Osteoporosis

Osteoporosis
Osteoporosis
KEY TERMS
Definition
Bouchard’s nodes—Swelling of the middle joint
of the finger. The word osteoporosis literally means “porous
bones.” It occurs when bones lose an excessive amount
Cartilage—Elastic connective tissue that covers
of their protein and mineral content, particularly calci-
and protects the ends of bones.
um. Over time, bone mass, and therefore bone strength,
Primary osteoarthritis—OA that results from is decreased. As a result, bones become fragile and break
hereditary factors or stresses on weight-bearing easily. Even a sneeze or a sudden movement may be
joints. enough to break a bone in someone with severe osteo-
Secondary osteoarthritis—OA that develops fol- porosis.
lowing joint surgery, trauma, or repetitive joint
injury. Description
Subchondral cysts—Fluid-filled sacs that form
Osteoporosis is a serious public health problem.
inside the marrow at the ends of bones as part of
Some 28 million people in the United States are affected
the development of OA.
by this potentially debilitating disease, which is responsi-
ble for 1.5 million fractures (broken bones) annually.
These fractures, which are often the first sign of the dis-
NUTRITIONAL SUPPLEMENTS In recent years, a com-
ease, can affect any bone, but the most common locations
bination of glucosamine and chondroitin sulfate has been are the hip, spine, and wrist. Breaks in the hip and spine
studied as a dietary supplement to help the body maintain are of special concern because they almost always
and repair cartilage. These substances are nontoxic and require hospitalization and major surgery, and may lead
do not require prescriptions, but studies continue to be to other serious consequences, including permanent dis-
conducted to evaluate their effectiveness. Other supple-
ability and even death.
ments that may be helpful in the treatment of OA include
To understand osteoporosis, it is helpful to under-
the antioxidant vitamins A, C, and E, and minerals sele-
stand the basics of bone formation. Bone is living tissue
nium and zinc.
that is constantly being renewed in a two-stage process
(resorption and formation) that occurs throughout life. In
Resources
the resorption stage, old bone is broken down and
BOOKS
removed by cells called osteoclasts. In the formation
Hellman, David B. “Arthritis & Musculoskeletal Disorders.”
stage, cells called osteoblasts build new bone to replace
In Current Medical Diagnosis and Treatment, edited by
the old. During childhood and early adulthood, more
Lawrence M. Tierney, Jr., et al. Stanford, CT: Appleton &
bone is produced than removed, reaching its maximum
Lange, 1998.
mass and strength by the mid-30s. After that, bone is lost
Neustadt, David H. “Osteoarthritis.” In Merck Manual of
at a faster pace than it is formed, so the amount of bone
Diagnosis and Theory, edited by Robert E. Rakel.
in the skeleton begins to slowly decline. Most cases of
Philadelphia: W. B. Saunders Company, 1998.
osteoporosis occur as an acceleration of this normal aging
PERIODICALS
process—a form referred to as primary osteoporosis. The
Gelber A.C., et al. “Joint injury in young adults and risk for
condition can also be caused by other disease processes
subsequent knee and hip osteoarthritis.” Annals of
or prolonged use of certain medications that result in
Internal Medicine 133 (2000): 321-328.
bone loss—a form called secondary osteoporosis.
Manek, N.J., and N. Lane. “Osteoarthritis.” Current Concepts
in Diagnosis and Management 61 (2000): 1796-1804. Osteoporosis occurs most often in older people and
in women after menopause. It affects nearly half of all
OTHER
men and women over the age of 75. Women, however,
National Library of Medicine. Medline Plus Health
are five times more likely than men to develop the dis-
Information. <http://www.nih.gov/medlineplus/
ease. They have smaller, thinner bones than men to begin
druginfo/antiinflammatorydrugsnonsteroi202743.html>.
(May 8, 2001). with, and they lose bone mass more rapidly after
menopause (usually around age 50), when they stop pro-
Michele R. Webb ducing a bone-protecting hormone called estrogen. In the
five to seven years following menopause, women can
Osteogenic sarcoma see Sarcomas lose about 20% of their bone mass. By age 65 or 70,

