Osteoporosis

Topic Overview

Illustration of the skeletal system

What is osteoporosis?

Osteoporosis is a disease that affects your bones. It means you have bones that are thin and brittle, with lots of holes inside them like a sponge. This makes them easy to break. Osteoporosis can lead to broken bones (fractures) in the hip, spine, and wrist. These fractures can be disabling and may make it hard for you to live on your own.

See a picture of healthy bone versus bone weakened by osteoporosis.

Osteoporosis affects millions of older adults. It usually strikes after age 60. It’s most common in women, but men can get it too.

What causes osteoporosis?

Osteoporosis is caused by a lack of bone strength or bone density. As you age, your bones get thinner naturally. But some things can make you more likely to have the severe bone thinning of osteoporosis. These things are called risk factors. Some risk factors you can change. Others you can't change.

Risk factors you can't change include:

  • Your age. Your risk for osteoporosis goes up as you get older.
  • Being a woman who has gone through menopause. After menopause, the body makes less estrogen. Estrogen protects the body from bone loss.
  • Your family background. Osteoporosis tends to run in families.
  • Having a slender body frame.
  • Your race. People of European and Asian background are most likely to get osteoporosis.

Risk factors you can change include:

  • Smoking.
  • Not getting enough weight-bearing exercise.
  • Drinking too much alcohol.
  • Not getting enough calcium and vitamin D in the things you eat or from supplements.

To check your risk for osteoporosis, use this Interactive Tool: Are You At Risk for Osteoporosis?

What are the symptoms?

Osteoporosis can be very far along before you notice it. Sometimes the first sign is a broken bone in your hip, spine, or wrist after a bump or fall.

As the disease gets worse, you may have other signs, such as pain in your back. You might notice that you are not as tall as you used to be and that you have a curved backbone.

How is osteoporosis diagnosed?

Your doctor will ask about your symptoms and do a physical exam. You may also have a test that measures your bone thickness (bone density test) and your risk for a fracture.

If the test finds that your bone thickness is less than normal but is not osteoporosis, you may have osteopenia, a less severe type of bone thinning.

It’s important to find and treat osteoporosis early to prevent bone fractures. The United States Preventive Services Task Force advises routine bone density testing for women age 65 and older. If you have a higher risk for fractures, it’s best to start getting the test at age 60.

How is it treated?

Treatment for osteoporosis includes medicine to reduce bone loss and to build bone thickness. Medicine can also give you relief from pain caused by fractures or other changes to your bones.

It’s important to take both calcium and vitamin D supplements along with any medicine you take for the disease. You need both of these supplements to build strong, healthy bones.

You can slow osteoporosis with new, healthy habits. If you smoke, quit. Get plenty of exercise. Walking, jogging, dancing, and lifting weights can make your bones stronger. Eat a healthy mix of foods that include calcium and vitamin D. Try dark green vegetables, yogurt, and milk (for calcium). Eat eggs, fatty fish, and fortified cereal (for vitamin D).

Making even small changes in how you eat and exercise, along with taking medicine, can help prevent a broken bone.

When you have osteoporosis, it’s important to protect yourself from falling. Reduce your risk of breaking a bone by making your home safer. Make sure there’s enough light in your home. Remove throw rugs and clutter that you may trip over. Put sturdy handrails on stairs.

Frequently Asked Questions

Learning about osteoporosis:

Being diagnosed:

Getting treatment:

Living with osteoporosis:

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

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. Decision Points focus on key medical care decisions that are important to many health problems.
  Osteoporosis: Should I have a dual X-ray absorptiometry (DEXA) test?
  Osteoporosis: Should I take bisphosphonate medicines?

Actionsets help people take an active role in managing a health condition. Actionsets are designed to help people take an active role in managing a health condition.
  Aging well: Making your home fall-proof
  Osteoporosis: Taking calcium

Interactive tools help people determine health risks, ideal weight, target heart rate, and more. Interactive tools are designed to help people determine health risks, ideal weight, target heart rate, and more.
  Interactive Tool: Are You at Risk for Osteoporosis?

