Osteoporosis Awareness and Treatment

By: Kristi Tough DeSapri, MD • Posted on May 23, 2016 • Updated April 22, 2020

May is Osteoporosis awareness month. However, awareness ALONE that osteoporosis affects 8 million US women and causes 2 million fractures per year will not solve this serious bone health condition.

Many women are surprised to learn that osteoporosis is a silent disease, meaning it causes no pain or symptoms until you sustain a bone fracture. And 1 in 2 women over the age of 50 will have a fracture in their lifetime. These fractures dramatically alter your current and future lifestyle. Sadly, 24% of patients over age 50 with hip fractures die in 1 year after their fracture. For many women with osteoporosis or osteopenia with high fracture risk, awareness is NOT enough. Awareness is nice, but treatment is what can save your life.

Screening Awareness

It is important to get a bone density screening (called DXA or dual-energy X-ray absorptiometry) to evaluate the bone strength at your spine and hip (and forearm in some women.) DXA is a painless, low radiation scan done at a doctor’s office or hospital. It is recommend in women age 65 and older or any postmenopausal female with risk factors of low bone mass. These risk factors usually contribute to weaker bone density or less peak bone mass. Examples of risk factors include:

• Being underweight
• Having a family history of osteoporosis or hip fracture
• Being a smoker/or former smoker
• Having certain conditions such as rheumatoid arthritis, lupus or bowel disease such as Crohn’s or Ulcerative colitis.

Certain medications can affect bone density such as taking the following medications:

• Oral steroids (prednisone 7.5 mg daily for more than 3 months)
• Aromatase inhibitors in breast cancer survivors (such as Arimidex, Aromacin, or Femara)
• Prolonged use of proton pump inhibitors for acid reflux (such as Prilosec, Nexium)
• Common anti-depressant, anti-anxiety, anti-PMS medications like Prozac (fluoxetine), Zoloft (sertraline), Celexa (citalopram), Lexapro (escitolopram) and others.

If you’ve appropriately had a DXA and reviewed your results with your physician, good for you! You need to have an understanding of your bone density and more importantly an awareness about your risk of bone breakage (fracture).

Treatment Awareness

For many women, the results uncover osteoporosis or osteopenia/ low bone mass. If you have osteopenia, your doctor will calculate a risk score called FRAX score to stratify your risk of fracture. If this score is elevated, you should discuss treatment and prevention of osteoporosis.

If you have sustained a low trauma so-called fragility fracture (i.e. fracture of wrist, forearm, leg, ankle, shoulder) from a standing height, then you already have clinical osteoporosis. A fracture that results from slipping on ice or tripping on carpet is also an osteoporotic fracture. If untreated, studies show women who’ve fractured are 4-6 X more likely to have another osteoporotic fracture!

Are you losing height? If you’ve lost more than 2 inches since your young adult height (or more than 1 inch/year after being measured by a professional) you may have sustained a vertebral (spine) fracture. Again, awareness is nice, but treatment may save your life as well as prevent a future fracture.

Work-Up

An educated discussion with a bone specialist (women’s health specialist, gynecologist, endocrinologist, or rheumatologist) will focus on your individual evaluation and treatment. Many experts and the National Osteoporosis Foundation recommend the following screenings to ensure a thorough evaluation and correc treatment to reverse bone loss:

1. screening 25-OH vitamin D level
2. parathyroid hormone
3. serum protein electrophoresis
4. calcium
5. electrolytes
6. 24-hour urine calcium (and sometimes cortisol) collection

Lifestyle and Medical Treatment

In addition, doing a combination of regular balance and weight bearing (brisk walking, jogging) exercise is important for maintaining bone density. Could your balance be better? Ask your doctor about physical therapy to improve posture and balance, and prevent falls.

Thankfully, we have panoply of safe, highly effective FDA-approved osteoporosis medications. And stay tuned, as there are more promising drugs in development. Will calcium and vitamin D alone treat osteoporosis? The answer is NO. Calcium and vitamin D are NECESSARY, but not always SUFFICIENT to treat bone loss.