G A L E E N C Y C L O P E D I A O F N U R S I N G A N D A L L I E D H E A LT H
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though, men and women lose bone mass at the same rate. fractures of the spine. These can happen even after a

Osteoporosis
seemingly normal activity, such as bending or twisting to
As an increasing number of men reach an older age, they
pick up a light object. The fractures can cause severe
are becoming more aware that osteoporosis is an impor-
back pain, but sometimes they go unnoticed—either
tant health issue for them as well.
way, the vertebrae collapse down on themselves, and the
person actually loses height. The hunchback appearance
Causes and symptoms
of many elderly women, sometimes called “dowager’s
A number of factors increase the risk of developing hump” or “widow’s hump,” is due to this effect of osteo-
osteoporosis. They include: porosis on the vertebrae.
• Age. Osteoporosis is more likely as people grow older
Diagnosis
and their bones lose tissue.
• Gender. Women are more likely to have osteoporosis Certain types of doctors may have more training and
because they are smaller and so start out with less bone. experience than others in diagnosing and treating people
They also lose bone tissue more rapidly as they age. with osteoporosis. These include geriatricians, who spe-
While women commonly lose 30–50% of their bone cialize in treating the aged; endocrinologists, who spe-
mass over their lifetimes, men lose only 20–33% of cialize in treating diseases of the body’s endocrine sys-
theirs. tem (glands and hormones); and orthopedic surgeons,
who treat fractures, such as those caused by osteoporosis.
• Race. Caucasian and Asian women are at higher risk for
the disease than women of African or Hispanic ethnic- Before making a diagnosis of osteoporosis, the doc-
ities. tor usually takes a complete medical history, conducts a
physical exam, and orders x-rays, as well as blood and
• Figure type. Women with small bones and those who
urine tests, to rule out other diseases that cause loss of
are thin are more liable to have osteoporosis.
bone mass. The doctor may also recommend a bone den-
• Early menopause. Women who stop menstruating early sity test. This is the only way to determine if osteoporo-
because of heredity, surgery or a lot of physical exer- sis is present. It can also show how far the disease has
cise may lose large amounts of bone tissue early in life. progressed.
Conditions such as anorexia and bulimia may also lead
Several diagnostic tools are available to measure the
to early menopause and osteoporosis.
density of a bone. The most accurate and advanced of the
• Lifestyle. People who smoke or drink too much, or do densitometers uses a technique called DEXA (dual ener-
not get enough exercise have an increased chance of gy x-ray absorptiometry). With the DEXA scan, a double
getting osteoporosis. x-ray beam takes pictures of the spine, hip, or entire body.
It takes about 20 minutes to do, is painless, and exposes
• Diet. Those who do not get enough calcium or protein
the patient to only a small amount of radiation—about
may be more likely to have osteoporosis. People who
one-fiftieth that of a chest x ray. The ordinary x ray is
constantly diet are more prone to the disease. It has
one, though it is the least accurate for early detection of
been shown that adolescent girls (but not boys) have
osteoporosis, because it does not reveal bone loss until the
insufficient calcium intake levels in the diet. This calci-
disease is advanced and most of the damage has already
um deficiency occurs during a period of rapid bone
been done. Other tools that are more likely to catch osteo-
growth, stunting the peak bone mass ultimately
porosis at an early stage are computed tomography scans
achieved; thus, these individuals are at greater risk of
(CT scans) and machines called densitometers, which are
developing osteoporosis.
designed specifically to measure bone density. The CT
• Genetics. People with a family history of osteoporosis
scan, which takes a large number of x rays of the same
are more likely to contract the disease.
spot from different angles, is an accurate test, but uses
• Chronic use of medication. Certain types of medica- higher levels of radiation than other methods.
tion, such as steroids, interfere with the body’s ability
People should talk to their doctors about their risk
to absorb calcium or accelerate calcium depletion,
factors for osteoporosis and if, and when, they should get
damaging bone density. the test. A woman should have bone density measured at
Osteoporosis is often called the “silent” disease, menopause, and periodically afterward, depending on the
because bone loss occurs without symptoms. People condition of their bones. Men should be tested around
often do not know they have the disease until a bone age 65. Men and women with additional risk factors,
breaks, frequently in a minor fall that would not normal- such as those who take certain medications, may need to
ly cause a fracture. A common occurrence is compression be tested earlier.