Cause

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 likely 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 a picture of healthy bone versus bone weakened by osteoporosis.

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

Symptoms

In the early stages of osteoporosis, you probably will not have symptoms. As the disease progresses, you may have 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 that may cause severe back pain. But sometimes these fractures cause only minor symptoms or no symptoms at all.

What Happens

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 of bone each year. Because most men build greater bone mass than women do, they tend to get osteoporosis later in life.

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.1 Men and women who have a spinal fracture have a higher risk of future spinal fractures.2 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. 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 every year for about 3 to 5 years after menopause.3

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

See a picture of healthy bone versus bone weakened by osteoporosis.

What Increases Your Risk

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 30.4

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 far more often than men. 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. But moderate alcohol use (no more than 2 drinks a day for men and 1 drink a day for women) 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. Thin people and those with small frames are more likely to develop osteoporosis. But 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 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 hyperparathyroidism, hyperthyroidism, or rheumatoid arthritis, that put you at greater risk for osteoporosis.
  • Taking certain medicines. Several medicines 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.
    • Medicines used to treat endometriosis.
    • Aromatase inhibitors, used to treat breast cancer.
    • Thyroid replacement medicine, 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 medicine given by injection. Longtime use may thin bones.
    • Antacids that contain aluminum, if they are overused. Aluminum-containing antacids remove calcium from your body.
    • Anticonvulsant medicines such as carbamazepine.
    • Hormone treatment for prostate cancer.
    • Medicines called SSRIs (selective serotonin reuptake inhibitors). SSRIs are used to treat many conditions, including depression, fibromyalgia, and premenstrual syndrome. Studies have found that daily use of SSRIs may increase the risk of bone fracture in adults over age 50. Before you take an SSRI, talk to your doctor about this risk.
  • 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.

When To Call a Doctor

Call your doctor 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 doctor 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 medicine 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 doctor 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:

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

Exams and Tests

A diagnosis of osteoporosis is based on your medical history, a physical exam, and a test to measure your bone thickness (density). During a physical exam, your doctor 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 a picture 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 or computed tomography (CT) scan. From this information, your doctor can estimate the strength of your bones. See a picture of a bone mineral density test.

Routine urine and blood tests can rule out other medical conditions, such as hyperparathyroidism, 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 doctor to monitor your condition.

Early Detection

If you or your doctor 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 60.7

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:

Click here to view a Decision Point. Should I have bone mineral testing to diagnose osteoporosis?

Experts recommend that men older than age 70, or with other risk factors for osteoporosis, have a bone mineral density test.8

Ultrasound is sometimes offered at events such as health fairs as a quick screening for osteoporosis. Ultrasound by itself is not a reliable test for diagnosing osteoporosis. But if results of an ultrasound screening find low bone density, your doctor can help you decide whether you should have a bone mineral density test.

Treatment Overview

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

  • 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 medicine to reduce bone loss and increase bone thickness. It's important to take calcium and vitamin D supplements along with any medicines you take for osteoporosis. Even small changes in diet, exercise, and medicine can help prevent spine and hip fractures. Adults who adopt healthy habits can slow the progress of osteoporosis.

See a picture of healthy bone versus bone weakened by osteoporosis.

Initial treatment

If you have been diagnosed with osteoporosis, your doctor likely will recommend lifestyle and diet changes. Eat foods rich in calcium and vitamin D, which are necessary for keeping bones healthy and strong. Take supplements if you think you are not getting enough of these nutrients in your diet. Recommendations vary, but the National Osteoporosis Foundation suggests that adults up to age 50 get 1,000 mg of calcium and 400 to 800 IU of vitamin D a day. If you are age 50 or older, the recommended amounts are 1,200 mg of calcium and 800 to 1,000 IU a day 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%.9 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.10 But other studies show little effect of supplements on fracture risk.11 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:

Click here to view an Actionset. Osteoporosis: Taking calcium.