There is no vitamin or herbal product ALONE that will significantly reverse bone loss. However, calcium and vitamin D are important foundations for all persons of all ages to ensure normal strength and bone development.

Individualized Osteoporosis Treatment Plans

Here are some simple counseling points I use in my comprehensive bone center in Chicago to individualize an osteoporosis treatment plan:

1. Oral bisphosphonates: Fosamax (Alendronate), Actonel or Atelvia (Risendronate), Boniva (Ibandronate0

Pros

1. Simple, oral dosing.
2. Many generics, very affordable.
3. FDA approved in 1990s, solid safety data.
4. Can be used 5-10 plus years.

Cons

1. May worsen or induce esophageal reflux.
2. Must remember to take at scheduled interval or it does not work.
3. Not effective in people with intestinal or gastric bypass surgery.

2. Intravenous bisphosphonates: Reclast (Zoledronic acid)

Pros

1. Once yearly 15-20 minute infusion.
2. Now generic.
3. Highly effective.
4. Can be used 3-6 plusyears.

Cons

1. IV must be placed.
2. 15% patients develop flu like reaction, can remedy with Tylenol/Advil/hydration and normal levels of vitamin D PRE-infusion.

3. Selective Estrogen Receptor Modulator: Evista (Raloxifene)

Pros

1. Daily pill.
2. Prevents/treats osteoporosis AND decreases risk of diagnosis of estrogen receptor breast cancer by 50% if taken for 5 years.
3. Excellent choice for women with strong family history of breast cancer.

Cons

1. Does not decrease hip fracture risk.
2. Small risk of blood clots in legs (Deep Venous Thrombosis) or lungs (Pulmonary Embolus)

4. Estrogen combined with Selective Estrogen Receptor Modulator: Duavee(Conjugated Estrogen/Bazedoxifene)

Pros

1. Daily pill
2. Duavee treats menopausal symptoms, vaginal dryness and is approved to manage Osteoporosis as the Bazedoxifene has additional bone effects which also protect the uterus and has a low side effect profile (link to 2 columns that mention Duavee)

Cons

1. Small risk of blood clots in legs (Deep Venous Thrombosis) or lungs (Pulmonary Embolus)

5. Subcutaneous human monoclonal antibody: Prolia (Denusomab)

Pros

1. Twice yearly injection (like a vaccine) in lower abdomen or arm, given at your doctor’s office.
2. Highly effective.

Cons

1. Usually reserved for women at highest risk for fracture OR if you have intolerance to another osteoporotic treatment.

6. Anabolic bone builder/ Forteo(teriparatide)

Pros

1. Daily, small self injection to abdomen (with very small syringe)
2. The only FDA approved medication for building new bone.
3. Usually reserved for women at highest risk of fracture based on daily injection and expense.

Cons

1. Used for 2 years and then followed by another treatment to maintain bone you’ve built.
2. Cannot be used in persons with Paget’s disease or those who have had radiation.

Additionally, it is well documented that hormone therapy (oral and transdermal at standard doses) with or without the new tissue selective estrogen complex (TSEC, that pairs estrogen and bazedoxifene, Duavee) will prevent progression to osteoporosis.

Women with menopausal symptoms of hot flashes, night sweats, severe vaginal dryness or painful intercourse who have mild to moderate bone loss are excellent candidates for these medicines which will treat all their menopausal symptoms and prevent fractures. Midlife without hot flashes and broken bones is the goal!

BOTTOM LINE: Treat Your Bones

Osteoporosis is a silent disease. In women, the incidence of fractures is more than breast cancer, stroke and heart attack combined. Please obtain and review your DXA with a doctor. If you have osteoporosis, osteopenia with high risk for fracture OR have previously sustained a non-traumatic, fagility fracture, see a bone specialist for an evaluation and treatment discussion plan.

There are so many effective options to prevent a primary or secondary fracture and keep your bones strong. Remember awareness is nice, but treatment will save your life and allow you an active fracture-free lifestyle!

Be Strong. Be Healthy. Be in Charge!

-Kristi Tough DeSapri, MD

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