

Once osteoporosis develops, getting enough calcium and vitamin D, along with other healthy habits, can slow the process and reduce the chances of bones breaking. It's common for a person's diet to supply only half the calcium the bones need, so you probably need to take supplements. Your bones need vitamin D to absorb calcium. One study showed that vitamin D may reduce an older person's risk of falling by 22%.¹⁰

Research studies do not agree about whether calcium plus vitamin D supplements can prevent fractures. Some studies show that calcium and vitamin D supplements reduce the risk of fracture.¹¹ But other studies show little effect of supplements on fracture risk.¹² The greatest benefit of supplements appears to be for people who have osteoporosis. Calcium and vitamin D supplements are recommended if you have been diagnosed with osteoporosis.

Most adults with osteoporosis need to take medication to slow bone loss. In addition to medication, there is much you can do to help slow the process and prevent broken bones:

• Get enough calcium. This is one of the first and then ongoing steps in trying to prevent and treat osteoporosis. If you are diagnosed with osteoporosis, your recommended daily calcium intake is 1,200 mg. Calcium is found in many foods, including dairy products such as milk or yogurt. If you think you may not be getting enough calcium in your diet, take calcium supplements.²³ Most Americans get only half the calcium they need from their diet. Research studies do not agree about whether calcium plus vitamin D supplements can prevent fractures.^{11, 12} The greatest benefit of supplements appears to be for people who have osteoporosis. Calcium and vitamin D supplements are recommended if you have been diagnosed with osteoporosis. For more information, see:

  Taking calcium for osteoporosis.

• Get enough vitamin D. Getting enough vitamin D, along with sufficient calcium, is one of the first steps toward preventing or reducing the effects of osteoporosis. Vitamin D helps your body absorb calcium; taking calcium without vitamin D probably is not beneficial. If you are diagnosed with osteoporosis, your recommended daily vitamin D intake is 400 to 800 IU. One glass of milk [8 fl oz (0.2 L)] has about 100 IU. Your bones need vitamin D to absorb calcium. One study showed that vitamin D may reduce an older person's risk of falling by 22%.¹⁰ Usually 10 to 15 minutes of sun exposure a day is enough to satisfy the body's vitamin D requirement. But as you age, you cannot make as much vitamin D through your skin. Vitamin D supplements can help older people who are not in the sun much.
• If you are taking medications to treat osteoporosis, also take calcium and vitamin D supplements.
• Exercise. Recent studies show that weight-bearing exercises (walking, jogging, stair climbing, dancing, or weight lifting), aerobics, and resistance exercises (using weights or elastic bands to help improve muscle strength) are all effective in increasing the bone mineral density and strength of the spine in postmenopausal women. Walking also increases bone mineral density of the hip.¹³ Regular exercise throughout life cuts in half the number of hip fractures in older people.²⁴ Develop an exercise program that fits your lifestyle and is easy to follow. For more information, see the topic Fitness.
• Eat a nutritional diet to keep your body healthy. For more information, see the topic Healthy Eating.
• Take steps to prevent falls that might result in broken bones. Have your vision and hearing checked regularly, and wear slippers or shoes with a nonskid sole. Exercises that improve balance and coordination, such as tai chi, can also reduce your risk of falling. You can also make changes in your home to prevent falls. For more information, see:

  Making your home fall-proof.

• Limit alcohol use. Heavy alcohol use can decrease bone formation, and it clearly increases the risk of falling. However, some studies show moderate alcohol use is linked to higher bone density. Most health professionals recommend limiting, but not eliminating, alcohol use as part of treatment for osteoporosis.⁵
• Stop smoking. Smoking reduces your bone density and speeds up the rate of bone loss. For information on how to stop, see the topic Quitting Tobacco Use.

Experts recommend that you choose calcium supplements that are known brand names with proven reliability. Most brand-name calcium products are absorbed easily by the body. The U.S. Food and Drug Administration (FDA) has taken action against companies that tout the benefits of coral calcium as a superior source of calcium and a cure for disease. There is no scientific evidence to support these claims.