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. Walking also increases bone mineral density of the hip.12 And exercise increases strength and balance so you are less likely to fall. 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 30 minutes most days of the week, and resistance exercises 2 to 3 days a week.13 If you stop exercising, your bones weaken and may be more likely to break.

Along with exercise and diet, your doctor will recommend that you not smoke and limit alcohol to no more than 2 drinks a day for men and 1 drink a day for women. For more information on quitting smoking, see the topic Quitting Smoking.

In some cases, medicines are prescribed to protect against bone loss. These medicines include raloxifene (Evista), 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 medicines you take for osteoporosis. For more information on taking bisphosphonates, see:

Click here to view a Decision Point. Should I take bisphosphonate medicines 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 medicines, such as bisphosphonates, while you are taking steroids.

In some cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. But hormone therapy can also increase the risk of other conditions, including stroke and breast cancer. 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.

Ongoing treatment

After 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 30.4 It is never too late to develop and then maintain healthy habits that can slow the 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. Recommendations vary, but the National Osteoporosis Foundation suggests that adults up to age 50 get 1,000 mg of calcium and 400 to 800 IU of vitamin D a day. If you are age 50 or older, the recommended amounts are 1,200 mg of calcium and 800 to 1,000 IU a day 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%.9 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.14 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 doctor likely will recommend that you take medicine to increase bone density and decrease your risk of spine and hip fractures. These medicines include bisphosphonates, such as risedronate (Actonel) or alendronate (Fosamax). It's important to take calcium and vitamin D supplements along with any medicines you take for osteoporosis. For more information about taking bisphosphonates, see:

Click here to view a Decision Point. Should I take bisphosphonate medicines for osteoporosis?

Calcitonin may be prescribed for women who are more than 5 years beyond menopause and who cannot take bisphosphonate medicines, or for men who are not receiving testosterone treatment. Calcitonin has the added advantage of helping reduce pain from spinal fractures. But studies show that calcitonin is less effective than bisphosphonate medicines at stopping bone loss.15

Raloxifene (Evista) may be prescribed for women, especially if you are 55 to 65 years old. Raloxifene has been proved to reduce the risk of spinal fractures but not hip fractures.16 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 some cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. But hormone therapy can also increase the risk of other conditions, including stroke and breast cancer. 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.

Treatment if the condition gets worse

It is never too late to build and then keep 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. Recommendations vary, but the National Osteoporosis Foundation suggests that adults up to age 50 get 1,000 mg of calcium and 400 to 800 IU of vitamin D a day. If you are age 50 or older, the recommended amounts are 1,200 mg of calcium and 800 to 1,000 IU a day 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%.9 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.

Medicines called bisphosphonates, such as alendronate (Fosamax) or zoledronic acid (Reclast), 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:

Click here to view a Decision Point. Should I take bisphosphonate medicines for osteoporosis?

In some cases, hormone replacement therapy (HRT) or estrogen replacement therapy (ERT) is given to women to slow bone loss from osteoporosis. But hormone therapy can also increase the risk of other conditions, including stroke and breast cancer. 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.

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

  • You may need to take both a bisphosphonate medicine and hormone therapy. Studies show that taking both medicines results in increased bone mass when compared to taking either alone.17, 18
  • Your doctor may prescribe teriparatide (Forteo). Forteo has been shown to slow bone loss and increase the rate of new bone growth.19 But Forteo is expensive and requires daily self-injections.

It's important to take calcium and vitamin D supplements along with any medicines 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).
  • 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 support 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 through a needle into the crushed spinal bones (vertebrae).

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.2

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. But hormone therapy can also increase the risk of other conditions, including stroke and breast cancer. 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.

