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X-Rays

Osteoporosis and
osteopenia

Let's start off with some definitions

Osteoporosis is a chronic health condition where bones become weaker and more prone to breaks and fractures.

Osteopenia is where there is a loss of bone mineral density but not enough to meet the criteria used to diagnose osteoporosis.

So, in terms of the progression of this condition of reduced bone mineral density (BMD), we tend to see:

Normal --> Osteopenia --> Osteoporosis

Image below reproduced under the terms of the 'Creative Commons Attribution' for Open Access content.

The numbers in the diagramme are from a DEXA/DXA scan - more about this below.

All well and good so far. But how does this happen? Lets investigate a bit further, initially looking at how bones are made, then considering a bit of detail, firstly on osteoporosis.

How bones are made - the scientific bit

Feel free to ignore this bit if you want after the first paragraph, which is the really important bit. 

 

Bones are tissue and they are constantly being remodelled – broken down and rebuilt. Around 5% of our bones are being remodelled at any time. This involves cells called osteoclasts, osteoblasts and osteocytes. 

 

Here is a very simplistic description of how these cells work. Imagine they are a team of workers on a construction site: the osteocytes are the supervisors who tell the osteoblasts (the bricklayers) to get building when they sense that bones (or walls) are under stress or slightly damaged and go through cell death (start to fall down). Meanwhile the osteoclasts (the cleaning squad) are already on the site to clear the damaged or broken walls away – they have already spotted the problems and they are there with their buckets and brooms to clear away the dead cells (walls) so that the new ones can be built. 

 

Normally this cleaning up and building are balanced – for all the bits of bones/walls that are cleared away by osteoclasts, there are new bits of bones/walls built by osteoblasts. The problems of osteoporosis begin when there is more clearing away activity than there is building activity, i.e., the osteoclasts are beavering away clearing unwanted debris, but the osteoblasts are on a bit of a go-slow and not rebuilding as quickly as the osteoclasts are clearing away. This can be for a variety of reasons (we come to this a bit later on). 

 

That’s the very basic overview of how bones are remodelled and what happens when the process goes wrong. There is a lot more involved in it, but this basic understanding might help you get your head around the process. Let’s move onto look into osteoporosis in a bit more detail. 

Understanding Osteoporosis

Developing osteoporosis isn’t an overnight event. Generally, we start to lose bone mineral density from our late 20s to early/mid-30s, with women experiencing an acceleration of the loss after menopause, either natural or early/surgical.  In osteoporosis, bones become weakened very quietly and silently with no pain or other symptoms. This leaves them susceptible to breaks or fractures. When the condition has become more severe, then mishaps like a simple fall or even something as trivial as a cough or sneeze, can lead to painful breaks in areas like the wrist, hip, spine, arm and pelvis. 

Pain is not a common symptom of osteoporosis unless there is a fracture. Pain may also be caused by conditions like osteoarthritis. Sometimes certain postural changes like kyphosis (or a significant rounding of the upper back, often called a Dowager’s Hump) can signal the presence of osteoporosis before a diagnosis has been made.

Occasionally tiny fractures can go undetected until a larger break happens. Below are some symptoms of a possible fracture:

  • A visibly out-of-place or misshapen limb or joint.

  • Swelling, bruising, or bleeding.

  • Intense pain. 

  • Numbness and tingling.

  • Broken skin with bone protruding.

  • Limited mobility or inability to move a limb or put weight on the leg.

If you get any of these symptoms, go straight to the nearest hospital emergency unit.

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Osteoporosis: a journey through 4 stages

I know that you’re thinking “Hang on a minute – didn’t you say that there are 3 stages?” Well, yes, sort of. There are 3 stages that we recognise and then there’s another one that we can add to the end. That’s the one we want to try to avoid by adopting good habits now. 

