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Osteoporosis in Men

Osteoporosis is a disease that causes the skeleton to weaken and the bones to break. It poses a significant threat to more than 2 million men in the United States. After age 50, 6 percent of all men will experience a hip fracture and 5 percent will have a vertebral fracture as a result of osteoporosis.

Despite these compelling figures, a majority of American men view osteoporosis solely as a "woman’s disease," according to a 1996 Gallup Poll. Moreover, among men whose lifestyle habits put them at increased risk, few recognize the disease as a significant threat to their mobility and independence.

Osteoporosis is called a "silent disease" because it progresses without symptoms until a fracture occurs. It develops less often in men than in women because men have larger skeletons, their bone loss starts later and progresses more slowly, and they have no period of rapid hormonal change and bone loss. However, in the last few years the problem of osteoporosis in men has been recognized as an important public health issue, particularly in light of estimates that the number of men above the age of 70 will continue to increase as life expectancy continues to rise.

Clearly, more information is needed about the causes and treatment of osteoporosis in men, and researchers are beginning to turn their attention to this long-neglected group.

For example, in 1999, the National Institutes of Health launched a major research effort that will attempt to answer some of the many remaining questions. The 7-year, multisite study will follow more than 5,000 men ages 65 and older to determine how much the risk of fracture in men is related to bone mass and structure, biochemistry, lifestyle, tendency to fall, and other factors.

The results of such studies will help doctors to better understand how to prevent, manage, and treat osteoporosis in men. This fact sheet describes the highlights of what is already known.

What Causes Osteoporosis?

Bone is constantly changing – that is, old bone is removed and replaced by new bone. During childhood, more bone is produced than removed, so the skeleton grows in both size and strength. For most people, bone mass peaks during the third decade of life. By this age, men typically have accumulated more bone mass than women. After this point, the amount of bone in the skeleton typically begins to decline slowly as removal of old bone exceeds formation of new bone.

Men in their 50s do not experience the rapid loss of bone mass that women do in the years following menopause. By age 65 or 70, however, men and women are losing bone mass at the same rate, and the absorption of calcium, an essential nutrient for bone health throughout life, decreases in both sexes. Excessive bone loss causes bone to become fragile and more likely to fracture.

Fractures resulting from osteoporosis most commonly occur in the hip, spine, and wrist, and can be permanently disabling. Hip fractures are especially dangerous. Perhaps because such fractures tend to occur at older ages in men than in women, men who sustain hip fractures are more likely than women to die from complications.

Primary and Secondary Osteoporosis

There are 2 main types of osteoporosis: primary and secondary. In cases of primary osteoporosis, either the condition is caused by age-related bone loss (sometimes called senile osteoporosis) or the cause is unknown (idiopathic osteoporosis). The term idiopathic osteoporosis is used only for men less than 70 years old; in older men, age-related bone loss is assumed to be the cause.

The majority of men with osteoporosis have at least one (sometimes more than one) secondary cause. In cases of secondary osteoporosis, the loss of bone mass is caused by certain lifestyle behaviors, diseases, or medications. The most common causes of secondary osteoporosis in men include exposure to glucocorticoid medications, hypogonadism (low levels of testosterone), alcohol abuse, smoking, gastrointestinal disease, hypercalciuria, and immobilization.

Causes of Secondary Osteoporosis in Men

* glucocorticoid medications
* other immunosuppressive drugs
* hypogonadism (low testosterone levels)
* excessive alcohol consumption
* smoking
* chronic obstructive pulmonary disease and asthma
* cystic fibrosis
* gastrointestinal disease
* hypercalciuria



* anticonvulsant medications
* thyrotoxicosis
* hyperparathyroidism
* immobilization
* osteogenesis imperfecta
* homocystinuria
* neoplastic disease
* ankylosing spondylitis and rheumatoid arthritis
* systemic mastocytosis

Glucocorticoid medications: Glucocorticoids are steroid medications used to treat diseases such as asthma and rheumatoid arthritis. Bone loss is a very common side effect of these medications. The bone loss these medications cause may be due to their direct effect on bone, muscle weakness or immobility, reduced intestinal absorption of calcium, a decrease in testosterone levels, or, most likely, a combination of these factors.

When glucocorticoid medications are used on an ongoing basis, bone mass often decreases quickly and continuously, with most of the bone loss in the ribs and vertebrae. Therefore, people taking these medications should talk to their doctor about having a bone mineral density (BMD) test. Men should also be tested to monitor testosterone levels, as glucocorticoids often reduce testosterone in the blood.

A treatment plan to minimize loss of bone during long-term glucocorticoid therapy may include using the minimal effective dose, and discontinuing the drug or administering it through the skin, if possible. Adequate calcium and vitamin D intake is important, as these nutrients help reduce the impact of glucocorticoids on the bones. Other possible treatments include testosterone replacement and osteoporosis medication. Alendronate and risedronate are two bisphosphonate medications approved by the U.S. Food and Drug Administration (FDA) for use by men and women with glucocorticoid-induced osteoporosis.

Hypogonadism: Hypogonadism refers to abnormally low levels of sex hormones. It is well known that loss of estrogen causes osteoporosis in women. In men, reduced levels of sex hormones may also cause osteoporosis.

While it is natural for testosterone levels to decrease with age, there should not be a sudden drop in this hormone that is comparable to the drop in estrogen experienced by women at menopause. However, medications like glucocorticoids (discussed above), cancer treatments (especially for prostate cancer), and many other factors can affect testosterone levels. Testosterone replacement therapy may be helpful in preventing or slowing bone loss. Its success depends on factors such as age and how long testosterone levels have been reduced. Also, it is not yet clear how long any beneficial effect of testosterone replacement will last. Therefore, doctors usually treat the osteoporosis directly, using medications approved for this purpose.

Recent research suggests that estrogen deficiency may also be a cause of osteoporosis in men. For example, estrogen levels are low in men with hypogonadism and may play a part in bone loss. Osteoporosis has been found in some men who have rare disorders involving estrogen. Therefore, the role of estrogen in men is under active investigation.

Alcohol abuse: There is a wealth of evidence that alcohol abuse may decrease bone density and lead to an increase in fractures. Low bone mass is common in men who seek medical help for alcohol abuse.

In cases where bone loss is linked to alcohol abuse, the first goal of treatment is to help the patient stop – or at least reduce – his consumption of alcohol. More research is needed to determine whether bone lost to alcohol abuse will rebuild once drinking stops, or even whether further damage will be prevented. It is clear, though, that alcohol abuse causes many other health and social problems, so quitting is ideal. A treatment plan may also include a balanced diet with lots of calcium- and vitamin D-rich foods, a program of physical exercise, and smoking cessation.

Smoking: Bone loss is more rapid, and rates of hip and vertebral fracture are higher, among men who smoke, although more research is needed to determine exactly how smoking damages bone. Tobacco, nicotine, and other chemicals found in cigarettes may be directly toxic to bone, or they may inhibit absorption of calcium and other nutrients needed for bone health. Quitting is the ideal approach, as smoking is harmful in so many ways. As with alcohol, it is not known whether quitting smoking leads to reduced rates of bone loss or to a gain in bone mass.

Gastrointestinal disorders: Several nutrients – including amino acids, calcium, magnesium, phosphorous, and vitamins D and K – are important for bone health. Diseases of the stomach and intestines can lead to bone disease when they impair absorption of these nutrients. In such cases, treatment for bone loss may include taking supplements to replenish these nutrients.

Hypercalciuria: Hypercalciuria is a disorder that causes too much calcium to be lost through the urine, which makes the calcium unavailable for building bone. Patients with hypercalciuria should talk to their doctor about having a BMD test and, if bone density is low, discuss treatment options.

Immobilization: Weight-bearing exercise is essential for maintaining healthy bones. Without it, bone density may decline rapidly. Prolonged bed rest (following fractures, surgery, spinal cord injuries, or illness) or immobilization of some part of the body often result in significant bone loss. It is crucial to resume weight-bearing exercise (such as walking, jogging, dancing, and lifting weights) as soon as possible after a period of prolonged bed rest. If this is not possible, you should work with your doctor to minimize other risk factors for osteoporosis.

How Is Osteoporosis Diagnosed in Men?

Osteoporosis can be effectively treated if it is detected before significant bone loss has occurred. A medical workup to diagnose osteoporosis will include a complete medical history, x rays, and urine and blood tests. The doctor may also order a BMD (bone mineral density) test. This test can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized bone mineral density test is called a dual-energy x-ray absorptiometry or DXA test. It is painless: a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.

It is increasingly common for women to be diagnosed with osteoporosis or low bone mass using a BMD test, often at midlife when doctors begin to watch for signs of bone loss. In men, however, the diagnosis is often not made until a fracture occurs or a man complains of back pain and sees his doctor. This makes it especially important for men to inform their doctors about risk factors for developing osteoporosis, loss of height or change in posture, a fracture, or sudden back pain.

What Are the Risk Factors for Men?