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. But the long-term risks of taking low-dose estrogen (and progesterone in one-third of the cases) were not studied and are unclear.20

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

Click here to view an Actionset. Osteoporosis: Taking calcium.

Prevention

After the age of about 30, bone thinning is a natural process and cannot be stopped completely. Whether you develop osteoporosis depends not only on the thickness of your bones early in life but also on 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 up to age 50 is 1,000 mg a day. Men and women age 50 and older need 1,200 mg of calcium each day. The recommended daily intake for vitamin D is 400 to 800 IU a day for adults up to age 50. If you are age 50 or older, the recommended amount is 800 to 1,000 IU of vitamin D a day. 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%.9
  • Take supplements if you are not getting enough calcium and vitamin D in your diet. Most doctors suggest daily vitamin D supplements for children and teens, starting by age 2 months. Talk with your doctor about how much and what sources of vitamin D are right for you and your child.
  • 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 2 alcohol drinks a day if you are a man, or 1 alcohol drink a day if you are a woman. 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.

After 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%.9

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.10 But other studies show little effect of supplements on fracture risk.11 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.

Home Treatment

Most adults with osteoporosis need to take medicine to slow bone loss. In addition to medicine, 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. 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.10, 11 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:
    Click here to view an Actionset.Osteoporosis: Taking calcium.
  • 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. Recommendations vary, but the National Osteoporosis Foundation suggests that adults up to age 50 get 400 to 800 IU of vitamin D a day. If you are age 50 or older, the recommended amount is 800 to 1,000 IU a day. 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%.9 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 medicines 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.12 Regular exercise throughout life cuts in half the number of hip fractures in older people.21 Develop an exercise program that fits your lifestyle and is easy to follow. For more information, see the topic Fitness.
  • Eat a nutritious 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:
    Click here to view an Actionset.Aging well: Making your home fall-proof.
  • Limit alcohol use. Heavy alcohol use can decrease bone formation, and it clearly increases the risk of falling. But some studies show moderate alcohol use (no more than 2 drinks a day for men and 1 drink a day for a women) is linked to higher bone density. Most doctors 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 Smoking.

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

Medicines are used to both prevent and treat osteoporosis. Some medicines 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 medicine 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

Medicines for treatment and prevention

Medicines used to prevent or treat osteoporosis include:

  • Bisphosphonates, such as alendronate (Fosamax), ibandronate (Boniva), risedronate (Actonel), and zoledronic acid (Reclast), which slow the rate of bone thinning and can lead to increased bone density.4 These medicines may be used in men and women.
    Click here to view a Decision Point.Should I take bisphosphonate medicines 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.22
  • 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. In rare cases, 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 U.S. Food and Drug Administration (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. 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.

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. But the long-term risks of taking low-dose estrogen (and progesterone in one-third of the cases) were not studied and are unclear.20 Experts recommend that HRT or ERT be used at the lowest dose for the shortest length of time 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 medicines, your doctor may recommend it under certain circumstances. If you continue to have bone loss while taking bisphosphonate medicine, such as risedronate (Actonel) or alendronate (Fosamax), you may need to take both bisphosphonate medicine and hormone therapy. Studies show that taking a bisphosphonate with hormone therapy results in increased bone mass when compared to taking either medicine alone.17, 18

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. Medicines available to relieve your pain include:

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

Statins are medicines 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. Evidence does not yet support the use of statins to prevent or treat osteoporosis.23, 24

Surgery

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

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.

Other Treatment

Exercise is an important part of managing osteoporosis. Your doctor 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.

Hip protectors have been recommended to help prevent hip fractures from osteoporosis. They look like a girdle or underwear with pads on both hips. The pads may help reduce the force of a fall. But a summary of several studies concluded that hip protectors do not prevent hip fractures in people who live at home. And they may not be helpful for people in nursing homes or other institutions. 25 One problem with studying hip protectors is that people do not like wearing them even if they might help protect the hips. Hip protectors are bulky under clothing. They can irritate the skin and are hard to fit properly.