 

For clarification, here they are:

  1. Stage 1: Strong Foundations (aka ‘normal’). Healthy, balanced bones.

  2. Stage 2: Osteopenia. A decrease in bone density, a silent alarm. 

  3. Stage 3: Osteoporosis. Porous, weaker bones with a higher fracture risk.

  4. Stage 4: Severe Osteoporosis. Critically low bone density, usually with frequent fractures.

5 warning signs of osteoporosis

Let’s have a closer look. Osteoporosis is usually unnoticed and unsuspected until we have a fracture, particularly from a seemingly innocent incident. Here are some clues that all may not be well with your bone density:

  1. Unexpected fractures – the sudden appearance of fractures in places like the hip, spine or wrist.

  2. The shrinking effect – a gradual loss of height and a slightly stooped posture 

  3. Pain in the back – chronic or sudden back pain signalling a hidden fracture

  4. Dowager’s Hump – a visible bent or stooped posture

  5. Subtle signs – brittle nails and weakened grip strength. 

With vigilance and, if possible, regular screenings, you can catch this early. The earlier you get a diagnosis – be it osteoporosis or osteopenia – the earlier you can start to change things. 

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Loss of bone density is a natural part of ageing, but for some this process speeds up leading to osteoporosis and a possible susceptibility to fractures. From women experiencing early menopause through to young people, no one is completely immune – yes, men can get osteoporosis too. Numerous risk factors might be hiding in your lifestyle:

  • Long-term steroid use.

  • Family history – were either of your parents diagnosed with osteoporosis?

  • Certain medications which can weaken your bones, see below.

  • Eating disorders like anorexia or bulimia which cause a lack of absorption of nutrients.

  • Lifestyle traps like very little exercise, heavy use of alcohol, or smoking.

What makes our bones fragile?

What medications can lead to bone loss?

There are certain times in our life when we, unfortunately, have an illness that requires medication, and that medication may have a side effect of making our bones a bit thinner. 

Drug-induced osteoporosis is a significant health problem and some doctors may be unaware that many commonly prescribed medications contribute to bone loss and fractures. 

Here are some medications, with just a couple of examples for each:

  • glucocorticoids e.g., prednisone or cortisone

  • proton pump inhibitors e.g., omeprazole or lansoprazole 

  • selective serotonin receptor inhibitors, e.g., citalopram or fluoxetine

  • anticonvulsants e.g., sodium valproate or carbamazepine

  • medroxyprogesterone acetate e.g., Provera 

  • aromatase inhibitors, e.g., anastrozole or letrozole

  • androgen deprivation therapy, e.g., bicalutamide or flutamide

  • heparin anticonvulsants, e.g., bemiparin sodium or dalteparin sodium

  • calcineurin inhibitors, e.g., tacrolimus or pimecrolimus creams

  • some chemotherapies which have adverse effects on bone health. 

 

Additionally, patients may be treated with combinations of these medications, which may heighten the harmful side-effects of these drugs. If you have ever had to take any of these medications, please consider asking your doctor if you can have a DEXA scan to check how your bones are at the moment. If you’d rather not do this, that’s completely understandable, but you might want to start taking measures to support your bones, just in case. 

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Diagnosing osteoporosis and osteopenia

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Dual Energy X-ray Absorptiometry - DEXA or DXA

Diagnosis is usually made using a DXA or DEXA scan. Special detectors in the DEXA machine measure how much radiation passes through your bones and sends this data to a computer. Generally, the bones scanned are the lumbar spine (the blue bit on the picture below), hips or wrists.

In order to understand this easier, imagine going into a curtained room on a sunny day – if the curtains on the window are thick, not much light will get into the room. However, if they are thin, maybe even lacy, much more light will come through. 

Your bone density measurements are compared with that of a young healthy adult, usually aged around30 – this is the T-score. Your scan printout will also show your Z-score, which is a comparison with an adult of your own age, gender and ethnicity. 

Don’t be afraid to ask your doctor for a printout of the scan so that you have your own copy of all the results, of which machine the scan was carried out on and the name of the operator. This is all useful information for follow-up scans, which should ideally be carried out using the same machine and by the same operator. In the UK, women over 65, or younger if at high risk, may be encouraged to have a DXA scan as part of the NHS’s preventative measures.