Several risk factors have been linked to osteoporosis in men:

* chronic diseases that affect the kidneys, lungs, stomach, and intestines or alter hormone levels
* regular use of certain medications, such as glucocorticoids
* undiagnosed low levels of the sex hormone testosterone
* unhealthy lifestyle habits: smoking, excessive alcohol use, low calcium intake, inadequate physical exercise
* age. The older you are, the greater your risk.
* race. Caucasian men appear to be at particularly high risk, but all men can develop this disease.

Some doctors may be unsure how to interpret the results of a BMD test in men, because it is not known whether the World Health Organization guidelines used to diagnose osteoporosis or low bone mass in women are also appropriate for men. Although controversial, the International Society for Clinical Densitometry recommends using separate guidelines when interpreting BMD test results in men.

What Treatments Are Available?

Once a man has been diagnosed with osteoporosis, his doctor may prescribe one of the medications approved by the FDA for this disease. Alendronate and residronate have been approved to treat the disease in men, postmenopausal women, and in men and women with glucocorticoid-induced osteoporosis. Teriparatide is approved to treat osteoporosis in men and women who are at increased risk of fracture.

The treatment plan will also likely include the nutrition, exercise, and lifestyle guidelines for preventing bone loss listed at the end of this fact sheet.

If bone loss is due to glucocorticoid use, the doctor may prescribe a bisphosphonate (e.g., alendronate or risedronate), monitor bone density and testosterone levels, and suggest using the minimum effective dose of glucocorticoid. The doctor may also suggest discontinuing the drug when practical, and/or administering it topically (through the skin).

Other possible prevention or treatment approaches include calcium and/or vitamin D supplements and regular physical activity.

If osteoporosis is the result of another condition (such as testosterone deficiency) or exposure to certain other medications, the doctor may design a treatment plan to address the underlying cause.

How Can Osteoporosis Be Prevented?

There have been fewer research studies on osteoporosis in men than in women. However, experts agree that all people should take the following steps to preserve their bone health:

* Avoid smoking, reduce alcohol intake, and increase your level of physical activity.
* Ensure a daily calcium intake that is adequate for your age.
* Ensure an adequate intake of vitamin D. Normally, the body makes enough vitamin D from exposure to as little as 10 minutes of sunlight a day. If exposure to sunlight is inadequate, dietary vitamin D intake should be between 200 and 600 IU (International Units) per day (See Table). 400 IU is the amount found in one quart of fortified milk and most multivitamins.
* Engage in a regular regimen of weight-bearing exercises in which bones and muscles work against gravity. This might include walking, jogging, racquet sports, stair climbing, team sports, lifting weights, and using resistance machines. A doctor should evaluate the exercise program of anyone already diagnosed with osteoporosis to determine if twisting motions and impact activities, such as those used in golf, tennis, or basketball, need to be curtailed.
* Discuss with your doctor the use of medications that are known to cause bone loss, such as glucocorticoids.
* Recognize and seek treatment for any underlying medical conditions that affect bone health.

Osteoporosis: The Diagnosis

Osteoporosis is a condition of low bone density that can progress silently over a long period of time. If diagnosed early, the fractures associated with the disease can often be prevented. Unfortunately, osteoporosis frequently remains undiagnosed until a fracture occurs.

An examination to diagnose osteoporosis can involve several steps that predict your chances of future fracture, diagnose osteoporosis, or both. It might include:

* an initial physical exam
* various x rays that detect skeletal problems
* laboratory tests that reveal important information about the metabolic process of bone breakdown and formation
* a bone density test to detect low bone density.

Before performing any tests, your doctor will record information about your medical history and lifestyle and will ask questions related to:

* risk factors, including information about any fractures you have had
* your family history of disease, including osteoporosis
* medication history
* general intake of calcium and vitamin D
* exercise pattern
* for women, menstrual history.

In addition, the doctor will note medical problems and medications you may be taking that can contribute to bone loss (including glucocorticoids, such as cortisone). He or she will also check your height for changes and your posture to note any curvature of the spine from vertebral fractures, which is known as kyphosis.

Risk Factors for Osteoporotic Fracture Include:

* personal history of fracture as an adult
* history of fracture in a first-degree relative
* Caucasian or Asian race, although African Americans and Hispanic Americans are at significant risk as well
* advanced age
* being female
* dementia
* poor health, frailty, or both
* current cigarette smoking
* low body weight
* anorexia nervosa
* estrogen deficiency (past menopause, menopause before age 45, having both ovaries removed, or the absence of menstrual periods for a year or more prior to menopause)*
* low testosterone levels in men
* use of certain medications such as corticosteroids and anticonvulsants
* lifelong low calcium intake
* excessive alcohol intake
* impaired eyesight despite adequate correction
* recurrent falls
* inadequate physical activity.

*Women lose bone rapidly in the first 4-8 years following menopause, making them more susceptible to osteoporosis.

X Ray Tests

If you have back pain, your doctor may order an x ray of your spine to determine whether you have had a fracture. An x ray also may be appropriate if you have experienced a loss of height or a change in posture. However, since an x ray can detect bone loss only after 30 percent of the skeleton has been depleted, the presence of osteoporosis may be missed.

Bone Mineral Density Tests

A bone mineral density (BMD) test is the best way to determine your bone health. BMD tests can identify osteoporosis, determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized bone mineral density test is called a dual-energy x-ray absorptiometry or DXA test. It is painless: a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.

During a BMD test, an extremely low energy source is passed over part or all of the body. The information is evaluated by a computer program that allows the doctor to see how much bone mass you have. Since bone mass serves as an approximate measure of bone strength, this information also helps the doctor accurately detect low bone mass, make a definitive diagnosis of osteoporosis, and determine your risk of future fractures.

BMD tests provide doctors with a measurement called a T-score, a number value that results from comparing your bone density to optimal bone density. When a T-score appears as a negative number such as -1, -2 or -2.5, it indicates low bone mass. The more negative the number, the greater the risk of fracture.

Although no bone density test is 100 percent accurate, this type of test is the single most important predictor of whether a person will fracture in the future.

Bone Scans

For some people, a bone scan may be ordered. A bone scan is different from the BMD test just described, although the term “bone scan” often is used incorrectly to describe a bone density test. A bone scan can tell the doctor whether there are changes that may indicate cancer, bone lesions, inflammation, or new fractures. In a bone scan, the person being tested is injected with a dye that allows a scanner to identify differences in the conditions of various areas of bone tissue.

Laboratory Tests

A number of laboratory tests may be performed on blood and urine samples. The results of these tests can help your doctor identify conditions that may be contributing to your bone loss.

The most common blood tests evaluate:

* blood calcium levels
* blood vitamin D levels
* thyroid function
* parathyroid hormone levels
* estradiol levels to measure estrogen (in women)
* follicle stimulating hormone (FSH) test to establish menopause status
* testosterone levels (in men)
* osteocalcin levels to measure bone formation.

The most common urine tests are:

* 24-hour urine collection to measure calcium metabolism
* tests to measure the rate at which a person is breaking down or resorbing bone.

Treatment

In addition to diagnosing osteoporosis, results from BMD tests assist the doctor in deciding whether to begin a prevention or treatment program. Once you and your doctor have definitive information based on your history, physical examination, and diagnostic tests, a specific treatment program can be developed for you.

Recommendations for optimizing bone health include a comprehensive program that consists of a well-balanced diet rich in calcium and vitamin D, physical activity, and a healthy lifestyle (including not smoking, avoiding excessive alcohol use, and recognizing that some prescription medications and chronic diseases can cause bone loss). If you already have experienced a fracture, your doctor may refer you to a specialist in physical therapy or rehabilitation medicine to help you with daily activities, safe movement, and exercises to improve your strength and balance.

Osteoporosis: Coping With Chronic Pain

Osteoporosis often causes very painful fractures, which can take many months to heal. In many cases, the pain starts to go away as the fracture heals. Most new fractures heal in approximately 3 months. Pain that continues after that is generally considered chronic pain. One cause of chronic pain is vertebral fractures. When a vertebra breaks, some people have no pain, while others have intense pain and muscle spasms that last long after the fracture has healed.

Pain is the body’s way of responding to an injury. When a bone breaks, nerves send pain messages through the spinal cord to the brain, where they are interpreted. Your response to pain is determined by many factors, including your emotional outlook. For example, depression seems to increase a person’s perception of pain and decrease her or his ability to cope with it. Often, treating the depression treats the pain as well.

Chronic pain is pain that lasts beyond the expected time for healing and interferes with normal life. The injury has healed, but the pain continues. The pain message may be triggered by muscle tension, stiffness, weakness, or spasms. Whatever the cause of chronic pain, feelings of frustration, anger, and fear can make the pain more intense. Chronic pain can affect all areas of your life and should be taken seriously.

The following information provides those who have chronic pain with an overview of different options for pain management. If you have chronic pain and need help managing it, you may wish to discuss these options with your doctor.

Coping Strategies: Physical Methods of Pain Management

Heat and ice: Heat, in the form of warm showers or hot packs, can relieve chronic pain or stiff muscles. Cold packs or ice packs provide pain relief by numbing the pain-sensing nerves in the affected area. Cold also helps reduce swelling and inflammation. Depending on which feels better, apply heat or cold for 15 to 20 minutes at a time to the area where you feel the pain. To protect your skin, place a towel between your skin and the source of the cold or heat. Some simple ways to make heat and ice packs are listed below:

* Warm towels or hot packs in the microwave for a quick source of heat. (Handle carefully.)
* Make instant cold packs from frozen juice cans or bags of frozen vegetables.
* Freeze a plastic, resealable bag filled with water to make a good ice bag.