1783

Osteoporosis mone replacement therapy (HRT). Many women partici-
pate in HRT when they undergo menopause, to alleviate
symptoms such as hot flashes, but hormones have other
important roles as well. They protect women against
heart disease, the number one killer of women in the
United States, and they help to relieve and prevent osteo-
porosis. HRT increases a woman’s supply of estrogen,
which helps build new bone, while preventing further
bone loss.
Some women, however, do not want to take or are
not candidates for hormones, because some studies show
they are linked to an increased risk of breast cancer or
uterine cancer. Other studies reveal that risk is due to
increasing age. (Breast cancer tends to occur more often
as women age.) Whether or not a woman takes hormones
is a decision she should make carefully with her doctor.
Women should talk to their doctors about personal risks
for osteoporosis, as well as their risks for heart disease
and breast cancer.
Novel delivery systems of HRT have been devel-
oped. For example, Vivelle is a estradiol transdermal sys-
tem that is used for prevention of osteoporosis. It uses a
“patch” to continously deliver the hormone estradiol
through the skin.
Studies have shown women who started taking HRT
within five years of menopause show significantly
reduced rates of hip fractures than women who began
HRT more than five years postmenopausal. However,
even while taking HRT, 10 to 20% of women continue to
A scanning electron micrograph (SEM) of cancellous lose bone density and therefore may require additional
(spongy) bone from an osteoporosis patient. Osteoporosis intervention.
is characterized by increased brittleness of the bones and
For people who cannot or will not take estrogen,
a greater risk of fractures. This is reflected here in the thin
appearance of the bony network of the cancellous bone other agents can be good choices. These include:
that forms the core of the body’s long bones (Photograph
• bisphosphonates
by Professor P. Motta, Photo Researchers, Inc. Reproduced by
permission.)
• calcitonin
Treatment • selective estrogen receptor modulators
• sodium fluoride
There are a number of good treatments for primary
osteoporosis, most of them medications. In addition, cal- • androgens
cium (0.5 to 2 g/day) and vitamin D (400 to 800 IU/day)
Although there are a number of bisphosphonates
supplementation can reduce the rate of bone loss in
used for the treatment of various forms of osteoporosis
women who are more than five years postmenopausal.
and resorptive bone diseases, alendronate (sold under the
Fracture reduction efficacy of calcium and vitamin D
brand name Fosamax), etidronate (sold under the brand
supplementation, administered independently, has been
name Didronel), and risedronate (sold under the brand
demonstrated in women older than 75 years of age.
name Actonel) are some of the agents most commonly
For people with secondary osteoporosis, treatment used for therapeutic treatment of postmenopausal osteo-
may focus on curing the underlying disease. porosis. Biphosphonates act by decreasing bone resorp-
tion or breakdown. For example, alendronate attaches
Drugs itself to bone that has been targeted by bone-eating osteo-
clasts. It protects the bone from these cells. Osteoclasts
For most women who have gone through
help the body break down old bone tissue.
menopause, the best treatment for osteoporosis is hor-

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Alendronate has shown to be an effective agent in The treatments currently available are antiresorptive,

