My mother has just been diagnosed with osteoporosis. Her doctor said that her tests show she is at risk and that 84 percent of people have better bone density. She presently exercises daily and is active. There is no history in the family. Should she continue an active life with exercise? Should she change her schedule to a more sedate lifestyle? She is 62 years old.
Osteoporosis is a condition that has been generating increased interest during the past few years. In part this interest has been fueled by the realization that the consequences of aging on the bones are not inevitable and can be treated, or at least modified. In addition, the development of much better diagnostic tools, particularly the dual-photon absorptiometry (DPA) or dual-energy X-ray absorptiometry (DXA) tests. These tests allow the accurate determination of bone loss and permit comparison with a standard, usually taken as the bones of the average healthy 35-year-old woman (or man if a man is being tested).
Osteoporosis is a degenerative condition affecting both men and women, although women tend to get a more severe form earlier than men. The bone in osteoporosis becomes thinner, and under a microscope one can see that many of the tiny calcified spicules of bone have disappeared. This is not only due to inadequate calcium intake, although that can play a role, but is a complex process involving calcium, hormones, other diseases, medications, smoking and decreased weight bearing activity.
Normal bone is constantly being absorbed and rebuilt during our entire lifetime. The rates of these two processes are equal in a healthy young adult, and therefore the total amount of bone does not change. But changes in activity, such as bed rest or space flight (the astronauts get osteoporosis during their stays in space), changes in hormones such as loss of estrogen during menopause, hyperthyroidism, or excessive cortisone production, chronic inflammatory diseases, such as rheumatoid arthritis, other conditions, such as diabetes and alcoholism, and many drugs can contribute to loss of bone. Among drugs that can lead to osteoporosis are prednisone (greater than 7.5 mg per day), excessive doses of thyroid hormone replacement, methotrexate, and some anticonvulsants.
Women at menopause, whether natural or surgical, suffer a sudden drop in estrogen production, and this leads to much more rapid bone resorption and therefore, often osteoporosis. Men are relatively protected by testosterone which does not drop suddenly, but they can still develop osteoporosis, albeit usually at an older age than women.
The weakened bone leads to an increased risk of fracture, which is often seen in the vertebrae, where it literally leads to shortening of the person, and the kind of bowed forward posture known as dowager’s hump. Hip and arm fractures are also common and may occur with relatively little trauma. Osteoporosis is usually not painful and produces no symptoms until a fracture takes place. Women therefore are often totally unaware of it until they break a bone, at which point a major amount of bone has already been lost.
The mother of today’s writer has lost a substantial amount of bone and should be treated actively to prevent fractures. This should include a calcium supplement of at least 1500 mg per day, with a vitamin D supplement unless she gets a lot of sun exposure. An estrogen replacement like Premarin is indicated unless there is a reason that she cannot take it. She should not adopt a sedate lifestyle, but should continue weight bearing exercise, especially walking, which stimulates the continued formation of new bone. If she is taking prednisone or thyroid replacement the dosages should be carefully adjusted. Treatment with one of the new drugs for osteoporosis called bisphosphonates (Fosamax and others) should be considered if the other treatments are not effective, if she cannot take estrogen, if she is on prednisone, which cannot be stopped, or has another condition aggravating the osteoporosis, such as rheumatoid arthritis, which cannot be better treated. If estrogen is contraindicated for some reason or she prefers not to take it, the new drug raloxifene (Evista) will also protect the bones without affecting the breasts. It also does not increase the risk of cancer of the lining of the uterus, which is increased with estrogen alone.
The fact that the mother of our writer has no family history doesn’t mean much, since until recent years few people were diagnosed with osteoporosis. Of more significance would be a history in her mother’s mother of loss of height, stooping in old age, a hip or other fracture, or severe unexplained back pain (not sciatica, which is not very common as a complication of osteoporosis). Today’s writer should consider that she does have a family history of this disease, and should be taking calcium, 1000 mg per day until menopause and 1500 mg per day after. In fact, it is now recommended that all women, even without a family history or known risk factors should take calcium in the above doses. I would also suggest that the writer give very serious thought to hormone replacement therapy as soon as she enters menopause.