When Should I Worry About...

What Are the Signs of Osteoporosis & How Is It Diagnosed?

Jan. 3, 2024 - Katie McCallum

Slips and falls happen. So do other accidents that lead to broken bones. But when are such breaks simply the unfortunate result of chance and circumstance and when are they a sign that bones have become weaker than they should be?

"Osteoporosis occurs when significant bone loss leads to an increased susceptibility to broken bones, also called fractures," explains Dr. Laila Tabatabai, an endocrinologist at Houston Methodist.

It's a common problem, particularly in women. In fact, one in two women over the age of 50 will develop an osteoporotic fracture in their lifetime. The odds are better, one in four, for men over the age of 50. Hip fracture is a well-known example of a life-altering bone break that can threaten a person's independence. It can lead to significant medical complications and reduce quality of life, as well as increase post-fracture depression and anxiety.

"It's important to diagnose and address osteoporosis, since the highest risk of fracture is when bone density is actively decreasing," says Dr. Tabatabai. "If osteoporosis is detected early, there are several lifestyle and nutritional measures that can be taken to optimize bone health. Also, osteoporosis medications have come a long way, with fewer side effects and health risks than in the past."

How is osteoporosis diagnosed? And are there symptoms to be on the lookout for? Dr. Tabatabai explains everything you need to know about catching and correcting osteoporosis.

What is osteoporosis?

Functioning as the frame for organs, muscles and other tissues, your bones can seem like permanent, unchanging fixtures in your body. But that's not entirely the case. Bone is living tissue, and your body is constantly breaking down old bone and rebuilding new bone tissue. When it's broken down faster than it's made, bone loss occurs.

"Osteopenia is the precursor to osteoporosis," says Dr. Tabatabai. "However, fragility fractures can occur in patients with osteopenia or osteoporosis. This is because there are factors other than bone density that predict fracture risk, including age, frequency of falls, family history of hip fracture, smoking, heavy alcohol use and several others."

Ideally, the problem is caught at an early stage through osteoporosis screening, specifically a bone density test. Many lifestyle measures can be used to help stabilize bone density and prevent further bone loss. Otherwise, osteoporosis eventually develops. This is when bones become so thin, weak and brittle that they're more likely to break, even when only mildly stressed, like bending to pick up a bag of groceries or lifting a small child.

What factors increase the risk of osteoporosis?

A number of factors contribute to osteopenia and osteoporosis. For starters, bone growth naturally slows with age. The older you get, the more likely bone loss will occur. There are many other things that accelerate this loss, though.

The most significant of the osteoporosis causes is menopause — which is why the condition is more prevalent in women than men.

"Declining estrogen production can lead to bone loss at a rate of 1%-3% per year for the first five years after menopause," says Dr. Tabatabai. "This is really significant and why we recommend women have a bone density test around the time of menopause."

Men can develop osteoporosis, too, which is why it's important to recognize the other personal, medical and lifestyle factors that lead to it.

The risk factors of osteoporosis include:

  • Increasing age – the vast majority of people with osteoporosis are over the age of 50
  • Post-menopause – low estrogen levels lead to bone loss in women
  • Race – the condition is more common in white and Asian women
  • A small body frame or low body weight – like muscles, bones grow stronger when subjected to weight
  • Smoking and/or heavy alcohol consumption
  • Low testosterone in men – this sex hormone plays important roles in bone maintenance
  • Some medications – such as long-term steroid use after organ transplant
  • Certain health issues – examples include rheumatoid arthritis, cirrhosis of the liver, kidney disease and conditions or treatments that affect nutrient absorption (such as gastric bypass and celiac disease)

What are the osteoporosis symptoms to be aware of?

Unfortunately, there aren't any obvious symptoms of osteoporosis. It doesn't cause pain — until a broken bone occurs — which is why the condition can silently lurk in the body. Many people don't realize they have it until they suffer a break, like a broken wrist or hip fracture.

That's why Dr. Tabatabai stresses the importance of knowing the risk factors of osteoporosis and getting screened if your doctor recommends it.