Osteoporosis
which limits the ability to increase bone mass. Other
preventing bone loss and building bone in recently post-
bone-building agents are under investigation including
menopausal women and is especially useful in women
parathyroid hormone which has been clinically evaluated
who have contraindications for HRT. It has been licensed
but is still awaiting FDA approval as of March 2001. The
for the treatment and prevention of vertebral and nonver-
biphosphonates have demonstrated the most dramatic
tebral postmenopausal osteoporosis. Alendronate has
reduction in fracture rates and may be the best choice for
proven safe in very large, multi-year studies, but not
women with severe osteoporosis. Estrogen’s effect may
much is known about the effects of its long-term use.
be similar, but has not been established in large random-
Side effects are generally minimal with abdominal pain,
ized trials. Raloxifene may be particularly useful in
nausea, dyspepsia, constipation and diarrhea occurring
women who wish to benefit from a breast cancer risk
in 3% to 7% of patients treated with alendronate. It can
reduction. Calcitonin may be the least potent but may be
be taken daily, and now a new formulation has been
useful in women who cannot tolerate other therapies.
developed that can be taken weekly.
Etidronate has been shown to reduce the rate of new Surgery
vertebral and nonvertebral fractures. It appears to be well
Unfortunately, treatment for osteoporosis is usually
tolerated in clinical studies.
tied to fractures that result from advanced stages of the
Calcitonin is a hormone that has been used as an disease. For complicated fractures, such as broken hips,
injection for many years. It is also marketed as a nasal hospitalization and a surgical procedure are required. In
spray. It also slows down bone-eating osteoclasts. Side hip replacement surgery, the broken hip is removed and
effects are minimal, but calcitonin builds bone by only replaced with a new hip made of plastic, or metal and
1.5% a year, which may not be enough for some women plastic. Though the surgery itself is usually successful,
to recover the bone they lose. complications of the hip fracture can be serious. Those
individuals have a 5%–20% greater risk of dying within
Selective estrogen receptor modulators (SERMs)
the first year following that injury than do others in their
such as raloxifene, droloxifene, idoxifene, and tamoxifen
age group. A large percentage of those who survive are
are used as alternatives to hormone replacement therapy
unable to return to their previous level of activity, and
(HRT) which commonly use estrogen. SERMs have been
many end up moving from self-care to a supervised liv-
shown to protect against postmenopausal bone loss with-
ing situation or nursing home. Getting early treatment
out the estrogenic side effects. Raloxifene was the first
and taking steps to reduce bone loss are vital.
SERM to be approved in the osteoporosis market for pre-
vention and treatment of osteoporosis. Raloxifene binds
Alternative treatment
to estrogen receptors and mimics estrogen’s action on
bone by preventing bone loss, and improving cholesterol Alternative treatments for osteoporosis focus on
metabolism, therefore acting as an agonist. It also acts as maintaining or building strong bones. A healthy diet low
an estrogen antagonist in the uterus and the breasts, by in fats and animal products and containing whole grains,
not imitating the action of estrogen. These drugs may fresh fruits and vegetables, and calcium-rich foods (such
thus improve blood lipid profiles and protect against as dairy products, dark-green leafy vegetables, sardines,
breast cancer. There is an enhanced risk of venous throm- salmon, and almonds), along with nutritional supple-
boembolic events during raloxifene therapy, especially ments (such as calcium, magnesium, and vitamin D), and
weight-bearing exercises are important components of
during the first four months of therapy. It also has a
both conventional prevention and treatment strategies and
propensity to induce hot flashes, and leg pain.
alternative approaches to the disease. In addition, alterna-
Sodium fluoride has been used as an anabolic agent
tive practitioners recommend a variety of botanical med-
to stimulate bone formation. However, a high incidence
icines or herbal supplements. Herbal supplements
of side effects, mainly gastrointestinal symptoms and
designed to help slow bone loss emphasize the use of cal-
lower extremity pain syndrome have occurred in clinical
cium-containing plants, such as horsetail (Equisetum
trials.
arvense), oat straw (Avena sativa), alfalfa (Medicago
Androgens have been used for reducing bone loss. sativa), licorice (Glycyrrhiza galbra), marshmallow
Androgens are classified as anabolic steroids, which (Althaea officinalis), and yellow dock (Rumex crispus).
include nandrolone, stanozolol and testosterone, are used Homeopathic remedies focus on treatments believed to
as antiresorptive agents. Androgens are important for help the body absorb calcium. These remedies are likely
postmenopausal women as they serve as a substrate for to include such substances as Calcarea carbonica (calci-
the peripheral production of estrogens. um carbonate) or silica. In traditional Chinese medicine,