Transcutaneous Electrical Nerve Stimulation (TENS): A TENS machine is a small device that sends electrical impulses to certain parts of the body to block pain signals. Two electrodes are placed on the body where you are experiencing pain. The electrical current that is produced is very mild, but it can prevent pain messages from being transmitted to the brain. Pain relief can last for several hours. Some people may use a small, portable TENS unit that hooks onto a belt for more continuous relief. TENS machines should only be used under the supervision of a physician or physical therapist. They can be purchased or rented from hospital supply or surgical supply houses; however, a prescription is necessary for insurance reimbursement.

Braces and supports: Spinal supports or braces reduce pain and inflammation by restricting movement. Following a vertebral fracture, a back brace or support will relieve pain and allow you to resume normal activities while the fracture heals. However, continuous use of a back support can weaken back muscles. For this reason, exercises to strengthen the muscles in the back should be started as soon as possible.

Exercise and physical therapy: Prolonged inactivity increases weakness and causes loss of muscle mass and strength. A regular exercise program and physical therapy can help you regain strength, energy, and a more positive outlook on life. Because exercise raises the body’s level of endorphins – or natural pain killers produced by the brain – it will relieve pain somewhat. Exercise also relieves tension, increases flexibility, strengthens muscles, and reduces fatigue.

A physical therapist can help you reorganize your home or work environment to avoid further injuries. Physical therapists also teach proper posture and exercises to strengthen the back and abdominal muscles without injuring a weakened spine. Water therapy in a pool, for example, is one of the best exercise techniques for gently improving back muscle strength and reducing pain.

Acupuncture and acupressure: Acupuncture is the use of special needles that are inserted into the body at certain points. These needles stimulate nerve endings and cause the brain to release endorphins. It may take several acupuncture sessions before the pain is relieved. Acupuncture has been used for centuries in China and other parts of Asia to treat many types of pain.

Acupressure is direct pressure applied to areas that trigger pain. This technique can be self-administered after training with an instructor.

Massage therapy: Massage therapy can be a light, slow, circular motion with the fingertips or a deep, kneading motion that moves from the center of the body outward toward the fingers or toes. Massage relieves pain, relaxes stiff muscles, and smoothes out muscle knots by increasing the blood supply to the affected area and warming it. The person doing the massage uses oil or powder so that her or his hands slide smoothly over the skin. Massage can also include gentle pressure over the affected areas or hard pressure over trigger points in muscle knots. Note: Deep muscle massage should not be done near the spine of a person who has spinal osteoporosis. Light, circular massage with fingers or the palm of the hand is best in this case.

Coping Strategies: Psychological Methods of Pain Management

Relaxation training: Relaxation involves concentration and slow, deep breathing to release tension from muscles and relieve pain. Learning to relax takes practice, but relaxation training can focus attention away from pain and release tension from all muscles. Relaxation tapes are widely available to help you learn these skills.

Biofeedback: Biofeedback is taught by a professional who uses special machines to help you learn to control bodily functions, such as heart rate and muscle tension. As you learn to release muscle tension, the machine immediately indicates success. Biofeedback can be used to reinforce relaxation training. Once the technique is mastered, it can be practiced without the use of the machine.

Visual imagery and distraction: Imagery involves concentrating on mental pictures of pleasant scenes or events or mentally repeating positive words or phrases to reduce pain. Tapes are also available to help you learn visual imagery skills.

Distraction techniques focus your attention away from negative or painful images to positive mental thoughts. This may include activities as simple as watching television or a favorite movie, reading a book or listening to a book on tape, listening to music, or talking to a friend.

Hypnosis: Hypnosis can be used in two ways to reduce your perception of pain. Some people are hypnotized by a therapist and given a post-hypnotic suggestion that reduces the pain they feel. Others are taught self-hypnosis and can hypnotize themselves when pain interrupts their ability to function. Self-hypnosis is a form of relaxation training.

Individual, group, or family therapy: These forms of psychotherapy may be useful for those whose pain has not responded to physical methods. People who suffer from chronic pain often experience emotional stress and depression. Therapy can help you cope with these feelings, making it easier to manage your pain.

Coping Strategies: Medication for Pain Management

Medications are the most popular way to manage pain. Commonly used medications include aspirin, acetaminophen, and ibuprofen. Although these are probably the safest pain relievers available, they sometimes cause stomach irritation and bleeding.

Narcotic drugs may be prescribed for short-term acute pain. These drugs should not be used for long periods because they are addictive and can affect your ability to think clearly. They also have other side effects, such as constipation.

Many people with persistent pain that has not responded to other forms of pain relief are treated with antidepressant medication. These drugs may work in a different way when used for treatment of unyielding pain. The body’s internal pain suppression system may depend upon the concentrations of various chemicals in the brain. These concentrations are increased by the use of antidepressants.

The above-mentioned methods of pain management are used in various hospitals and clinics across the country. If you have chronic pain that has not responded to treatment, you should consult your physician for a referral to a physical therapist or a clinic specializing in pain management.

Pain Management Resources

National Institute of Arthritis and Musculoskeletal and Skin Diseases
National Institutes of Health
1 AMS Circle
Bethesda, MD 20892-3675
http://www.niams.nih.gov
Phone: 877-22-NIAMS (226-4267) (free of charge) or 301-495-4484
Fax: 301-718-6366
The National Institute of Arthritis and Musculoskeletal and Skin Diseases publishes Pain Research: An Overview. This publication is available at: http://www.niams.nih.gov/hi/topics/pain/pain.htm.

National Institute of Dental and Craniofacial Research
National Institutes of Health
Bethesda, MD 20892-2190
E-mail: nidcrinfo@mail.nih.gov
http://www.nidcr.nih.gov/
Phone: 301-496-4261
The National Institute of Dental and Craniofacial Research is the primary NIH organization for research on pain.

National Institute of Neurological Disorders and Stroke
NIH Neurological Institute
P.O. Box 5801
Bethesda, MD 20824
http://www.ninds.nih.gov
Phone: 800-352-9424 (free of charge) or 301-496-5751
The National Institute of Neurological Disorders and Stroke has developed a Chronic Pain Information Page. This resource is available at: http://www.ninds.nih.gov/health_and_medical/disorders/chronic_pain.htm.

American Pain Society
4700 West Lake Avenue
Glenview, IL 60025-1485
E-mail: info@ampainsoc.org
http://www.ampainsoc.org
Phone: 847-375-4715
Fax: 877-734-8758 (free of charge)
This society provides general information to the public and maintains a directory of resources, including referrals to pain centers.

American Chronic Pain Association
P.O. Box 850
Rocklin, CA 95677-0850
E-mail: ACPA@pacbell.net
http://www.theacpa.org
Phone: 800-533-3231 (free of charge) or 919-632-0922
Fax: 919-632-3208
This association provides information on positive ways to deal with chronic pain and can provide guidelines on selecting a pain management center.

NIH Pain Consortium
National Institutes of Health
9000 Rockville Pike
Bethesda, Maryland 20892
E-mail: NIHInfo@od.nih.gov
http://painconsortium.nih.gov
Phone: 301-496-4000
The NIH Pain Consortium was established to enhance pain research and promote collaboration among researchers across the many NIH Institutes and Centers that have programs and activities addressing pain.

For Your Information

This publication contains information about medications used to treat the health condition discussed here. When this fact sheet was printed, we included the most up-to-date (accurate) information available. Occasionally, new information on medication is released.

For updates and for any questions about any medications you are taking, please contact the U.S. Food and Drug Administration at 1-888-INFO-FDA (1-888-463-6332, a toll-free call) or visit their Web site at www.fda.gov

Osteoporosis: The Bone Thief

Helen grew up on a farm in the Midwest. She drank lots of milk as a child. She also walked a lot. After graduating from high school, she got married and found a job. Family and work kept her too busy to exercise. Helen went through menopause at age 47. At age 76, she was enjoying retirement — traveling and working in her garden. But then she slipped on a small rug in her kitchen and broke her hip. After Helen recovered, she needed a cane to walk, and gardening was a lot harder to enjoy.

Helen had osteoporosis, but she didn’t know it before she fell. Osteoporosis is a disease that weakens bones to the point where they break easily—most often bones in the hip, backbone (spine), and wrist. Osteoporosis is called the “silent disease”—you may not notice any changes until a bone breaks. But your bones have been losing strength for many years.

Bone is living tissue. To keep bones strong, your body is always breaking down old bone and replacing it with new bone tissue. As people enter their forties and fifties, more bone is broken down than is replaced. A close look at the inside of bone shows something like a honeycomb. When you have osteoporosis, the spaces in this honeycomb grow larger. And the bone that forms the honeycomb gets smaller. The outer shell of your bones also gets thinner. All this loss makes your bones weaker.
Who Has Osteoporosis?

