Preventing Brittle Bones - Osteoporosis in Women: Frequently Asked Questions

Susan R. Johnson, M.D.
Department of Obstetrics and Gynecology
University of Iowa Hospitals and Clinics

First Published: August 2000
Last Revised: February 2004
Peer Review Status: Internally Peer Reviewed

As you may know, osteoporosis is one of the most common disease conditions affecting older people. We tend to think of osteoporosis as being something that only affects older white women, the group that has the largest number of people with the condition. We should remember that men and other women in other ethnic/racial groups could get osteoporosis as well. Fortunately, there has been a lot of research going on this area, and this morning we will talk about new findings that will help women and men reduce their chances of having osteoporosis and having fractures.

What can a woman do to prevent osteoporosis, if it is possible?

That is an excellent question. Let me start by saying it is not possible to totally eliminate your chance of getting osteoporosis, but there are lots of things you can do to reduce your risk of getting it. The first thing that is important throughout life is getting enough calcium and Vitamin-D. This is important starting in childhood, but it is not too late to start getting adequate calcium even when you are older. The current recommendation, by expert groups, for the amount of calcium that you should be taking in your diet is 1200 mg a day. For many people, that will require taking a calcium supplement in addition to the amount of calcium you get in your diet. An easy guideline to check your own diet for whether or not you are getting enough calcium is to remember that one cup of milk has about 300 mg of calcium and a cup of yogurt has about 400. If you can add up the number of cups of those two things that you take per day and then add about 200 mg for the amount of calcium you are getting in the rest of your diet from other foods, that will give you a rough estimate. If that number is less than 1000, you should probably be taking a calcium supplement as well. The second important thing that you should do is get exercise in a form that will help your bones. The best kind of exercise is weight-bearing exercise because your body has weight. Walking and jogging will count as weight-bearing exercise, and you can probably add to the effect by doing actual strength training. The strength training doesn't have to be complicated or involve going to a gym. There are programs that you can find out about from your doctor. Although weight training doesn't have a big effect on the thickness of your bones, it has the added benefit of improving your muscle strength and improving your balance. Both of those things, strength and balance, will help lower the chance that you will fall. Particularly for older men and women over the age of 75, falling is one of the most important reasons that hip fractures occur so weight training in that age group can help reduce the risk of fracture. The other things that you can do are to avoid doing things that we know contribute toward thinning bones. These include avoiding excess alcohol and caffeine, and most importantly, not smoking. Of the three things I just mentioned, smoking is the most important to stop.

If you drink a lot of caffeine, does that increase your chances of developing it?

Research has shown that if a woman gets adequate calcium in her diet (around 1000 or more mg daily), caffeine does not affect her bones. However, if she has low calcium intake, getting the amount of caffeine that would be found in two to three or more cups of brewed coffee a day could lead to faster bone loss. The best thing to do, then, is to increase calcium intake up to the recommended levels, and not worry about caffeine.

Can osteoporosis lead to more serious health problems?

Well, the health problem that occurs because of osteoporosis is fracture of the bones. Bone fractures then can lead to other problems. The most serious problem caused by hip fractures is death. People often aren't aware that about 25 percent of elderly women who have a hip fracture die in the first year after that fracture. Further, the number of deaths per year from osteoporosis is the same as the number of deaths per year for breast cancer. Perhaps an equal problem is that particularly for hip fractures, elderly women often find themselves unable to be independent, and hip fracture is a major reason why women need to move to nursing home care. Other kinds of fractures of the spine and wrists, both of which are quite common, don't lead to these kinds of very bad outcomes but cause considerable discomfort and disability.

What are some of the symptoms of osteoporosis?

One of the problems with osteoporosis is that it generally has no symptoms. Let me stop a minute and say more clearly what we mean when we say osteoporosis. Osteoporosis is a condition in which the bones, particularly in the spine and the hip, become thinner and lose strength. As a result of being thin and weak, when a woman falls, her bones are unable to absorb the impact, and they break. This process of losing bone is a silent one. This means that women are not aware that it is going on. Once a fracture has occurred of the hip or wrist, you would of course be aware of that. Fractures in the spine, however, may be silent, and the only thing that a woman may notice is that she is getting shorter, or, noticing a change in the shape of her back. Some women with spine fractures do have pain. If that is the case, they can seek medical care and an x-ray will tell if they have had a fracture. The most important message is that substantial bone loss can occur putting women at risk for fracture without her being aware of it.

What about people who are lactose intolerant?

That group needs to work with their health care professional to find ways of taking in calcium that will avoid the lactose. I believe there are lactose-free dairy products that contain calcium and that would be one option. This group of people is more likely to need to take calcium supplements because it may be difficult to get enough in food products to satisfy the recommended daily allowance of calcium.

At what age should you be concerned and what mg of calcium should be taken?