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Osteoporosis Prognosis
KEY TERMS There is no cure for osteoporosis, but it can be con-
trolled. Most people who have osteoporosis fare well
Alendronate—A nonhormonal drug used to treat
once they get treatment. The medicines available now
osteoporosis in postmenopausal women.
build bone, protect against bone loss, and halt the
Anticonvulsants—Drugs used to control seizures,
progress of this disease.
such as in epilepsy.
Biphosphonates—Compounds (like alendronate) Health care team roles
that slow bone loss and increase bone density.
Doctors, nurses, physical therapists, radiation tech-
Calcitonin—A hormonal drug used to treat post-
nologists, and dietitians all play roles in the process of
menopausal osteoporosis.
controlling osteoporosis. Because osteoporosis is treat-
Estrogen—A female hormone that also keeps
able but not curable, the main responsibility for control-
bones strong. After menopause, a woman may
ling the progress of the disease rests with the patient. All
take hormonal drugs with estrogen to prevent
of these team members play an important role in identi-
bone loss.
fying risk of osteoporosis before it strikes and in con-
Glucocorticoids—Any of a group of hormones
vincing the patient to take appropriate steps (including
(like cortisone) that influence many body func-
lifestyle modification) to minimize the dangers of frac-
tions and are widely used in medicine, such as for
turing major bones.
treatment of rheumatoid arthritis inflammation.
Hormone replacement therapy (HRT)—Also
Prevention
called estrogen replacement therapy, this contro-
versial treatment is used to relieve the discomforts Building strong bones, especially before the age of
of menopause. Estrogen and another female hor- 35, and maintaining a healthy lifestyle are the best ways
mone, progesterone, are usually taken together to of preventing osteoporosis. To build as much bone mass
replace the estrogen no longer made by the body.
as early as possible in life, and to help slow the rate of
It has the added effect of stopping bone loss that
bone loss later in life:
occurs at menopause.
Menopause—The ending of a woman’s menstrual Get calcium in foods
cycle, when production of bone-protecting estro-
Experts recommend 1,500 milligrams (mg) of calci-
gen decreases.
um per day for adolescents, pregnant or breast-feeding
Osteoblasts—Cells in the body that build new
women, older adults (over 65), and postmenopausal
bone tissue.
women not using hormone replacement therapy. All oth-
Osteoclasts—Cells that break down and remove
ers should get 1,000 mg per day. Foods are the best
old bone tissue.
source for this important mineral. Milk, cheese, and
Selective estrogen receptor modulator—A hor- yogurt have the highest amounts. Other foods that are
monal preparation that offers the beneficial effects high in calcium are green leafy vegetables, tofu, shell-
of hormone replacement therapy without the fish, Brazil nuts, sardines, and almonds.
increased risk of breast and uterine cancer associ-
ated with HRT.
Take calcium supplements
Many people, especially those who do not like or
cannot eat dairy foods, do not get enough calcium in their
practitioners recommend herbs thought to slow or prevent
diets and may need to take a calcium supplement.
bone loss, including dong quai (Angelica sinensis) and
Supplements vary in the amount of calcium they contain.
Asian ginseng (Panax ginseng). Natural hormone thera-
py, using plant estrogens (from soybeans) or progesterone Those with calcium carbonate have the most amount of
(from wild yams), may be recommended for women who useful calcium. Supplements should be taken with meals
cannot or choose not to take synthetic hormones. and accompanied by six to eight glasses of water a day.
Calcium supplements and antacids interfere with
It should be noted, however, that very few clinical
absorption of alendronate and should be taken at least
trials are conducted on alternate therapies and therefore
efficacy cannot be established. one half hour later.