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 a day had a lower risk of fracture.26 (As an example, 1 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.

Other Places To Get Help

Organizations

National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health
1 AMS Circle
Bethesda, MD  20892-3675
Phone: 1-877-22-NIAMS (1-877-226-4267) toll-free
(301) 495-4484
Fax: (301) 718-6366
TDD: (301) 565-2966
E-mail: niamsinfo@mail.nih.gov
Web Address: www.niams.nih.gov
 

The National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) is a governmental institute that serves the public and health professionals by providing information, locating other information sources, and participating in a national federal database of health information. NIAMS supports research into the causes, treatment, and prevention of arthritis and musculoskeletal and skin diseases and supports the training of scientists to carry out this research.

The NIAMS Web site provides health information referrals to the NIAMS Clearinghouse, which has information packages about diseases.


National Institute on Aging
Building 31, Room 5C27
31 Center Drive, MSC 2292
Bethesda, MD  20892
Phone: (301) 496-1752
1-800-222-2225, Information Center
Fax: (301) 496-1072
TDD: 1-800-222-4225 (TTY)
Web Address: www.nih.gov/nia
 

The National Institute on Aging (NIA), one of the centers of the U.S. National Institutes of Health, leads a broad scientific effort to understand the nature of aging and to extend the healthy, active years of life. The NIA funds research and provides information about health and research advances to the public and interested groups.


National Osteoporosis Foundation (NOF)
1232 22nd Street NW
Washington, DC  20037-1292
Phone: (202) 223-2226
Web Address: www.nof.org
 

The National Osteoporosis Foundation (NOF) funds research and publishes educational material about osteoporosis for consumers and health professionals. The NOF also provides information about bone density testing sites, new treatment, and local groups interested in osteoporosis. The foundation's mission is to prevent osteoporosis, to promote lifelong bone health, to help improve the lives of those affected by osteoporosis and related fractures, and to find a cure.


NIH Osteoporosis and Related Bone Diseases—National Resource Center
2 AMS Circle
Bethesda, MD  20892-3676
Phone: 1-800-624-BONE (1-800-624-2663)
(202) 223-0344
Fax: (202) 293–2356
TDD: (202) 466-4315
E-mail: NIAMSBoneInfo@mail.nih.gov
Web Address: www.niams.nih.gov/bone
 

The NIH Osteoporosis and Related Bone Diseases–National Resource Center is a government resource center that helps health professionals, patients, and the public learn about and locate current information on metabolic bone diseases such as osteoporosis, Paget's disease, osteogenesis imperfecta, and hyperparathyroidism.


North American Menopause Society (NAMS)
P.O. Box 94527
Cleveland, OH  44101-4527
Phone: (440) 442-7550
Fax: (440) 442-2660
E-mail: info@menopause.org
Web Address: www.menopause.org
 

The North American Menopause Society (NAMS) is a nonprofit organization that promotes the understanding of menopause and thereby improves the health of women as they approach menopause and beyond. NAMS members include experts from medicine, nursing, sociology, psychology, nutrition, anthropology, epidemiology, pharmacy, and education. The NAMS Web site has information on perimenopause, early menopause, menopause symptoms and long-term health effects of estrogen loss, and a variety of therapies.