Medications are used to both prevent and treat osteoporosis. Some medications slow the rate of bone loss or increase bone thickness. Even small amounts of new bone growth can reduce your risk of broken bones.

If you take medication for osteoporosis, you will also need to take calcium and vitamin D supplements, eat a healthy diet, and exercise regularly. A large part of treating or reducing the effects of osteoporosis is getting enough calcium and vitamin D.

Medication Choices

Medications for treatment and prevention

Medications used to prevent or treat osteoporosis include:

• Bisphosphonates, such as alendronate (Fosamax), ibandronate (Boniva), and risedronate (Actonel), which slow the rate of bone thinning. These medications may be used in men and women.

  Should I take bisphosphonate medications for osteoporosis?

• Raloxifene (Evista), a selective estrogen receptor modulator (SERM), which is used only in women. Raloxifene slows bone thinning and causes some increase in bone thickness.
• Calcitonin (Calcimar or Miacalcin), a naturally occurring hormone that helps regulate calcium levels in your body and is part of the bone-building process. When taken by shot or nasal spray, it slows the rate of bone thinning. Calcitonin also relieves pain caused by spinal compression fractures. Calcitonin is used in men and women.
• Parathyroid hormone (teriparatide [Forteo]), used for the treatment of men and postmenopausal women with severe osteoporosis who are at high risk for bone fracture. It is given by injection.

Hormone therapy

Hormone therapy for osteoporosis in women includes:

• Estrogen. Estrogen without progestin (estrogen replacement therapy, or ERT) may be used to treat osteoporosis in women who have gone through menopause and do not have a uterus. Because taking estrogen alone increases the risk of developing cancer of the lining of the uterus (endometrial cancer), ERT is only used if a woman has had her uterus removed (hysterectomy).
• Estrogen and progestin. Rarely, the combination of estrogen and progestin (hormone replacement therapy, or HRT) is recommended for women who have osteoporosis.

For men, testosterone (shots, gel, or patches) sometimes is given to prevent osteoporosis caused by low testosterone levels, although use of testosterone to treat osteoporosis has not been approved by the FDA.

A woman's level of the hormone estrogen, which affects the growth and loss of bone, decreases naturally during and after menopause. Estrogen replacement therapy (ERT) or combination estrogen/progesterone replacement therapy (HRT) can help to reduce bone loss. The Women's Health Initiative (WHI) study found that HRT decreased the risk of hip fracture, but it also led to small increases in a woman's risk of breast cancer, heart attack, stroke, blood clots (pulmonary embolism and deep vein thrombosis), and Alzheimer's disease and other dementias.^{14, 15} Estrogen alone (ERT), used for women who have had a hysterectomy, was found to increase a woman's risk of stroke, but it did not appear to affect rates of breast cancer or heart attack. Many experts recommend that long-term hormone replacement therapy only be considered for women with a significant risk of osteoporosis that outweighs the risks of taking HRT or ERT.^{16, 17} To learn more about the study, see:

WHI: Risks and benefits of taking HRT or ERT

Researchers are studying the effects of low-dose estrogen on women age 65 and older. An early, small study indicates that a low estrogen dose (one-quarter that of conventional ERT) may provide the same benefit—increased bone density and decreased fractures—as the higher dose. In the same study, about one-third of the women were given the low estrogen dose and progesterone (because these women had not had hysterectomies). This group of women also experienced increased bone density. However, the long-term risks of taking low-dose estrogen (and progesterone in one-third of the cases) were not studied and are unclear.²² Experts recommend that HRT or ERT should be used at the lowest dose for the shortest duration to reach your treatment goals.

While hormone therapy is typically not recommended for most women with osteoporosis, if you are at high risk and cannot take other medications, your health professional may recommend it under certain circumstances. If you continue to have bone loss while taking bisphosphonate medication, such as risedronate (Actonel) or alendronate (Fosamax), you may need to take both bisphosphonate medication and hormone therapy. Studies show that taking a bisphosphonate with hormone therapy results in increased bone mass when compared to taking either medication alone.^{19, 20}

What To Think About

Calcium, vitamin D, bisphosphonates, calcitonin, and teriparatide may be used by men or women. HRT, ERT, and raloxifene are prescribed only for women. Testosterone is prescribed only for men.