We think that calcium intake is important from childhood on. A useful way to think about this is during childhood and adolescents, the bones are growing and, in fact, bones get to their maximum thickness around the age of 20 to 25. It is important then for children and adolescents to get enough calcium so that their bones will be as thick as they were meant to be. The dietary calcium recommendation for adolescents is around 1000 mg a day. It is important to check with your family physician or pediatrician to make sure you have the right dose for your child. Bones stay fairly stable after the early 20's, but it is important to take in adequate calcium, about 1000 mg a day, during early adulthood and early middle age. Just like other tissues in the body, the bones are continually remaking themselves, and they need calcium in order to maintain that normal thickness. Once women go through menopause, they begin to lose bone and it is during this period which starts for many women between 45 and 55 that calcium intake should be increased. That is to 1200 - 1500 mg a day. That level should then be maintained throughout the rest of life. Although calcium, by itself, may not be adequate to prevent fractures for all women, we know that taking adequate calcium will slow down bone loss in most women.

What types of exercise can help with prevention of osteoporosis?

Bone will become a bit thicker when it has stress placed on it. So, weight bearing exercise like walking which is probably the best choice for older individuals, or jogging, puts the weight of the body as the stress on the bones. Another way to achieve that level of stress on bones is to do weight lifting, making sure you are just not lifting to strengthen the arms but also for the important bones in the hips, so you need to do weight training with the legs. Exercise has another benefit in that it maintains the strength and balance, both of which help prevent falls. This is particularly important for older individuals and important for older individuals to do strength training in order to maximize the chance that they will not fall.

Is there anything different men should do than women in order to prevent osteoporosis?

As I mentioned earlier, the problem is osteoporosis is not quite as common in men. In men who live to be older than 80, the risk of hip fracture is very similar to that in women. Men should also maintain adequate calcium intake and exercise. Those two pieces of advice are true for them as well. About one-third of men who develop osteoporosis have lower than average testosterone levels and that is a condition they may not be aware of. For some men who are at risk for osteoporosis, checking a testosterone level may be helpful. There has not been as much research done in osteoporosis in men but it is an area that is generating more interest so over the next few years we should see the results of that research.

What can my family and I do to help my grandmother who suffers from osteoporosis, what specific needs can we help with, in general?

Two things come to mind. The first is to help her "fall proof" her living environment. This is to reduce the chance that she will fall because, as I have said, falling is the most important thing that will lead to hip fracture. Removing throw rugs so she won't trip; putting handles in the bathroom so she can pull herself up and down easily from the toilet/bathtub; making sure rooms are well lit; minimizing the number of stairs she needs to go up and down; and just taking a general look around to see if there are other things that may cause her to fall. Perhaps an equally important thing is to encourage her to be active and to consider beginning an exercise program. There is research that has been done in very elderly, frail individuals who live in nursing homes showing that a weight-training program is of benefit in reducing the risk of fall and in improving bone strength. This may be something you don't want to take on, on your own, but perhaps you can find a physical therapist or talk to her physician about finding someone who can help her with that program.

What is a bone density test, and who should have it done?

A bone density test is a test which measures the thickness of bones. There are two general types of tests that are currently used. The first type, which is done on a machine, usually found only in a hospital or doctorÕs office and that machine, called a DXA, is used to measure the thickness of the hips and the spine. The other kind of test which is either done in a doctor's office or sometimes in a place in a community like a pharmacy or even a shopping mall is a test that uses ultrasound to measure the thickness of the bone in the heel. Both of these tests can provide information about bone thickness but the DXA test is more accurate. Your doctor may recommend the DXA if you have had a heel test that was abnormal, for example. The reason that these bone tests are useful is that we know that women who have thinner than average bones are at an increased risk for fracture so it is one way of helping us identify women who might benefit from treatment with just calcium and exercise. The question of who should get a bone density test is a bit more difficult to answer. That is because we haven't yet done the kind of scientific studies that help us to know who will most benefit from them. However, while we are waiting for those studies to be done, here is some advice that has been put together by an expert group affiliated with the National Osteoporosis Foundation (NOF). First, these recommendations apply only to postmenopausal white women. That is because that is the group we know the most about. Postmenopausal white women who have had a fracture as an adult should have a test when they become menopausal. Women who have not had a fracture should then decide based on their age and other risk factors that they should have for osteoporosis. Based on age, we divide women into two groups, 65 and older and under 65. The NOF recommends that all women who have not been screened before have a test at age 65. If you happen to be older than 65 now, you should also get a test. Women who are under 65 should get a test if they have at least one risk factor for osteoporosis from among this list: smoking, a mother, grandmother or sister with a hip fracture, being excessively thin. That is defined as for an average height woman weighing less than 125 pounds. Other women may choose to get a bone density even if they don't meet these requirements, as long as they are postmenopausal, if they think it will help them to go on a therapy such as estrogen therapy or one of the other drugs that can help prevent osteoporosis.

I doubt very much that I had adequate amounts of calcium as a child and young adult, as I avoided dairy products in general. Now in my 40's is there something I can do to catch-up on calcium to prevent osteoporosis?