This little graphic shows the range of numbers that make up the T-score. This is your bones in comparison with a young adult of the same gender. So, anything above -1.0 is normal bone density. Between -1.0 and -2.5 is reduced bone mass, i.e., osteopenia and -2.5 and below is osteoporosis. The lower the number below -2.5, the more severe the osteoporosis is and the less dense your bones are. 

FRAX

Certain tools like FRAX or Q-Fracture are also used to expand on the DEXA diagnosis. The FRAX tool, developed by the University of Sheffield in England, evaluates the fracture risk of individuals. You can find more about it, and use their calculation tool here:

https://frax.shef.ac.uk/FRAX/ 

REMS or EchoS

There is a newer type of scan available for diagnosis of osteoporosis and osteopenia. It is called a Radiofrequency Echographic Multispectrometry - REMS or EchoS for short. It is a radiation-free, diagnostic device but currently is only offered privately and is not recognised by the NHS. A company in the UK that offers this scan is Osteoscan UK. You can find their website here:

https://www.osteoscanuk.com/

Don't Panic!

One thing to remember at this stage can be summed up in the words of Corporal Jones from Dad’s Army (you need to be of a certain age for that reference to work) – “Don’t panic”! The FRAX tool is based on thousands of people across the world and it allows for differences in where people live. It shows the 10-year probability of fracture, but it is not an absolute. There are some things that you cannot change – gender, family history, medications taken in the past – but there are also lots of factors that you can change now to help you and to maybe even reduce your FRAX score. 

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Managing and treating osteoporosis

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After diagnosis, you may experience a range of emotions, which may include fear, perhaps a sense of helplessness or doom and, understandably, asking the question “Why me”? 

When I was diagnosed, I went through fear, anger, despair and then decided to find out everything I could about the condition so that I could work out a plan to try to deal with it. I’m fortunate in that I’ve not had any broken bones, which reduces my risk slightly. We can fight osteoporosis with a strategy tailored to our age, gender and bone density. Nutrition and lifestyle changes may well make a difference. 

Managing osteoporosis is a multi-faceted activity, and includes: 

  • Diet and nutrition: Including vitamins like vitamin D, vitamin K2 and minerals like calcium and magnesium in our diet can help, as well as getting sufficient protein. Reducing sugar may help. In some cases we have to supplement with certain nutrients that we simply cannot get from diet alone. However, we must get levels tested before starting any supplementation over the recommended daily level, especially vitamin D.

  • Exercise: Regular specific weight-bearing exercise with great posture is crucial. Building muscles helps put our bones under very slight stress and that stress helps bones to strengthen and grow. Working on our leg strength helps with balance, which is vital to help balance and reduce the possibility of falls and broken bones. 

  • Lifestyle changes: Prioritise sleep and lessening/managing stress where possible. Try to have fun – laughter is a great medicine!

  • Regular monitoring: Work with your doctor to establish your starting point. You can also work with a nutritional therapist to check that your digestive system is working as well as possible so that your body is absorbing the nutrients you are eating and your nervous system is working well to improve sleep and stress management. 

  • Fall prevention, including improving balance: There are studies that show exercises like Qigong and Tai Chi can be beneficial in this regard. Also, take measures to make certain your home environment is fall-proofed as much as you can (see below). 

  • Medication and, if necessary, pain management: Again, work with your doctor to make certain you are taking the best possible medication for you, including if you have to deal with pain from a fracture.

Everyday living

Have a look around your home. Are there trip hazards, rugs not anchored down, furniture that you have to move regularly, steps that aren’t easy to see, perhaps areas that are dimly lit? Any of these can provide a challenge for balance. Also consider your sight and vision, and get your hearing and eyesight checked regularly.

Understanding osteopenia

Osteopenia is the silent early alarm in your skeletal system that signals a decrease in bone mass. Often this weakening of bones begins as an unnoticeable aspect of ageing – you know, it’s that change that we assume is simply part of getting older, so we ignore it, but your bones may be getting more brittle due to calcium loss! Osteopenia is a stealthy condition that, depending on nutrition and lifestyle, may progress to the more severe condition of osteoporosis and an increased risk of fractures. Osteopenia is a bit like a quiet storm, brewing on the horizon without warning, yet with potentially serious consequences.

