For many women, osteoporosis comes as a complete surprise. One day they slip and fall from standing height, pick up a heavy object, or even cough and suddenly a bone breaks, leaving them in pain and ending their independence. For one of the endocrinologists at Anzara Health, the toll of osteoporosis hits close to home and close to the heart.
Osteoporosis: A mother and daughter’s struggle
Despite medical training, when someone you love is in danger, the news still comes as a shock.
“Mom fell and she can’t move,” my brother said on the other end of the phone. “She’s in excruciating pain. What should we do?”
I leaned into my medical training and began assessing the situation. What were her symptoms? Where was the pain located? What had happened specifically?
“She was just lifting her suitcase and then she doubled over,” my brother explained.
I absorbed this news, knowing what it likely meant, then rushed to contact former colleagues at an area hospital. I told them that my mom was inbound to their emergency department.
By this point, adrenaline had begun to take hold. But all the while the part of me that will forever be my mother’s daughter was wondering, how much pain is she in? And how do I take away the pain?
Ultimately, the source of my mother’s pain was common and tragic—one that endocrinologists like me strive to avoid. My mother is 65, fit, healthy, and before this difficult day had no medical history. But hiding in her bones was a problem: osteoporosis.
The day my brother called, she had broken her back lifting a 50-pound suitcase at the airport. Then several months later, a simple slip-and-fall from standing height left her with a broken pelvis. My mother—and so many women like her—was fit, active, and had no toxic habits. But the silent disease of osteoporosis robbed her of her mobility and independence.
– Dr. Sarah Musleh
Osteoporosis: The silent disease
Like Dr. Musleh’s mother, many people who have osteoporosis are unaware that they have the disease until they break a bone. Bone mineral density decreases along with bone mass in osteoporosis. Consequently, weakened bones are more susceptible to fractures (breaks).1Osteoporosis. Overview, Symptoms, & Causes. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Updated December 2022. Accessed January 26, 2023.
Osteoporosis can lead to vertebral fractures (broken spinal bones). It can also cause a person to lose height, or change the shape of their spine. What would be a minor fall from standing for a person with healthy bones can be devastating for a person with osteoporosis. So can simple movements like lifting, bending, or even coughing.2Osteoporosis. Overview, Symptoms, & Causes. National Institute of Arthritis and Musculoskeletal and Skin Diseases. Updated December 2022. Accessed January 26, 2023.
Who’s at risk for osteoporosis?
The CDC estimates that 18.8% of women over the age of 50 have osteoporosis of the femur neck or lumbar spine. By comparison, only 4.2% of men of the same age have osteoporosis in those bones.3Osteoporosis. Centers for Disease Control and Prevention. Updated November 4, 2022. Accessed January 26, 2023.
In addition to being female, the risk factors for osteoporosis tend to fall into three categories: modifiable risks (meaning they can be addressed through behavior change), non-modifiable risks (meaning they cannot be addressed through behavior change) and secondary causes, which are usually related to other conditions.4Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049.
Modifiable risk factors include:5Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049.
- Stress
- Air pollution
- Problems with absorbing nutrition
- Drinking alcohol
- Smoking cigarettes
- Weight loss
Another common modifiable osteoporosis risk factor is sedentary living, especially in childhood. For example, one study demonstrated that children who spent more time doing moderate and high intensity activity had better bone mineral content and bone mineral density.6Heidemann M, Mølgaard C, Husby S, et al. The intensity of physical activity influences bone mineral accrual in childhood: the childhood health, activity and motor performance school (The CHAMPS) study, Denmark. BMC Pediatr. 2013;13(1):32. A second study showed that the more screen time a child had, the more likely the strength and health of their bones would suffer.7de Lamas C, Sánchez-Pintos P, José de Castro M, Sáenz de Pipaon M, Couce ML. Screen time and bone status in children and adolescents: A systematic review. Front Pediatr. 2021;9:675214.
Nutrition deficiencies are another modifiable osteoporosis risk that begins in childhood. It’s well demonstrated that childhood dietary deficiencies in calcium, vitamin D, and protein can contribute to osteoporosis later in life.8Kostecka M. The role of healthy diet in the prevention of osteoporosis in perimenopausal period. Pak J Med Sci. 2014;30(4). Women tend to reach peak bone density around age 22, and men tend to reach it around age 26. Depriving bones of these essential nutrients, minerals, and hormones during critical developmental years can result in bones that never reach their maximum density.9Lu J, Shin Y, Yen MS, Sun SS. Peak bone mass and patterns of change in total bone mineral density and bone mineral contents from childhood into young adulthood. Journal of Clinical Densitometry. 2016;19(2):180-191.
While people can address the aforementioned risk factors with diet and exercise, other risk osteoporosis factors are outside of our control. Common non-modifiable risks include:10Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049.
- Having a history of falls
- Family history of osteoporosis
- Aging
- White ethnicity
- Having a prior facture
Finally, secondary causes of osteoporosis can include chronic conditions, such as cardiovascular disease,11Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049. kidney disease,12Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049. liver disease,13Handzlik-Orlik G, Holecki M, Wilczyński K, Duława J. Osteoporosis in liver disease: pathogenesis and management. Therapeutic Advances in Endocrinology. 2016;7(3):128-135. or diabetes.14Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049. Vitamin D deficiency can also contribute,15Pouresmaeili F, Kamalidehghan B, Kamarehei M, Goh YM. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018;14:2029-2049. as can taking certain medications, such as certain corticosteroids, proton pump inhibitors, antiepileptic drugs, SSRIs, aromatase inhibitors, certain hormone therapies, thiazolidinediones, calcineurin inhibitors, anticoagulants, certain chemotherapy drugs, and certain types of birth control.16Panday K, Gona A, Humphrey MB. Medication-induced osteoporosis: screening and treatment strategies. Therapeutic Advances in Musculoskeletal. 2014;6(5):185-202.