Millions of Americans have osteoporosis. They are mostly women, but more than 2 million men also have this disease. White and Asian women are most likely to have osteoporosis. Other women at great risk include those who:

* have a family history of the disease,
* have broken a bone while an adult,
* had surgery to remove their ovaries before their periods stopped,
* had early menopause,
* have not gotten enough calcium throughout their lives,
* had extended bed rest,
* used certain medicines for a long time, or
* have a small body frame.

The risk of osteoporosis grows as you get older. At the time of menopause women may lose bone quickly for several years. After that, the loss slows down, but continues. In men the loss of bone mass is slower. But, by age 65 or 70 men and women are losing bone at the same rate.
What Is Osteopenia?

Millions more Americans have osteopenia. Whether your doctor calls it osteopenia or just says you have low bone mass, consider it a warning. Bone loss has started, but you can still take action to keep your bones strong and maybe prevent osteoporosis later in life. That way you will be less likely to break a wrist, hip, or vertebrae (bone in your spine) when you are older.
Can My Bones Be Tested?

For some people the first sign of osteoporosis is to realize they are getting shorter or to break a bone easily, like Helen. Don’t wait until that happens to see if you have osteoporosis. You can have a bone density testto find out how solid your bones are. Your doctor may suggest a type of bone density test called a DEXA-scan (dual-energy x-ray absorptiometry) if you are age 65 or older or if he or she thinks you are at risk for osteoporosis.

The DEXA-scan tells what your risk for a fracture or broken bone is. It could show that you have normal bone density. Or, it could show that you have low bone mass or even osteoporosis.
How Can I Keep My Bones Strong?

There are things you should do at any age to prevent weakened bones. Eating foods that are rich in calcium and vitamin D is important. So is including regular weight-bearing exercise in your lifestyle. These are the best ways to keep your bones strong and healthy.

Calcium. Getting enough calcium all through your life helps to build and keep strong bones. People over age 50 need 1200 mg of calcium every day. Foods that are high in calcium are the best source. For example, eat low-fat dairy foods, canned fish with soft bones such as salmon, dark green leafy vegetables, and calcium-fortified foods like orange juice, breads, and cereals.

If you think you aren’t getting enough calcium in your diet, check with your doctor first. He or she may tell you to try a calcium supplement. Calcium carbonate and calcium citrate are two common forms. You have to be careful though. Too much calcium can cause problems for some people. On most days you should not get more than 2,500 mg of total calcium. That includes calcium from all sources—foods, drinks, and supplements.

Vitamin D. Your body uses vitamin D to absorb calcium. Most people’s bodies are able to make enough vitamin D if they are out in the sun for a total of 20 minutes every day. You can also get vitamin D from eggs, fatty fish, and cereal and milk fortified with vitamin D. If you think you are not getting enough vitamin D, check with your doctor. Each day you should have:

* 400 IU (international unit) if you are age 51 to 70
* 600 IU if you are over age 70.

As with calcium, be careful. More than 2000 IU of vitamin D each day may cause side effects.

Exercise. Your bones and muscles will be stronger if you are physically active. Weight-bearing exercises, done three to four times a week, are best for preventing osteoporosis. Walking, jogging, playing tennis, and dancing are examples of weight-bearing exercises. Try some strengthening and balance exercises, too. They may help you avoid falls which could cause a broken bone.

Medicines. Some common medicines can make bones weaker. These include a type of steroid drug called glucocorticoids used for arthritis and asthma, some antiseizure drugs, certain sleeping pills, treatments for endometriosis, and some cancer drugs. An overactive thyroid gland or using too much thyroid hormone for an underactive thyroid can also be a problem. If you are taking these medicines, talk to your doctor about what you can do to help protect your bones.

Lifestyle. Smoking increases loss of bone mass. For this and many other health reasons, stop smoking. Limit how much alcohol you drink. Too much alcohol can put you at risk for falling and breaking a bone.
What Can I Do for My Osteoporosis?

Treating osteoporosis means stopping the bone loss and rebuilding bone to prevent breaks. Diet and exercise can help make your bones stronger. But they may not be enough if you have lost a lot of bone density. There are also several medicines to think about. Some will slow your bone loss, and others can help rebuild bone. Talk with your doctor to see if one of these might work for you:

* Bisphosphonates. These medicines slow the breakdown of bone and increase bone density. They can make it less likely that you will break a bone, most of all in your spine, hip, or wrist. Side effects may include nausea, heartburn, and stomach pain. A few people have muscle, bone, or joint pain while using these medicines. These drugs must be taken in a certain way—when you first get up, before you have eaten, and with a full glass of water. You should not lie down, eat, or drink for at least one-half hour after taking the drug. Even if you follow the directions closely, these drugs can cause serious digestive problems, so be aware of any side effects. These pills are available in once-daily, once-a-week, and once-a-month versions.
* Raloxifene. This drug is used to prevent and treat osteoporosis. It is a SERM (selective estrogen receptor modulator). It prevents bone loss and spine fractures but may cause hot flashes or increase the risk of blood clots in some women.
* Estrogen. Doctors sometimes prescribe this female hormone around the time of menopause to treat symptoms like hot flashes or vaginal dryness. Estrogen also slows bone loss and increases bone mass in your spine and hip, so women can use it to prevent or treat osteoporosis. But, estrogen use is thought to be risky for some women. Talk to your doctor. Ask about the benefits, risks, and side effects, as well as other possible treatments for you.
* Calcitonin. This hormone increases bone mass in your spine and can lessen the pain of fractures already there. It comes in two forms—a shot or nasal spray. The shot may cause an allergic reaction and has some side effects like nausea, diarrhea, or redness in your face, ears, hands, or feet. The only side effect of the nasal spray is a runny nose in some people. Calcitonin is most useful for women who are 5 years past menopause.
* Parathyroid hormone (PTH). Also called teriparatide, this shot is given daily for up to two years to postmenopausal women and men who are at high risk for broken bones. It improves bone density in the spine and hip. Common side effects include nausea, dizziness, and leg cramps.

Can I Avoid Falling?

When your bones are weak, a simple fall can cause a broken bone. This can mean a trip to the hospital and maybe surgery. It might also mean being laid up for a long time, especially in the case of a hip fracture. So, it is important to prevent falls. Some things you can do are:

* Make sure you can see and hear well. Use your glasses or a hearing aid if needed.
* Ask your doctor if any of the drugs you are taking can make you dizzy or unsteady on your feet.
* Use a cane or walker if your walking is unsteady.
* Wear rubber-soled and low-heeled shoes.
* Make sure all the rugs and carpeting in your house are firmly attached to the floor, or don’t use them.
* Keep your rooms well lit and the floor free of clutter.
* Use nightlights.

You can find more suggestions in the National Institute on Aging’s Preventing Falls and Fractures Age Page, also available from the National Institute on Aging Information Center listed in the resource section.
Do Men Have Osteoporosis?

Osteoporosis is not just a woman’s disease. Not as many men have it as women do, but men need to worry about it as well. This may be because most men start with more bone density than women and lose it more slowly as they grow older.

Experts don’t know as much about this disease in men as they do in women. However, many of the things that put men at risk are the same as those for women:

* family history
* not enough calcium or vitamin D
* too little exercise
* low levels of testosterone
* too much alcohol
* taking certain drugs
* smoking.

Older men who break a bone easily or are at risk for osteoporosis should talk with their doctors about testing and treatment. Men can use bisphsphonates or parathyroid hormone to increase bone density. Testosterone supplements may help some men with low levels of testosterone.
Resources

National Osteoporosis Foundation
1232 22nd Street, NW
Washington, DC 20037-1292
202-223-2226
www.nof.org

National Institutes of Health
Osteoporosis and Related Bone Diseases~NationalResourceCenter
2 AMS Circle
Bethesda, MD 20892-3676
800-624-BONE (800-624-2663)
202-466-4315 (TTY)
www.niams.nih.gov/bone

National Library of Medicine
MedlinePlus
In Health Topics, go to:
“Osteoporosis”
“Falls”
www.medlineplus.gov

The National Institute on Aging has information on health and aging, including a booklet and video about exercise for older people and several helpful Age Pages. Contact:
National Institute on AgingInformationCenter
P.O. Box 8057
Gaithersburg, MD 20898-8057
800-222-2225 (toll-free)
800-222-4225 (TTY, toll-free)
www.nia.nih.gov

To order publications (in English or Spanish) or sign up for regular email alerts, go to www.nia.nih.gov/HealthInformation.

Visit NIHSeniorHealth.gov (www.nihseniorhealth.gov), a senior-friendly website from the National Institute on Aging and the National Library of Medicine. This simple-to-use website features popular health topics for older adults. It has large type and a talking function that “reads” the text out loud.

National Institute on Aging
U. S. Department of Health and Human Services
Public Health Service
National Institutes of Health
December 2004
Updated 2006

Osteoporosis and Hispanic Women

It is a common misconception that osteoporosis only affects white women. But, according to the Surgeon General’s Report on Bone Health and Osteoporosis, in the United States, the prevalence of osteoporosis in Hispanic women is similar to that in white women. Fortunately, osteoporosis is preventable and treatable. As a Hispanic woman, it is important that you understand your risk for osteoporosis, the steps you can take to protect your bones, and, if you have the disease, the options for treating it.