Our bones reach their height of density in our late 20s/early 30s, after which bone mineral density decreases a little each year. Could you be at risk? 

Causes of osteopenia

The causes of osteopenia are exactly the same as those for osteoporosis. It’s just that osteopenia is a staging post on the journey from normal bone density to osteoporosis bone density. Osteopenia is a story of balance, growth, and loss within the framework of our bones.

In osteopenia, women who have undergone surgical removal of ovaries or early menopause are particularly susceptible, although certain medications taken to support their hormones after early menopause may reduce the risk. Caucasian or Asian ancestry also plays a role, making osteopenia a complex and multi-faceted issue. 

Just to reiterate (in case you rushed past osteoporosis to check out reasons for osteopenia), here are some risk factors and causes:

  • Ageing – as we age, bone mineral density decreases and bone health suffers.

  • Hormonal changes – menopause can speed up bone loss. This is important for all women, but especially for anyone going through an earlier menopause, either natural or surgically induced. The sad fact is that women lose bone mass faster than men and this is partly down to reduced oestrogen after menopause.

  • Long-term (e.g., longer than 3 months) steroid use, e.g., corticosteroids, which are an integral part of many chemotherapy treatment protocols, or glucocorticoids. 

  • Family history/genetic factors – were either of your parents diagnosed with osteoporosis?

  • Certain medical conditions, treatments and medications which can weaken your bones.

  • Eating disorders like anorexia or bulimia which cause a lack of absorption of nutrients.

  • Lifestyle traps like very little exercise, heavy use of alcohol, or smoking.

 

The good news is that it’s not an absolute that we will progress inevitably from normal bones, through osteopenia to osteoporosis – depending on current nutrition and lifestyle, and the ability and desire to make changes, there is still a possibility of slowing down or halting deterioration. 

Diagnosis of osteopenia

Osteopenia is diagnosed in the same way as osteoporosis – predominantly by a DXA scan. However, you may need to push to get your doctor to agree to this if you have no history of fracture, no family history of osteoporosis, or any other symptoms.

If you really want to do the best for your own bone health, then try to get a bone scan when you are in your late 20s/early30s so that you know the highest levels of your bone density and can monitor it from there. This is particularly important if you have any other health issues, especially if they mean that you have to take any of the medications shown above (What medications can lead to bone loss).

Preventing and avoiding osteopenia

Prevention isn't always in our control, but understanding and monitoring the factors that contribute to osteopenia might help mitigate its progression. From recognising risk factors based on gender, ethnicity, and age, to maintaining an ongoing dialogue with healthcare providers, you can equip yourself to guard against this silent thief of bone strength.

Unlocking strategies to deal with osteopenia

  • Nutrition and dietary changes: Fortify your diet with nutrients, including calcium, magnesium, vitamin D and vitamin K2. Remember that it’s always best to get nutrients from food first, only supplement if we can’t get enough of a nutrient through diet. For instance, in some areas, it’s impossible to get vitamin D from the sun for part of the year – in this case, supplementation may be required, depending on your existing levels.

  • Regular exercise: Strengthen your bones with weight-bearing exercises. Be careful, though, and find a trainer who knows about good posture for osteopenia and osteoporosis.

  • Reduce stress where possible: have some fun, laugh with friends, watch daft movies or TV programmes.

  • Avoid tobacco and limit alcohol: Preserve your bones by reducing, and preferably ditching harmful habits.

  • Monitor bone density: Stay on top of your bone health with regular DXA screenings. In the UK, that tends to be every 3-5 years, unless there are extenuating circumstances. There are also other ways of monitoring bone behaviour.

  • Fall prevention: Make your environment as safe as you can.

  • Consult healthcare professionals, including a nutritional therapist: work with them to create a personalised plan to include nutrition and lifestyle.

  • Education and support: Knowledge is power, and support can make the journey easier.

  • Medication: Consult with your doctor for prescribed treatments.

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