There are sometimes warning signs of osteoporosis, though. They include:

  • Abnormal forward curvature in the upper spine – known as kyphosis, this occurs when osteoporosis leads to micro-compression fractures in the thoracic and lumbar spine, resulting in a permanent curvature at the shoulders and neck
  • Chronic lower back pain – occurs when osteoporosis leads to a vertebral compression fractures, which is typically caught during spinal imaging to investigate back pain that won't go away
  • Low-trauma fracture – also called a "fragility fracture," this is a broken bone sustained after falling from standing height or less and without any major trauma occurring

Both kyphosis and chronic lower back pain can have other causes, so a detailed workup is needed to determine whether these symptoms are caused by osteoporosis or something else. A fragility fracture, on the other hand, is diagnostic of osteoporosis — though the break will need to be correctly identified as a low-trauma fracture.

If you notice any of these signs or you have one or more or the risk factors listed above, ask your doctor if you might benefit from a bone density test.

Osteoporosis screening: Who should get a bone density test?

A bone density test, also referred to as a DXA scan, is the primary way of screening for, diagnosing and surveilling osteoporosis.

"It's a very low radiation X-ray test," says Dr. Tabatabai. "The patient lies down on an exam table with the help of the technician and the imaging portion lasts just a few minutes. Usually, the hips and spine are scanned during the X-ray, but sometimes we image the forearm as well."

A DXA scan measures bone mineral density, reported as what's called a T-score. The lower the number on the DXA report, the weaker the bones. Since the test itself is very operator-dependent, obtaining a high-quality DXA scan requires a facility where the DXA technician has undergone specialized training and certification.

"Given how common osteoporosis becomes as women age, we recommend that all women receive a DXA scan at the time of menopause or age 50, whichever comes first," says Dr. Tabatabai. "For men, the recommendation is to be screened around age 65, or earlier if risk factors of osteoporosis are present."

If DXA scan results are normal, no further testing is needed for five years — unless clinical circumstances change and your risk increases.

Osteoporosis self-care and when medications are needed

A DXA scan only takes a few minutes to complete and the results are immediate. Dr. Tabatabai says patients are often scheduled to speak with her right after the scan.

"We look at the numbers and, if they're in the range of osteopenia or osteoporosis, we discuss the steps needed to slow bone loss," says Dr. Tabatabai. "This includes lifestyle measures and calcium intake, but can also include prescription medications if osteoporosis is severe or fracture risk is significantly elevated."

The lifestyle measures that can help slow bone loss and prevent osteoporotic fractures include:

  • Doing weight-bearing exercises three to five days per week. Exercise performed while upright, such as resistance training, walking, elliptical or stair-climbing, helps preserve bone density. Swimming and biking don't, as body weight is supported by the water or bike.
  • Eating calcium-rich foods. Aim to get 1,000 mg of calcium per day from the food you eat. Good options include dairy (milk, yogurt, cheese, ice cream), as well as fortified plant based milks (almond, soy and oat milk) and calcium-fortified orange juice.
  • Supplementing when needed. You can supplement your dietary intake with up to 600 milligrams of calcium per day from a tablet, capsule or chewable, but only if you're not getting 1,000 milligrams of calcium per day from your diet.
  • Limiting alcohol consumption. Either avoiding alcohol altogether or limiting yourself to one drink per day.
  • Stopping smoking, if you smoke
  • Considering home safety. This includes ensuring rugs aren't tripping hazards, using anti-slip padding for rugs placed on wood or tile, installing grab bars in the shower and utilizing nighttime lighting.

"People often ask me whether they can improve their bone density numbers without medications and, by and large, I tell them to have modest expectations," says Dr. Tabatabai. "But even small improvements are helpful since the greatest risk of osteoporotic fracture comes when you're actively losing bone. If lifestyle measures are enough to get numbers stabilized, that's excellent news."

Medications are sometimes recommended to improve bone density, but not always. It's a complex decision that's very individualized, and Dr. Tabatabai encourages consulting a doctor with expertise in bone health to determine whether prescription medications are needed.

"Someone who's in their 50s and 60s and is really active but has early-stage osteoporosis might not need medications," says Dr. Tabatabai. "Whereas someone who's in their 70s or 80s with osteoporosis and other risk factors, balance issues or a higher fall risk will benefit from a bone builder or bone maintenance medication."

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