What Is Osteoporosis?

Osteoporosis is a debilitating disease characterized by low bone mass and, thus, bones that are susceptible to fracture. If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks, typically in the hip, spine, or wrist. A hip fracture can limit mobility and lead to a loss of independence, while vertebral fractures can result in a loss of height, stooped posture, and chronic pain.

What Are the Risk Factors for Osteoporosis?

Risk factors for developing osteoporosis include:

* a thin, small-boned frame
* previous fracture or family history of osteoporotic fracture
* estrogen deficiency resulting from early menopause (before age 45), either naturally, from surgical removal of the ovaries, or as a result of prolonged amenorrhea (abnormal absence of menstruation) in younger women
* advanced age
* a diet low in calcium
* Caucasian and Asian ancestry (African American and Hispanic women are at lower but significant risk)
* cigarette smoking
* excessive use of alcohol
* prolonged use of certain medications, such as those used to treat diseases like lupus, asthma, thyroid deficiencies, and seizures.

Are There Any Special Issues for Hispanic Women Regarding Bone Health?

Several studies indicate a number of facts that highlight the risk Hispanic women face with regard to developing osteoporosis:

* Ten percent of Hispanic women aged 50 and older are estimated to have osteoporosis, and 49 percent are estimated to have bone mass that is low, but not low enough for them to be diagnosed with osteoporosis.
* The incidence of hip fractures among some Hispanic women appears to be on the rise.
* Studies have shown that Hispanic women consume less calcium than the Recommended Dietary Allowance in all age groups.
* Hispanic women are twice as likely to develop diabetes as white women, which may increase their risk for osteoporosis.

How Can Osteoporosis Be Prevented?

Osteoporosis prevention begins in childhood. The recommendations listed below should be followed throughout life to lower your risk of osteoporosis.

* Eat a well-balanced diet adequate in calcium and vitamin D.
* Exercise regularly, with an emphasis on weight-bearing activities such as walking, jogging, dancing, and lifting weights.
* Live a healthy lifestyle. Avoid smoking, and, if you drink alcohol, do so in moderation.

Talk to your doctor if you have a family history of osteoporosis or other factors that may put you at increased risk for the disease. Your doctor may suggest that you have your bone density measured through a safe and painless test that can determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized bone mineral density test is called a dual-energy x-ray absorptiometry or DXA test. It is painless: a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.

What Treatments Are Available?

Although there is no cure for osteoporosis, there are treatments available to help stop further bone loss and reduce the risk of fractures:

* bisphosphonate drugs: alendronate (Fosamax1), alendronate plus vitamin D (Fosamax Plus D), risedronate (Actonel), risedronate with calcium (Actonel with Calcium), and ibandronate (Boniva)
* calcitonin (Miacalcin)
* raloxifene (Evista), a Selective Estrogen Receptor Modulator
* teriparatide (Forteo), a form of the hormone known as PTH, which is secreted by the parathyroid glands
* estrogen therapy (also called hormone therapy when estrogen and another hormone, progestin, are combined).

Osteoporosis and Arthritis: Two Common but Different Conditions

Many people confuse osteoporosis and some types of arthritis. This fact sheet will discuss the similarities and differences between these conditions.

Osteoporosis

Osteoporosis is a major health threat for 44 million Americans, 68 percent of whom are women. In osteoporosis, there is a loss of bone tissue that leaves bones less dense and more prone to fracture. It can result in a loss of height, severe back pain, and a change in one’s posture. Osteoporosis can impair a person’s ability to walk and can cause prolonged or permanent disability.

Risk factors for developing osteoporosis include:

* thinness or small frame
* family history of osteoporosis
* being postmenopausal, and particularly having had early menopause
* abnormal absence of menstrual periods
* prolonged use of certain medications, such as those used to treat diseases like systemic lupus erythematosus, asthma, thyroid deficiencies, and seizures
* low calcium intake
* physical inactivity
* smoking
* excessive alcohol intake.

Osteoporosis is a silent disease that often can be prevented. However, if undetected, it can progress for many years without symptoms until a fracture occurs. Osteoporosis is diagnosed by a bone mineral density (BMD) test, which is a safe and painless way to detect low bone density.

Although there is no cure for the disease, several medications have been approved by the Food and Drug Administration to prevent and treat osteoporosis. In addition, a diet rich in calcium and vitamin D, regular weight-bearing exercise, and a healthy lifestyle can prevent or lessen the effects of the disease.

Arthritis

Arthritis is a general term for conditions that affect the joints and surrounding tissues. Joints are places in the body where bones come together, such as the knees, wrists, fingers, toes, and hips. The two most common types of arthritis are osteoarthritis and rheumatoid arthritis.

* Osteoarthritis (OA) is a painful, degenerative joint disease that often involves the hips, knees, neck, lower back, or the small joints of the hands. OA usually develops in joints that are injured by repeated overuse from performing a particular task or playing a favorite sport, or from carrying around excess body weight. Eventually this injury or repeated impact thins or wears away the cartilage that cushions the ends of the bones in the joint. As a result, the bones rub together, causing a grating sensation. Joint flexibility is reduced, bony spurs develop, and the joint swells. Usually, the first symptom of OA is pain that worsens following exercise or immobility. Treatment usually includes analgesics, topical creams, or nonsteroidal anti-inflammatory medications (known as NSAIDs); appropriate exercises or physical therapy; joint splinting; or joint replacement surgery for seriously damaged larger joints, such as the knee or hip.

* Rheumatoid arthritis (RA) is an autoimmune inflammatory disease that usually involves various joints in the fingers, thumbs, wrists, elbows, shoulders, knees, feet, and ankles. An autoimmune disease is one in which the body releases enzymes that attack its own healthy tissues. In RA, these enzymes destroy the linings of joints. This causes pain, swelling, stiffness, malformation, and reduced movement and function. People with RA also may have systemic symptoms, such as fatigue, fever, weight loss, eye inflammation, anemia, subcutaneous nodules (bumps under the skin), or pleurisy (a lung inflammation).

While osteoporosis and OA are two very different medical conditions with little in common, the similarity of their names causes great confusion. These conditions develop differently, have different symptoms, are diagnosed differently, and are treated differently. While it is possible to have both osteoporosis and arthritis, studies show that people with OA are less likely to develop osteoporosis. On the other hand, people with RA may be more likely than average to develop osteoporosis. This is especially true because some medications used to treat RA can contribute to osteoporosis.

Osteoporosis and arthritis do share many coping strategies. With either or both of these conditions, many people benefit from exercise programs that may include physical therapy and rehabilitation. In general, exercises that emphasize stretching, strengthening, posture, and range of motion are appropriate. Examples include low-impact aerobics, swimming, tai chi, and low-stress yoga. However, people with osteoporosis must take care to avoid activities that include bending forward from the waist, twisting the spine, or lifting heavy weights. People with arthritis must compensate for limited movement in affected joints. Always check with your doctor to determine if a certain exercise or exercise program is safe for your specific medical situation.

Osteoporosis and African American Women

While African American women tend to have higher bone mineral density (BMD) than white women throughout life, they are still at significant risk of developing osteoporosis. The misperception that osteoporosis is only a concern for white women can delay prevention and treatment in African American women who do not believe they are at risk for the disease.

What Is Osteoporosis?

Osteoporosis is a metabolic bone disease characterized by low bone mass, which makes bones fragile and susceptible to fracture. Osteoporosis is known as a silent disease because symptoms and pain do not appear until a fracture occurs. Without prevention or treatment, osteoporosis can progress painlessly until a bone breaks, typically in the hip, spine, or wrist. A hip fracture can limit mobility and lead to a loss of independence, while vertebral fractures can result in a loss of height, stooped posture, and chronic pain.

What Are the Risk Factors for Osteoporosis?

Risk factors for developing osteoporosis include:

* a thin, small-boned frame
* previous fracture or family history of osteoporotic fracture
* estrogen deficiency resulting from early menopause (before age 45), either naturally, from surgical removal of the ovaries, or as a result of prolonged amenorrhea (abnormal absence of menstruation) in younger women
* advanced age
* a diet low in calcium
* Caucasian and Asian ancestry (African American and Hispanic women are at lower but significant risk)
* cigarette smoking
* excessive use of alcohol
* prolonged use of certain medications, such as those used to treat diseases like lupus, asthma, thyroid deficiencies, and seizures.

Are There Special Issues for African American Women Regarding Bone Health?

Many scientific studies highlight the risk that African American women face with regard to developing osteoporosis and fracture.

* Osteoporosis is underrecognized and undertreated in African American women.
* As African American women age, their risk for hip fracture doubles approximately every 7 years.
* African American women are more likely than white women to die following a hip fracture.
* Diseases more prevalent in the African American population, such as sickle-cell anemia and lupus, can increase the risk of developing osteoporosis.
* African American women consume 50 percent less calcium than the Recommended Dietary Allowance. Adequate intake of calcium plays a crucial role in building bone mass and preventing bone loss.
* As many as 75 percent of all African Americans are lactose intolerant. Lactose intolerance can hinder optimal calcium intake. People with lactose intolerance often may avoid milk and other dairy products that are excellent sources of calcium because they have trouble digesting lactose, the primary sugar in milk.