There is no way to replace the calcium that you missed when you were a child. The good news is that you can do a lot to prevent your later risk of osteoporosis by starting now to get the recommended dose of calcium, aiming at 1200 mg in your diet beginning now and continuing that for life. If you have other risk factors for osteoporosis like the ones I just mentioned, family history, being thin, smoking or other medical conditions that put you at risk for osteoporosis, you may wish to consider getting a bone density test after you are menopausal. We have learned, however, through a recent study that long-term estrogen therapy has more risks than benefits for many women over 50 years of age. Thus, hormone treatment is not a good choice for preventing osteoporosis for many women.

What treatments are out there for osteoporosis?

There is a lot of good news in the treatments available for osteoporosis. We have known for a long time that estrogen therapy is helpful in women in slowing down bone loss and preventing fractures of the spine. However, we have learned through a recent study that long term estrogen thearpy has more risks than benefits for many women over 50 years of age. Thus hormone treatment is not a good choice for preventing osteoporosis for many women. In the last five years, the FDA has approved 3 drugs for prevention and treatment of osteoporosis. These other drugs have significant differences from estrogen so that most women who need to take a drug can now find one that will work for them. The first of these three drugs is Raloxifene (Evista). Evista is a kind of synthetic estrogen-like drug that has the same benefit for the bones that regular estrogen does. Evista has, however, some important differences from estrogen. First, it does not have any effects in the uterus, and so it does not cause vaginal bleeding, and it is not necessary to take progesterone with it. Secondly, it does not have any effect on breast cancer, unlike estrogen, which may increase breast cancer risk when it is taken for a long time. The other two drugs Alendronate (Fosamax) and brand-new drugs Risendronate (Actonel) are both a kind of drug called bisphosphonates. These drugs are very effective in the bones and have very few side effects.

Are the number's of people with it growing or slowing down?

The number of people with osteoporosis is probably increasing. That is partly because as our baby boom generation ages, there is a much larger generation of women/men who are living into old age and so the number will probably increase over the next 10 to 15 years.

Can you die from osteoporosis?

Yes. About 25 percent of men/women who have a hip fracture die within the first year after the fracture.

Any link to osteoporosis and arthritis?

Osteoporosis and arthritis are two separate diseases, but men and women with arthritis are at higher risk for getting osteoporosis. One major reason for that is that arthritis is commonly treated with steroid drugs like prednisone. Prednisone taken for a long time leads to weakening of the bones. This is such an important problem that most doctors now recommend that people who are on a drug like prednisone for more than two or three months should get their bones tested and probably also take a drug like Fosamax to prevent bone loss.

Are you ever "cured" of osteoporosis?

Once you have lost enough bone to have osteoporosis, it is almost impossible to get the bone back up to a normal thickness. Thus technically, it is not possible to "cure" osteoporosis. That is different from knowing that you can do quite a lot by calcium, exercise and taking one of the drugs I mentioned to substantially reduce your chance of fracture. Really the news is pretty good for people who have developed osteoporosis.

Is the pain of osteoporosis similar to that of arthritis? How can you tell the difference?

Arthritis pain usually occurs in the joints of the hip or the elbow or the hands. Osteoporosis does not cause pain in those joints. There is another kind of arthritis called osteoarthritis that also causes pain in those joints and sometimes in the spine. If there is back pain, it is more difficult to discover what that pain is from. If you are having a sudden back pain that just came on in the last few days or weeks, that could be from osteoporosis but there are many other conditions that can cause that so you should see your doctor.

What is the earliest age one can suffer from osteoporosis?

There are some individuals who could develop osteoporosis at a very young age, even in childhood, if they have had to take steroid drugs like prednisone for a long period of time. That is relatively rare, however. There are probably a larger group of young women, perhaps in their 20's and 30's who may develop osteoporosis because their body has stopped producing estrogen for a very long period of time. The group of women at highest risk is women who have eating disorders like anorexia nervosa. Let me emphasize that the vast majority of people with osteoporosis are in over 70.

Osteoporosis is a common problem but we have made important strides in the last few years in understanding how to prevent and treat this condition. People of all ages should get adequate calcium in their diet and should exercise and should not smoke. Postmenopausal women who are at highest risk for this condition should begin thinking about measurements for prevention. Postmenopausal women may consider a bone density scan in order to determine whether they should take drugs such as estrogne, Evista, Fosamax, or Actonel which can help prevent osteoporosis from happening. If a women develops osteoporosis, these same drugs, particularly Fosamax and Actonel have been shown to reduce hip fracture by about half so taking one of these drugs with calcium and exercising can be of tremendous benefit.

See related Patient Topics Bones, Joints and Muscles, Calcium, Food, Nutrition and Metabolism, Osteoporosis, Preventing Disease and Staying Healthy, Seniors' Health, Wellness and Lifestyle or Women's Health.

See related Provider Topics Bones, Joints and Muscles, Calcium, Food, Nutrition and Metabolism, Osteoporosis, Preventing Disease and Staying Healthy, Seniors' Health, Wellness and Lifestyle or Women's Health.

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