Menopause and osteoporosis
Aging is also something that’s outside of our control. And for females, menopause accompanies aging. This transition has marked implications for bone health. After menopause, the rate of bone loss in women increases, along with chances of developing osteoporosis. Women can experience as much as 20% bone loss during this time.17Menopause and bone loss. Endocrine society. Updated January 24, 2022. Accessed January 31, 2023.
This bone loss stems from estrogen deficiency. When a woman transitions into menopause, estrogen levels dip.18Ji M, Yu Q. Primary osteoporosis in postmenopausal women. Chronic Diseases and Translational Medicine. 2015;1(1):9-13. Declining estrogen accelerates the bone-remodeling process, part of which is bone resorption. During resorption, old bone is broken down and its minerals are used to create new bone.19Hadjidakis DJ, Androulakis II. Bone remodeling. Annals of the New York Academy of Sciences. 2006;1092(1):385-396., 20Rowe P, Koller A, Sharma S. Physiology, Bone Remodeling. StatPearls. Updated January 27, 2022. Accessed January 31, 2023.
While new bone production is still happening during menopause, it falls behind the resorption process. In other words, bone is broken down, but not replaced quickly enough. This in turn leads to weakness of the porous structures beneath the surface of the bones. And when these structures become weak, a person is more prone to fractures of the spine, hips, or wrist, sometimes with minimal force.21Rowe P, Koller A, Sharma S. Physiology, Bone Remodeling. StatPearls. Updated January 27, 2022. Accessed January 31, 2023.
When a woman begins menopause also has implications for bone health. One study found that menopause before the age of 47 leads to an increased risk of fractures and osteoporosis at age 77.22Svejme O, Ahlborg H, Nilsson JÅ, Karlsson M. Early menopause and risk of osteoporosis, fracture and mortality: a 34-year prospective observational study in 390 women: Early menopause and osteoporosis, fracture and mortality. BJOG: An International Journal of Obstetrics & Gynaecology. 2012;119(7):810-816. Another study echoed these findings, concluding that osteoporosis accompanies several long-term health risks associated with early menopause.23Shuster LT, Rhodes DJ, Gostout BS, Grossardt BR, Rocca WA. Premature menopause or early menopause: Long-term health consequences. Maturitas. 2010;65(2):161-166.
How Anzara Health endocrinologists treat osteoporosis
While the risks of osteoporosis are serious, they can be managed. The process begins with proper screening. The U.S. Preventive Services Task Force recommends that all women who are 65 and older receive bone measurement testing. Postmenopausal women younger than 65 should also be screened.24Osteoporosis to prevent fractures: Screening. Final recommendation statement. U.S. Preventive Services Task Force. June 26, 2018.
At Anzara Health, we will also check your calcium, magnesium, and vitamin D levels, as well as check liver, thyroid, kidney, and parathyroid function in addition to performing bone-density scans. In men, we assess testosterone levels, which have implications for bone health. Finally, we screen all patients for bone marrow disorders, such as multiple myeloma, which can affect bone strength, contributing to fractures.
If we detect osteoporosis, prescription medications may be a treatment option. Typically, these medications are taken orally in pill form, or subcutaneously as an intravenous injection. Some injections are daily. Others are administered every six months or annually. All are administered for varying lengths of time. Every medication has pros and cons. We take the time to discuss these pros and cons with patients so that they can make an informed decision.
Nutrition is also an essential part of how we treat osteoporosis. First, we carefully assess our patients’ diets to make sure they are consuming an adequate amount of calcium. Our target is 1,200 mg daily, with a maximum of 1,500 mg daily. Dairy products, such as milk, cheese, and yogurt are the most abundant sources of calcium. But green leafy vegetables, nuts, and seeds are also good sources.
Finally, the other major component of osteoporosis care and prevention is physical activity. Put simply, the more active a person is, the better their balance tends to be, and the less likely they are to fall. And if they don’t fall, they don’t break bones.
We like to see our patients perform a mix of aerobic and resistance training. Aerobic exercise can include walking, dancing, swimming, or cycling. For resistance training, we recommend light, weight-bearing training. This can include body weight exercises, or work with resistance bands or light dumbbells. We recommend three sessions of resistance training weekly, along with two to four cardio sessions.
Osteoporosis: A cautionary tale
Ultimately, we want Dr. Musleh’s mother’s ordeal to be a cautionary tale for all women. Osteoporosis is a stealth disease that’s often decades in the making.
As such, preventing osteoporosis is a long-term commitment. It begins early in life with adherence to an active lifestyle and a nutritious, calcium-rich diet. And as we age, it morphs into a commitment to those healthy habits, as well as routine screening.
The commitment is well worth it. Unfortunately, osteoporosis is not something physicians can treat once and cure. Once it’s discovered, the fight against osteoporosis becomes a long-term, ongoing battle. And tragically, it can lead to loss of independence, loss of mobility, and chronic pain—pain that any daughter would gladly spare their mother.