How Can Osteoporosis Be Prevented?

Osteoporosis prevention begins in childhood. The recommendations listed below should be followed throughout life to lower your risk of osteoporosis.

* Eat a well-balanced diet adequate in calcium and vitamin D.
* Exercise regularly, with an emphasis on weight-bearing activities such as walking, jogging, dancing, and lifting weights.
* Live a healthy lifestyle. Avoid smoking, and, if your drink alcohol, do so in moderation.

Talk to your doctor if you have a family history of osteoporosis or other risk factors that may put you at increased risk for the disease. Your doctor may suggest that you have your bone density measured through a safe and painless test that can determine your risk for fractures (broken bones), and measure your response to osteoporosis treatment. The most widely recognized bone mineral density test is called a dual-energy x-ray absorptiometry or DXA test. It is painless: a bit like having an x ray, but with much less exposure to radiation. It can measure bone density at your hip and spine.

What Treatments Are Available?

Although there is no cure for osteoporosis, there are treatments available to help stop further bone loss and reduce the risk of fractures:

* bisphosphonate drugs: alendronate (Fosamax1), alendronate plus vitamin D (Fosamax Plus D), risedronate (Actonel), risedronate with calcium (Actonel with Calcium), and ibandronate (Boniva)
* calcitonin (Miacalcin)
* raloxifene (Evista), a Selective Estrogen Receptor Modulator
* teriparatide (Forteo), a form of the hormone known as PTH, which is secreted by the parathyroid glands
* estrogen therapy (also called hormone therapy when estrogen and another hormone, progestin, are combined).

1 Brand names included in this publication are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Medications to Prevent and Treat Osteoporosis

Although there is no cure for osteoporosis, several medications approved by the U.S. Food and Drug Administration (FDA) can help stop or slow bone loss, or help form new bone, and reduce the risk of fractures. Currently, alendronate, raloxifene, risedronate, and ibandronate are approved for preventing and treating postmenopausal osteoporosis. Teriparatide is approved for treating the disease in postmenopausal women and men at high risk for fracture. Estrogen/hormone therapy (ET/HT) is approved for preventing postmenopausal osteoporosis, and calcitonin is approved for treatment. In addition, alendronate is approved to treat bone loss that results from glucocorticoid medications like prednisone or cortisone. It is also approved for treating osteoporosis in men. Risedronate is approved to prevent and treat glucocorticoid-induced osteoporosis and to treat ostoeporosis in men.

Bisphosphonates

Alendronate (Fosamax¹), risedronate (Actonel), and ibandronate (Boniva) are medications from the class of drugs called bisphosphonates.

Alendronate and risedronate have been shown to increase bone mass and reduce the incidence of spine, hip, and other fractures. Ibandronate has been shown to reduce the incidence of spine fractures.

Alendronate is available in daily and weekly doses. Risedronate is available in daily and weekly doses. Ibandronate is available in a monthly dose and as an intravenous injection administered once every three months.

Oral bisphosphonates should be taken on an empty stomach and with a full glass of water first thing in the morning. It is important to remain in an upright position and refrain from eating or drinking for at least 30 minutes after taking a bisphosphonate.

Side effects for bisphosphonates include gastrointestinal problems such as difficulty swallowing, inflammation of the esophagus, and gastric ulcer. There have been rare reports of osteonecrosis of the jaw and of visual disturbances in people taking bisphosphonates.

Some bisphosphonates are fortified with calcium and vitamin D. These nutrients are important for everyone, and people should include adequate amounts of them in their diets.

¹Brand names included in this publication are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

Raloxifene

Raloxifene (Evista) is approved for the prevention and treatment of postmenopausal osteoporosis. It is from a class of drugs called Selective Estrogen Receptor Modulators (SERMs) that appear to prevent bone loss in the spine, hip, and total body. Raloxifene has beneficial effects on bone mass and bone turnover and can reduce the risk of vertebral fractures. While side effects are not common with raloxifene, those reported include hot flashes and blood clots in the veins, the latter of which is also associated with estrogen therapy. Additional research studies on raloxifene will continue for several more years.

Calcitonin

Calcitonin (Miacalcin, Fortical) is a naturally occurring hormone involved in calcium regulation and bone metabolism. In women who are at least 5 years past menopause, calcitonin slows bone loss, increases spinal bone density, and according to anecdotal reports, relieves the pain associated with bone fractures. Calcitonin reduces the risk of spinal fractures and may reduce hip fracture risk as well. Studies on fracture reduction are ongoing. Calcitonin is currently available as an injection or nasal spray. While it does not affect other organs or systems in the body, injectable calcitonin may cause an allergic reaction and unpleasant side effects including flushing of the face and hands, frequent urination, nausea, and skin rash. The only side effect reported with nasal calcitonin is a runny nose.

Teriparatide

Teriparatide (Forteo) is an injectable form of human parathyroid hormone. It is approved for postmenopausal women and men with osteoporosis who are at high risk for having a fracture. Teriparatide stimulates new bone formation in both the spine and the hip. It also reduces the risk of vertebral and nonvertebral fractures in postmenopausal women. In men, teriparatide reduces the risk of vertebral fractures. However, it is not known whether teriparatide reduces the risk of nonvertebral fractures. Side effects include nausea, dizziness, and leg cramps. Teriparatide is approved for use for up to 24 months.

Estrogen/Hormone Therapy

Estrogen/hormone therapy (ET/HT) has been shown to reduce bone loss, increase bone density in both the spine and hip, and reduce the risk of hip and spine fractures in postmenopausal women. ET/HT is approved for preventing postmenopausal osteoporosis and is most commonly administered in the form of a pill or skin patch. When estrogen – also known as estrogen therapy or ET – is taken alone, it can increase a woman’s risk of developing cancer of the uterine lining (endometrial cancer). To eliminate this risk, physicians prescribe the hormone progestin – also known as hormone therapy or HT – in combination with estrogen for those women who have not had a hysterectomy. Side effects of ET/HT include vaginal bleeding, breast tenderness, mood disturbances, blood clots in the veins, and gallbladder disease.

The Women’s Health Initiative (WHI), a large Government-funded research study, recently demonstrated that the drug Prempro, which is used in hormone therapy, is associated with a modest increase in the risk of breast cancer, stroke, and heart attack. The WHI also demonstrated that estrogen therapy is associated with an increase in the risk of stroke. It is unclear whether estrogen therapy is associated with an increased risk of breast cancer or cardiovascular events. A large study from the National Cancer Institute indicated that long-term use of estrogen therapy may be associated with an increased risk of ovarian cancer. It is unclear whether hormone therapy carries a similar risk.

Any estrogen therapy should be prescribed for the shortest period of time possible. When used solely for the prevention of postmenopausal osteoporosis, any ET/HT regimen should only be considered for women at significant risk of osteoporosis, and nonestrogen medications should be carefully considered first.

Medications for Osteoporosis Prevention and Treatment

Types


Brand
Names


Therapy Options


FDA Approval


Forms of
Administration


Other Considerations


Possible Side Effects

alendronate


Fosamax¹


Bisphosphonates


Fosamax approved for preventing and treating osteoporosis in postmenopausal women. Fosamax approved for treating glucocorticoid-induced osteoporosis in women and men and for treating osteoporosis in men.


Fosamax available as pill in daily and weekly doses.


Oral medication should be taken on an empty stomach with a full glass of water first thing in the morning. After taking the medication, remain in an upright position and do not eat or drink for at least 30 minutes.


May include abdominal or musculoskeletal pain, nausea, heartburn, irritation of the esophagus, and rarely osteonecrosis of the jaw.

ibandronate


Boniva


Bisphosphonates


Boniva approved for preventing and treating osteoporosis in postmenopausal women.


Boniva available as pill in monthly dose and as an intravenous injection administered once every 3 months.


Oral medication should be taken on an empty stomach with a full glass of water first thing in the morning. After taking the medication, remain in an upright position and do not eat or drink for at least 30 minutes.


May include abdominal or musculoskeletal pain, nausea, heartburn, irritation of the esophagus, and rarely osteonecrosis of the jaw.

risedronate


Actonel


Bisphosphonates


Actonel approved for preventing and treating osteoporosis in postmenopausal women and for treating osteoporosis in men. Actonel approved for preventing and treating glucocorticoid-induced osteoporosis in women and men.


Actonel available as pill in daily and weekly doses.


Oral medication should be taken on an empty stomach with a full glass of water first thing in the morning. After taking the medication, remain in an upright position and do not eat or drink for at least 30 minutes.