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Get vitamin D

Otoscope
PERIODICALS
Feder, G., et al. “Guidelines for the Prevention of Falls in
Vitamin D helps the body absorb calcium. People People over 65.” British Medical Journal 321 (2000):
can get vitamin D from sunshine with a quick (15–20 1007-1011.
minutes) walk each day or from foods such as liver, fish McClung, Michael R., et al. “Effect of Risedronate on the
oil, and vitamin-D fortified milk. During the winter Risk of Hip Fracture in Elderly Women.” The New
months it may be necessary to take supplements England Journal of Medicine 344, no. 5 (2001): 333-40.
(400–800 IU/day).
ORGANIZATIONS
Arthritis Foundation, 1330 W. Peachtree St., PO Box 7669,
Avoid smoking and alcohol
Atlanta, GA 30357-0669. (800) 283-7800.
<http://www.arthritis.org>.
Smoking reduces bone mass, as does heavy drink-
National Center for Complementary and Alternative Medicine
ing. To reduce risk, do not smoke and limit alcoholic
(NCCAM), 31 Center Dr., Room #5B-58, Bethesda, MD
drinks to no more than two per day. An alcoholic drink is
20892-2182. (800) NIH-NCAM. Fax: (301) 495-4957.
1.5 oz (44 mL) of hard liquor, 12 oz (355 mL) of beer, or
<http://nccam.nih.gov>.
5 oz (148 mL) of wine.
National Osteoporosis Foundation, 1150 17th Street, Suite 500
NW, Washington, DC 20036-4603. (800) 223-9994.
Exercise
<http://www.nof.org>.
Exercising regularly builds and strengthens bones. Osteoporosis and Related Bone Diseases-National Resource
Center. 1150 17th St., NW, Ste. 500, Washington, DC
Weight-bearing exercises—where bones and muscles
20036-4603. (800) 624-BONE. <http://www.osteo.org>.
work against gravity—are best. These include aerobics,
dancing, jogging, stair climbing, tennis, walking, and lift-
Crystal Kaczkowski, MSc
ing weights. People who have osteoporosis may want to
attempt gentle exercise, such as walking, rather than jog-
ging or fast-paced aerobics, which increase the chance of
falling. Try to exercise three to four times per week for
20–30 minutes each time. As physical activity improves
muscle strength and coordination it may also aid in Otoscope
reducing the risk of fall-related fractures.
Definition
Those at risk should avoid medications known to
compromise bone density, such as glucocorticoids, thy- An otoscope is a hand-held device for visual exami-
roid hormones and chronic heparin therapy. nation of the auditory canal, inner ear, and tympanic
membrane.
Resources
Purpose
BOOKS
Adams, John S. and Barbara P. Lukertet. Osteoporosis:
An otoscope is designed to enable the health care
Genetics, Prevention and Treatment. Boston: Kluwer
professional to view the auditory canal, inner ear, and
Academic, 1999.
tympanic membrane as part of a normal physical exam-
Kessler, George J., et al. The Bone Density Diet: 6 Weeks to a
ination. It is also used if infection of the auditory canal
Strong Body and Mind. New York: Ballantine Books,
is suspected, if there is a blockage due to the presence of
2000.
a foreign object or build up of wax, and to inspect the
Krane, Stephen M., and Michael F. Holick. “Metabolic Bone
tympanic membrane for signs of rupture, puncture, or
Disease: Osteoporosis.” In Harrison’s Principles of
hearing loss.
Internal Medicine. 14th ed. Ed. by Anthony S. Fauci, et
al. New York: McGraw-Hill, 1998.
Lane, Nancy E., ed. The Osteoporosis Book. New York: Description
Oxford University Press, 1998.
An otoscope consists of a handle with power source,
McIlwain, Harris, et al. Osteoporosis Cure: Reverse the
an optical head with fiberoptic strands, a lens, specula, a
Crippling Effects With New Treatment. New York: Avon
small light bulb, a polished reflector, and may have pneu-
Books, 1998.
moscopy bellows as an option. The unit is designed to be
Notelovits, Morris, et al. Stand Tall! Every Woman’s Guide to
operated by one hand, enabling the other hand to manip-
Preventing and Treating Osteoporosis. 2nd ed.
ulate the patient’s ear.
Gainesville, FL: Triad Publishing Co., 1998.

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Osteoporosis

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