Compression fractures and other broken bones resulting from osteoporosis can cause significant pain that lasts for several months. Medications available to relieve your pain include:

• Nonprescription nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen and naproxen.
• Nonprescription acetaminophen, such as Tylenol, Panadol, or Tempra.
• A narcotic pain reliever, such as codeine or morphine.
• Calcitonin, such as Calcimar or Miacalcin.

If you are taking medication but still have pain or have side effects from the medication, such as an upset stomach, talk with your health professional.

Statins are medications used to treat high cholesterol, which increases the risk of developing life-threatening diseases, such as coronary artery disease, heart attack and stroke. Recent studies have reported conflicting results on statins' potential for lowering a woman's risk of bone fractures. For the present, evidence does not support the use of statins to prevent or treat osteoporosis.^{25, 26}

Two surgical treatments, vertebroplasty and kyphoplasty, may relieve pain from spinal compression fractures resulting from osteoporosis. In these procedures, a surgeon injects bone cement into the crushed spinal bones (vertebrae) through a needle.

If you experience a hip fracture due to osteoporosis, you may need surgery to repair your hip. For more information, see the topic Hip Fracture.

Exercise is an important part of managing osteoporosis. Your health professional may recommend physical therapy. Your physical therapist may teach you how to safely do weight-bearing exercises, which can slow bone loss. Exercising will help maintain your muscle strength, which is necessary to avoid falls. You may also learn exercises to help maintain flexibility and improve balance.

Your health professional may recommend that you use hip protectors. Hip protectors look like a girdle or underwear with pads on both sides of the hips to help reduce the force of a fall. When hip protectors are used both day and night by those at high risk of falling, the number of hip fractures is greatly reduced.²⁷

Some women use alternative treatments to try to reduce their risk of osteoporosis. Soy products may help reduce the chance of broken bones due to osteoporosis. One large study showed that postmenopausal women who ate an average of 11 grams of soy protein per day had a lower risk of fracture.²⁸ (As an example, one cup of soy milk contains 7 to 11 grams of soy protein). There is not enough evidence to show if other natural products, such as black cohosh, work to reduce bone loss.

Organizations

• Fitness
• Hip Fracture
• Menopause and Perimenopause
• Quitting Tobacco Use

Citations

1. American College of Obstetricians and Gynecologists (2004). Osteoporosis. Clinical Management Guidelines for Obstetrician-Gynecologists. ACOG Practice Bulletin No. 50. Obstetrics and Gynecology, 103(1): 203–216.

2. Anderson JJB (2004). Nutrition and bone health. In LK Mahan, S Escott-Stump, eds., Krause's Food, Nutrition, and Diet Therapy, pp. 642–666. Philadelphia: Elsevier.

3. Feldstein A, et al. (2003). Bone mineral density measurement and treatment for osteoporosis in older individuals with fractures. Archives of Internal Medicine, 163(18): 2165–2172.

4. Cummings SR, Melton LJ III (2002). Epidemiology and outcomes of osteoporotic fractures. Lancet, 359(9319): 1761–1767.

5. Nieves J (2002). Nutrition. In SR Cummings et al., eds., Osteoporosis: An Evidence-Based Guide to Prevention and Management, pp. 85–108. Philadelphia: American College of Physicians–American Society of Internal Medicine.

6. Tucker KL, et al. (2006). Colas, but not other carbonated beverages, are associated with low bone mineral density in older women: The Framingham osteoporosis study. American Journal of Clinical Nutrition, 84(4): 936–942.

7. American College of Rheumatology (2001). Recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis and Rheumatism, 44(7): 1496–1503.

8. Ensrud KE, et al. (2004). Antiepileptic drug use increases rates of bone loss in older women. Neurology, 62(11): 2051–2057.