May include abdominal or musculoskeletal pain, nausea, heartburn, irritation of the esophagus, and rarely osteonecrosis of the jaw.

salmon calcitonin


Miacalcin
Fortical


Calcitonin


Approved for treating osteoporosis in postmenopausal women


Daily nasal spray or injection


Approved for use in women at least 5 years beyond menopause


Use of nasal spray may result in runny, irritated nose. Injectable form may cause flushing of the face and hands, frequent urination, nausea, and skin rash.

estrogen therapy


Including:
Climara
Estrace
Estraderm
Estratab
Ogen
Ortho-Est
Premarin
Vivelle


Estrogen/ Hormone Therapy (ET/HT)


Approved for preventing osteoporosis in postmenopausal women


Pill and skin patch forms


Estrogen taken without progesterone increases the risk of uterine cancer. ET should be considered only for women at significant risk of postmenopausal osteoporosis and only after nonestrogen medications have been considered.


May increase risk of blood clots in the veins, stroke, heart attack, and breast and ovarian cancer. Also, vaginal bleeding, breast tenderness, mood disturbances, and gallbladder disease.

hormone therapy


Including:
Activella
Femhrt
Ortho-
Prefest
Premphase
Prempro


Estrogen/ Hormone Therapy (ET/HT)


Approved for preventing osteoporosis in postmenopausal women


Pill and skin patch forms


HT should be considered only for women at significant risk of postmenopausal osteoporosis and only after nonestrogen medications have been considered.


May increase risk of blood clots in the veins, stroke, heart attack, and breast and ovarian cancer. Also, vaginal bleeding, breast tenderness, mood disturbances, and gallbladder disease.

teriparatide


Forteo


Parathyroid Hormone


Approved for treating osteoporosis in postmenopausal women and men at high risk for fracture


Daily injection


Approved for use for up to 24 months


May include nausea, dizziness, and cramps

raloxifene


Evista


Selective Estrogen Receptor Modulators (SERMs)


Approved for preventing and treating osteoporosis in postmenopausal women


Pill in daily dose


May have a protective effect against breast cancer


May include hot flashes and blood clots in the veins

¹ Brand names included in this publication are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

For People With Osteoporosis: How to Find a Doctor

Isabel Johnson, age 64 years old, picked up a brochure on osteoporosis at her local pharmacy. What she read about the “silent disease” concerned her. She learned that she had several of the risk factors: she had gone through menopause at an early age, and her mother had suffered several fractures in her seventies and eighties.

Isabel called her neighbor, a registered nurse, who suggested that she discuss her concerns with a doctor. Isabel wondered how to find a doctor with expertise in osteoporosis.

For many people, finding a doctor who is knowledgeable about osteoporosis can be difficult. There is no physician specialty dedicated solely to osteoporosis, nor is there a certification program for health professionals who treat the disease. A variety of medical specialists treat people with osteoporosis, including internists, gynecologists, family physicians, endocrinologists, rheumatologists, physiatrists, orthopaedists, and geriatricians.

There are a number of ways to find a doctor who treats osteoporosis patients. If you have a primary care physician or a family doctor, discuss your concerns with him or her. Your doctor may treat the disease or be able to refer you to an osteoporosis specialist.

If you are enrolled in an HMO or managed care health plan, consult your assigned physician about osteoporosis. This doctor should be able to give you an appropriate referral.

If you do not have a personal physician or your doctor cannot help, you should contact your nearest university hospital or academic health center and ask for the department that cares for patients with osteoporosis. The department will vary from institution to institution. For example, in some facilities, the department of endocrinology or metabolic bone disease treats osteoporosis patients. In other medical centers, the appropriate department may be rheumatology, orthopedics, or gynecology. Some hospitals have a separate osteoporosis program or women’s clinic that treats osteoporosis patients.

Once you have identified a doctor, you may wish to ask whether the physician has specialized training in osteoporosis, how much of the practice is dedicated to osteoporosis, and whether he or she uses bone mass measurement.

Your own primary care doctor – whether an internist, orthopaedist, or gynecologist – is often the best person to treat you because she or he knows your medical history, your lifestyle, and your special needs.

Medical Specialists Who Treat Osteoporosis

After an initial assessment, it may be necessary to see an endocrinologist, a rheumatologist, or another specialist to exclude the possibility of an underlying disease that may contribute to osteoporosis:

Endocrinologists treat the endocrine system, which comprises the glands and hormones that help control the body’s metabolic activity. In addition to osteoporosis, endocrinologists also treat diabetes and diseases of the thyroid and pituitary glands.

Rheumatologists diagnose and treat diseases of the joints, muscles, bones, and tendons, including arthritis and collagen diseases.

Family physicians have a broad range of training that includes internal medicine, gynecology, and pediatrics. They place special emphasis on caring for an individual or family on a long-term, continuing basis.

Geriatricians are family physicians or internists who have received additional training on the aging process and the conditions and diseases that often occur among the elderly, including incontinence, falls, and dementia. Geriatricians often care for patients in nursing homes, the patient’s home, or in office or hospital settings.

Gynecologists diagnose and treat conditions of the female reproductive system and associated disorders. They often serve as primary care physicians for women and follow their patients’ reproductive health over time.

Internists are trained in general internal medicine. Internists diagnose and treat many diseases of the body. They provide long-term comprehensive care in the hospital and office, have expertise in many areas, and often act as consultants to other specialists.

Orthopaedic surgeons are physicians trained in the care of patients with musculoskeletal problems. Congenital skeletal malformations, bone fractures and infections, and metabolic problems are some of the conditions addressed by orthopaedists.

Physiatrists are physicians who specialize in physical medicine and rehabilitation. Physiatrists evaluate and treat patients with impairments, disabilities, or pain arising from various medical problems, including bone fractures. Physiatrists focus on restoring the physical, psychological, social, and vocational functioning of the individual.

Bone Health and Osteoporosis: A Guide for Asian Women Aged 50 and Older

When you think about your health, you probably do not think about your bones. But keeping your bones healthy and reducing your risk of fractures by preventing osteoporosis is very important throughout life and especially as you get older. Here is some important information to help you.

Risk Factors

Factors that increase your chances of having osteoporosis and fractures include:

* being Asian
* being female
* being older (50+ years)
* low body weight
* menopause or surgery to remove both ovaries prior to menopause (resulting in lower levels of the hormone estrogen)
* history of fracture as an adult
* close relative with history of fracture as an adult
* long-term low calcium intake
* inadequate physical activity
* current cigarette smoking
* alcoholism
* use of certain medications such as corticosteroids and anticonvulsants
* history of anorexia nervosa.

What Is Osteoporosis?

Osteoporosis is a disease that makes bones fragile and more likely to break. There are no symptoms to warn you. The first sign is usually a fracture that occurs after your bones have already become fragile. Fractures occur most often in the hip, spine, and wrist. Spinal fractures cause stooped posture, loss of height, and chronic back pain. Hip fractures, the most serious consequence of osteoporosis, can result in permanent disability and even death.

You can take steps to protect your bones in your older years. These include a good diet with plenty of calcium and vitamin D, a regular exercise program, a healthy lifestyle, and, sometimes, medication.

Calcium and Vitamin D

You need calcium to help maintain healthy, strong bones throughout your life. Adult women under age 50 need 1,000 mg (milligrams) of calcium every day. Over age 50, they need 1,200 mg of calcium every day.

Many Asian diets are low in calcium. Examples of foods that contain calcium in different amounts include:

* almonds
* bok choy
* broccoli
* calcium-fortified orange juice
* calcium-fortified soy milk
* calcium-fortified rice
* canned sardines with bones
* canned salmon with bones
* milk, yogurt, cheese, ice cream
* napa cabbage
* oysters
* sesame seeds
* soybeans
* tofu
* turnip leaves.

Many Asian Americans have trouble digesting milk products. This is called lactose intolerance. If you are lactose intolerant, here are some things you can do:

* eat dairy foods in small amounts spread out over the day
* eat more nondairy, calcium-rich foods
* take calcium supplements
* use lactase pills, which make milk products more digestible.

Vitamin D helps your body absorb calcium. You need 400 to 800 IU (International Units) of vitamin D every day. Most people get enough vitamin D from such sources as:

* 15 minutes of exposure to sunlight
* egg yolks
* saltwater fish
* fortified dairy products
* vitamin and mineral supplements.

Exercise

Physical activity is also important to prevent osteoporosis and reduce falls that can result in fractures. Weight-bearing activities can help you maintain strong bones. Examples include:

* walking
* climbing stairs
* dancing
* lifting weights.

Other kinds of exercise will help you increase your flexibility and improve your balance to prevent falls. Examples include:

* tai chi
* bike riding
* swimming.

Talk to your doctor about an exercise program that is safe for you. If you have low bone density or osteoporosis, you should protect your spine by avoiding exercises and activities that flex, bend, or twist your spine.

A Healthy Lifestyle

Smoking and drinking too much alcohol are bad for bones. To protect your bones, do not smoke, and if you drink alcoholic beverages, do so in moderation.

Bone Density Testing

If you are at high risk for osteoporosis, you may want to ask your doctor if a bone density test is right for you. This test will help your doctor decide if you need medication to reduce your risk of fractures.

Bone density tests are quick and painless. You usually do not need to get undressed. The most widely recognized test is called a dual-energy x-ray absorptiometry or DXA test, which measures bone density at the hip and spine. If you are 65 years old or older, Medicare may pay for your test. Ask your doctor for more information.