References

Citations

  1. Anderson JJB (2008). Nutrition and bone health. In LK Mahan, S Escott-Stump, eds., Krause's Food and Nutrition Therapy, pp. 614–635. St. Louis: Saunders Elsevier.
  2. 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.
  3. Cummings SR (2002). Bone biology, epidemiology, and general principles. In SR Cummings et al., eds., Osteoporosis: An Evidence-Based Guide to Prevention and Management, pp. 3-25. Philadelphia: American College of Physicians–American Society of Internal Medicine.
  4. American College of Obstetricians and Gynecologists (2004, reaffirmed 2008). Clinical management guidelines for obstetrician-gynecologists. Osteoporosis. ACOG Practice Bulletin No. 50. Obstetrics and Gynecology, 103(1): 203–216.
  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. U.S. Preventive Services Task Force (2002). Screening for osteoporosis in postmenopausal women: Recommendations and rationale. Annals of Internal Medicine, 137(6): 526–528.
  8. Qaseem A, et al. (2008). Screening for osteoporosis in men: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 148(9): 680–684.
  9. Bischoff-Ferrari HA, et al. (2004). Effect of vitamin D on falls: A meta-analysis. JAMA, 291(16): 1999–2006.
  10. Mosekilde L, et al. (2008). Fracture prevention in postmenopausal women, search date January 2007. Online version of BMJ Clinical Evidence. Also available online: http://www.clinicalevidence.com.
  11. Jackson RD, et al. (2006). Calcium plus vitamin D supplementation and the risk of fractures. New England Journal of Medicine, 354(7): 669–683.
  12. Bonaiuti D, et al. (2006). Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews (1). Oxford: Update Software.
  13. National Osteoporosis Foundation (2008). Prevention. Available online: www.nof.org/prevention/index.htm.
  14. Cummings SR, Melton LJ III (2002). Epidemiology and outcomes of osteoporotic fractures. Lancet, 359(9319): 1761–1767.
  15. Silverman SL (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.
  16. Cosman F (2002). Selective estrogen-receptor modulators. In SR Cummings et al., eds., Osteoporosis: An Evidence-Based Guide to Prevention and Management, pp. 151–167. Philadelphia: American College of Physicians–American Society of Internal Medicine.
  17. 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.
  18. 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.
  19. 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.
  20. 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.
  21. Fiechtner JJ (2003). Hip fracture prevention. Postgraduate Medicine, 114(3): 22–32.
  22. Drugs for postmenopausal osteoporosis (2008). Treatment Guidelines From The Medical Letter, 6(74): 67–74.
  23. 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.
  24. 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.
  25. Parker MJ, et al. (2006). Effectiveness of hip protectors for preventing hip fractures in elderly people: Systematic review. BMJ, 332(7541): 571–574.
  26. 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

  • 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.
  • Cummings SR (2002). Bone biology, epidemiology, and general principles. In SR Cummings et al., eds., Osteoporosis: An Evidence-Based Guide to Prevention and Management, pp. 3-25. Philadelphia: American College of Physicians–American Society of Internal Medicine.
  • Heiss G, et al. (2008). Health risks and benefits 3 years after stopping randomized treatment with estrogen and progestin. JAMA, 299(9): 1036–1045.
  • Holt EH (2008). Diseases of calcium metabolism and metabolic bone disease. In DC Dale, DD Federman, eds., ACP Medicine, section 3, chap. 6. Hamilton, ON: BC Decker.
  • Liu H, et al. (2008). Screening for osteoporosis in men: A systematic review for an American College of Physicians guideline. Annals of Internal Medicine, 148(9): 685–701.
  • MacLean C, et al. (2008). Systematic review: Comparative effectiveness of treatments to prevent fractures in men and women with low bone density or osteoporosis. Annals of Internal Medicine, 148(3): 197–213.
  • Qaseem A, et al. (2008). Pharmacologic treatment of low bone density or osteoporosis to prevent fractures: A clinical practice guideline from the American College of Physicians. Annals of Internal Medicine, 149(6): 404–415.
  • Vondracek SF, Hansen LB (2004). Current approaches to the management of osteoporosis in men. American Journal of Health-System Pharmacists, 61(17): 1801–1811.

Credits

Author Shannon Erstad, MBA/MPH
Editor Kathleen M. Ariss, MS
Associate Editor Pat Truman, MATC
Primary Medical Reviewer Anne C. Poinier, MD - Internal Medicine
Specialist Medical Reviewer Kirtly Jones, MD - Obstetrics and Gynecology
Last Updated November 21, 2008

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