9. American Association of Clinical Endocrinologists (2003). Medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis. Endocrine Practice, 9(6): 544–564.

10. Bischoff-Ferrari HA, et al. (2004). Effect of vitamin D on falls: A meta-analysis. JAMA, 291(16): 1999–2006.

11. Mosekilde L, et al. (2005). Fracture prevention in postmenopausal women, search date February 2006. Online version of Clinical Evidence (14): 1–18.

12. Jackson RD, et al. (2006). Calcium plus vitamin D supplementation and the risk of fractures. New England Journal of Medicine, 354(7): 669–683.

13. Bonaiuti D, et al. (2006). Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.

14. Fletcher SW, Colditz GA (2002). Failure of estrogen plus progestin therapy for prevention. JAMA, 288(3): 366–368.

15. Shumaker SA, et al. (2003). Estrogen plus progestin and the incidence of dementia and mild cognitive impairment in postmenopausal women. The Women's Health Initiative memory study: A randomized controlled trial. JAMA, 289(20): 2651–2662.

16. National Heart, Lung, and Blood Institute (2003). Postmenopausal hormone therapy: Questions and answers. Available online: http://www.nhlbi.nih.gov/health/women/q_a.htm.

17. Women's Health Initiative Steering Committee (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy. JAMA, 291(14): 1701–1712.

18. SL Silverman (2002). Calcitonin. In SR Cummings et al., eds., Osteoporosis: An Evidence-based Guide to Prevention and Management, pp. 197–208. Philadelphia: American College of Physicians–American Society of Internal Medicine.

19. Harris ST, et al. (2001). Effect of combined risedronate and hormone replacement therapies on bone mineral density in postmenopausal women. Journal of Clinical Endocrinology and Metabolism, 86(5): 1890–1897.

20. Greenspan SL, et al. (2003). Combination therapy with hormone replacement and alendronate for prevention of bone loss in elderly women. JAMA, 289(19): 2525–2533.

21. U.S. Food and Drug Administration (2002). FDA approves teriparatide to treat osteoporosis. FDA Talk Paper T02-49. Available online: http://www.fda.gov/bbs/topics/ANSWERS/2002/ANS01176.html.

22. Prestwood KM, et al. (2003). Ultralow-dose micronized 17 B-estradiol and bone density and bone metabolism in older women. JAMA, 290(8): 1042–1048.

23. National Institutes of Health (2006). Osteoporosis overview. Available online: http://www.niams.nih.gov/bone/hi/overview.htm.

24. Fiechtner JJ (2003). Hip fracture prevention. Postgraduate Medicine, 114(3): 22–32.

25. LaCroix AZ, et al. (2003). Statin use, clinical fracture, and bone density in postmenopausal women: Results from the Women's Health Initiative Observational Study. Annals of Internal Medicine, 139(2): 97–104.

26. Bauer DC, et al. (2004). Use of statins and fracture: Results of 4 prospective studies and cumulative meta-analysis of observational studies and controlled trials. Archives of Internal Medicine, 164(2): 146–152.

27. Cameron ID (2002). Hip protectors. BMJ, 324(7334): 375–376.

28. Zhang X, et al. (2005). Prospective cohort study of soy food consumption and risk of bone fracture among postmenopausal women. Archives of Internal Medicine, 165(16): 1890–1895.

Other Works Consulted

• De Jong Z, et al. (2003). Is a long-term, high-intensity exercise program effective and safe in patients with rheumatoid arthritis? Arthritis and Rheumatism, 48(9): 2415–2424.

• Vondracek SF, Hansen LB (2004). Current approaches to the management of osteoporosis in men. American Journal of Health-System Pharmacists, 61(17): 1801–1811.

Author:	Robin Parks, MS	Last Updated December 1, 2006
Medical Review:	Joy Melnikow, MD, MPH - Family Medicine Carla J. Herman, MD, MPH - Internal Medicine
This information is not intended to replace the advice of a doctor. Healthwise disclaims any liability for the decisions you make based on this information. For more information, click here.