Treatment of Osteoporosis

If bone density testing indicates that you have low bone density or osteoporosis, your doctor may prescribe treatment that includes calcium and vitamin D, exercise, and medication. Medications approved by the U.S. Food and Drug Administration (FDA) include:

* bisphosphonate drugs: alendronate (Fosamax¹), risedronate (Actonel), and ibandronate (Boniva)
* calcitonin (Miacalcin)
* raloxifene (Evista), a Selective Estrogen Receptor Modulator
* teriparatide (Forteo), a form of the hormone known as PTH, which is secreted by the parathyroid glands
* estrogen therapy (also called hormone therapy when estrogen and another hormone, progestin, are combined).

These medications provide a variety of choices. Your doctor can help you find the one that is best for you.
¹ Brand names included in this fact sheet are provided as examples only, and their inclusion does not mean that these products are endorsed by the National Institutes of Health or any other Government agency. Also, if a particular brand name is not mentioned, this does not mean or imply that the product is unsatisfactory.

A New Way to Build Bone

The osteoblast cytoplasm is colored red in this transmission electron micrograph of a mature osteoblast on the bone surface.

Howard Hughes Medical Institute (HHMI) researchers at Stanford University have found that they can increase bone mass in mice by tweaking the shape of a regulatory protein.

HHMI investigator Gerald Crabtree and HHMI predoctoral fellow Monte Winslow report that slightly increasing the activity of a protein called NFATc1 causes massive bone accumulation, suggesting that NFATc1 or other proteins that regulate its activity will make good targets for drugs to treat osteoporosis. They report their findings in a study published in the June 6, 2006, issue of Developmental Cell.


“If you could find a small molecule that would flip 10 percent of the existing NFATc into the active form, you could favor the formation of osteoblasts and make stronger bones.”
Gerald R. Crabtree

In vertebrates, bone is constantly being formed and being broken down throughout life. Cells called osteoclasts continuously degrade bone, while cells called osteoblasts replenish it.

“Ideally, they are perfectly balanced,” said Crabtree, the senior author of the study. “Over the course of a lifetime, if everything goes well, we'll maintain almost exactly identical bone mass.” However, if the balance is upset, and more bone is destroyed than formed, osteoporosis results, increasing the risk of fractures.

The new study arose from the researchers' curiosity about reports that patients who were treated with the drug cyclosporine—often given to suppress the immune system before organ transplants—tend to lose bone mass. Those patients were also at increased risk of bone fractures, said first author Winslow, who led the study as an HHMI predoctoral fellow in Crabtree's lab. Winslow is now working as a postdoctoral fellow in the lab of HHMI investigator Tyler Jacks at the Massachusetts Institute of Technology.

Cyclosporine inhibits a signaling protein complex known as calcineurin, which chemically modifies the NFATc family of proteins. This modification changes its shape. With its new shape, NFATc can move into the nucleus of the cell, where it can trigger the activation of many genes. Although initially shown to regulate immune cell function, NFATc also functions in other cells to regulate heart development, blood vessel formation, neural development and function, and muscle development. Its function seems to depend on the time and place of its activation, like a context-sensitive key on a computer. In bone, it is NFATc1 that seems particularly important.

Since people with suppressed calcineurin/NFATc activity experience bone loss, Winslow, Crabtree, and their colleagues wanted to see whether this pathway would be important in bone development and function as well. They studied mutant mice in which the NFATc1 in osteoblasts had been modified so that it could move more easily to the nucleus and become a little more active than usual.

Mice with the hyperactive NFATc in their osteoblasts had an immense increase in bone mass compared to normal mice, suggesting that the balance between bone formation and breakdown had tipped.

When the researchers examined the cells in these mice, they found that up-regulating NFATc signaling in osteoblasts increased the numbers of both types of bone cells. “It was clear that increased NFATc activity in osteoblasts influenced both osteoblasts and osteoclasts,” Winslow said.

The researchers found that mice with enhanced NFATc activity in their osteoblasts had many more of these bone-forming cells, which explained the increase in bone mass. They also found a possible explanation for why there were more bone-destroying osteoclasts. Osteoblasts with hyperactive NFATc expressed higher levels of inflammatory proteins called chemokines, which promote osteoclast development.

“Osteoblasts produce factors that recruit the progenitors of osteoclasts, and so when osteoblast numbers go up, osteoclast numbers go up,” Crabtree said. This link between osteoblast and osteoclast numbers explains in part how the two types of cells normally stay balanced in animals, he added.

Mice with abnormally active NFATc probably develop so much bone mass because this delicate balance between osteoblasts and osteoclasts has been altered, Crabtree suggested. In the mutant mice, “there's also a huge increase in osteoclasts, but they never catch up,” he said. “The balance has been tipped.”

This imbalance between bone formation and degradation could potentially be recreated by drug treatments for osteoporosis, Crabtree said. Very little NFATc1 must be activated to build extra bone, Winslow noted, which means that it may be possible to up-regulate the calcineurin/NFATc pathway to promote bone formation without disturbing other organ systems that use this same pathway.

“The results were dramatic, yet the molecular alteration is very, very minimal,” Crabtree said. NFATc1 in the mice that developed extra bone mass was only 10 percent more active than it is in normal mice.

The researchers are now screening chemical libraries for small molecules that could increase NFATc just enough to promote bone formation in people with osteoporosis, without causing undesirable side effects. “If you could find a small molecule that would flip 10 percent of the existing NFATc into the active form,” Crabtree said, “you could favor the formation of osteoblasts and make stronger bones."

Bear Bones May Provide Key to Osteoporosis

Bears don’t go to Florida when the snow flies, but they get to do the next best thing: curl up in a den and sleep away the winter.

If people did this, according to the prevailing medical wisdom, we’d wake up in the spring with a colossal appetite and bones the texture of sugar cookies. Bears, however, seem to have a special mechanism that protects them from developing weak bones, even though they sometimes lay around for months at a time.

Dr. Seth Donahue, an assistant professor in Michigan Tech’s Department of Biomedical Engineering, has been trying to figure out how bears manage to avoid osteoporosis, despite their sedentary ways.

The answer may lie in their hormones.

As in humans, bear bone tissue does break down during inactivity. However, while human bones don't rebuild while their owners are inactive, bears seem to be able to recycle their calcium with almost total efficiency. Even mother bears, who give birth and nurse their cubs during winter hibernation, don't lose bone density.

Donahue made this discovery while a doctoral student at Pennsylvania State University, analyzing blood serum from radio-collared bears. The results were published in the journal “Clinical Orthopaedics and Related Research.”

He’s continuing his work at Michigan Tech, trying to determine which hormones—or other molecules—help bears resist osteoporosis. He is also studying the bones of black bears donated by Upper Peninsula hunters.

Donahue and graduate student Kristin Harvey have been taking small sections from bear leg bones and observing them under a microscope to see if, as bears age, the bones are becoming more porous, a sign of osteoporosis. They aren’t. Chemical analysis of the bones also shows that they aren’t losing minerals, which are essential for strength.

Lastly, they have also been subjecting small pieces of bone to varying degrees of mechanical pressure, to determine how much stress is required to cause a breakage. No matter what the bears’ age, their bones are remarkably strong.

“Their teeth have rings, like trees, so we know exactly how old they are,” Donahue said. “Our preliminary results suggest that their bone density and fracture strength remains high, even as they age.”

“Bears aren’t affected by these annual periods of disuse, while other species have negative consequences,” he said.

Donahue thinks the key to bone health in bears may be a hormone that regulates calcium uptake. “It’s possible that the bears’ hormone has just a couple of amino acids out of sequence,” he said. If that’s the case, then maybe it would be possible to produce that hormone synthetically and prescribe it to people suffering from osteoporosis.

“Now, we don't have a treatment that works,” he said. “A few therapies slow down bone loss, but nothing can recover bone that's already been lost.”

One hundred years ago, osteoporosis was rare. But now, as people routinely live into their 70s, 80s and longer, it can degrade the quality of life.

As we get older, broken bones can be slow to heal and can cause chronic pain. Plus, most elderly patients are ill equipped to handle the stress of surgical treatment, and as a result their lives can be shortened. Approximately 24 percent of individuals over age 50 die within a year following a hip fracture.

Plus, the cost of treating and caring for the victims of osteoporosis runs into the billions of dollars.

According to the National Osteoporosis Foundation, osteoporosis is responsible for more than 1.5 million fractures annually (300,000 hip fractures, 700,000 vertebral fractures, 250,000 wrist fractures and 300,000 fractures at other sites).

In 2001, an estimated $17 billion was spent on the care of patients with osteoporotic and associated fractures in hospitals and nursing homes. Public health officials expect all these figures to climb as the numbers of frail elderly rise.

Donahue plans to publish the results of his most-recent research soon. He’s hoping to garner funding to begin studying the calcium-regulating hormone in bears. The calcium-regulating hormones are proteins, and determining their structure is a complicated and expensive process.

But the study of bears’ unique resistance to osteoporosis shows unusual promise, he believes. “It’s a model that shows a lot of potential,” Donahue said. “It’s naturally occurring, so we already know it works.”

Ultimately, all we need to know is whether it could work as well in people as it does in bears.