Osteoporosis

What is happening

Bone is living tissue, constantly broken down and rebuilt. Bone mass peaks in the late twenties, holds, then declines. When breakdown outpaces rebuilding, the internal structure thins and the bone loses strength.

Women lose bone rapidly for several years after the menopause, when oestrogen — which restrains bone breakdown — falls away. That period is the single biggest determinant of later fracture risk in women.

Risk factors you cannot change

• Age
• Female sex, and early menopause — before 45 — or premature ovarian insufficiency, which is a major and under-appreciated risk
• A parent who fractured a hip
• Previous fragility fracture
• White or Asian ethnicity
• Small frame and low body weight

Risk factors you can do something about

• Smoking — directly toxic to bone
• More than three units of alcohol a day
• Physical inactivity, and prolonged bed rest
• Low body weight, and inadequate calcium or vitamin D
• Excessive exercise with low body weight causing periods to stop — relevant to athletes and to eating disorders, and a cause of osteoporosis in young women that is regularly missed

Medical causes — which matter because they are treatable

• Steroid tablets — the leading drug cause. Prednisolone at 7.5mg or more daily for three months or longer warrants bone protection, and this is one of the commonest omissions in practice
• An overactive thyroid — including over-replacement with levothyroxine. Being on slightly too much thyroid hormone for years causes bone loss, and it is entirely avoidable with proper monitoring
• Coeliac disease and inflammatory bowel disease, through malabsorption
• Rheumatoid arthritis
• Low testosterone in men, and androgen deprivation therapy for prostate cancer
• Aromatase inhibitors for breast cancer
• Chronic kidney or liver disease
• Type 1 diabetes
• Some anti-epileptic medication; long-term proton pump inhibitors, to a lesser degree

Men get osteoporosis too

Around a third of hip fractures happen in men, who are considerably less likely to be assessed or treated. Men are also more likely to have an underlying cause — low testosterone, steroids, alcohol, coeliac disease — so a diagnosis in a man should always prompt a look for a reason.

Most of the assessment is history and risk calculation, both of which work well remotely — and a good deal can be decided without a scan at all.

Risk calculation

FRAX and QFracture estimate your ten-year risk of fracture from your history alone. That result determines who needs a scan, who needs treatment regardless of a scan, and who can simply be reassured. It is quick and it should be done before anything else.

Assessment is recommended for: women over 65 and men over 75; anyone over 50 with a risk factor; anyone with a fragility fracture; anyone on long-term steroids; and anyone with early menopause.

What we ask

• Any previous fracture, and exactly how it happened — whether it was a fall from standing height
• Your tallest ever adult height, compared with now. More than 4cm lost suggests spinal fracture. Almost nobody is asked this
• Parental hip fracture
• Menopause age, and any period of absent periods
• Steroid use, thyroid treatment, and all long-term medication
• Smoking, alcohol, activity, diet
• Falls — how many, and why. Fracture risk is bone strength and falls risk, and only one of them gets attention

DEXA scan

A low-dose X-ray of hip and spine, taking about fifteen minutes.

• T-score of −2.5 or below: osteoporosis
• T-score between −1 and −2.5: osteopenia — lower than average bone density, not a disease. For most people it means attending to bone health and reassessing later, not starting drug treatment
• Above −1: normal

The score is not the whole decision. Someone with osteopenia and several risk factors may warrant treatment; someone with a low score and none may not. We treat people, not numbers.

Blood tests to look for a cause

Particularly important in men, in anyone under 50, and where bone loss is more than expected:

• Vitamin D, calcium, phosphate and alkaline phosphatase
• Thyroid function — including checking whether levothyroxine replacement is too high
• Kidney and liver function
• Coeliac serology
• Testosterone in men
• Full blood count, and myeloma screening in older adults with bone pain
• Parathyroid hormone where calcium is abnormal

What needs referral

Spinal X-ray or DEXA vertebral assessment for suspected spinal fracture; specialist referral for very low bone density, fractures despite treatment, unusual causes, or anyone needing the injectable bone-building treatments.

Exercise — the two kinds you need

Both matter, and most people are only ever told about the first:

• Weight-bearing impact exercise — brisk walking, jogging, dancing, stair climbing, racquet sports. Bone responds to load and impact. Swimming and cycling are excellent for you generally but do not build bone, because they do not load the skeleton
• Resistance training — weights or resistance bands, two or three times a week. Muscle pulling on bone stimulates it directly, and this is the part most often left out
• Balance training — tai chi, or a structured strength-and-balance programme. It does not build bone at all; it prevents the fall, and preventing falls prevents as many fractures as any drug

If you already have spinal fractures, avoid heavy forward bending and twisting, and get advice from a physiotherapist rather than guessing.

Calcium and vitamin D from food

• Calcium: dairy, fortified plant milks, tinned fish with bones, tofu set with calcium, leafy greens, almonds. Aim for around 1000mg a day, from food where you can
• Vitamin D: oily fish, eggs, fortified foods, and sunlight from late March to September. In the UK, supplement through autumn and winter — this applies to nearly everyone, and particularly to anyone with darker skin or who covers up

What harms bone

• Smoking — directly toxic, and one of the most effective things to change
• More than three units of alcohol a day
• Being underweight
• Prolonged inactivity
• Very high caffeine intake, to a modest degree

Falls-proofing your home — which prevents fractures as reliably as tablets

• Remove loose rugs and trailing cables; the commonest single hazard
• Good lighting, especially on stairs and at night
• Grab rails in the bathroom, and a non-slip mat
• Have your eyes tested regularly — and be careful with new varifocals on stairs, a genuinely common cause of falls
• Well-fitting shoes with a firm sole; not slippers or bare feet on hard floors
• Ask for a medication review. Sedatives, sleeping tablets, some blood pressure drugs and anything causing dizziness raise fall risk considerably, and are often reducible

Measure your height

Once a year, properly, against a doorframe. Losing more than 4cm from your tallest adult height suggests a spinal fracture, and it is one of the few signs osteoporosis gives you before something breaks. It costs nothing and almost nobody does it.

On the fear of the medication

Two rare side effects — jaw problems and unusual thigh bone fractures — receive a great deal of attention online, and they frighten people off effective treatment.

Both are genuinely rare, and the risk of an untreated hip fracture is very much larger. A hip fracture in an older adult carries a substantial risk of death within a year and of permanent loss of independence. Keep your dental health in order, mention treatment before dental surgery, and report any new thigh or groin pain — and take the treatment.

I broke my wrist falling in the street. Does that mean anything?

Yes, and it is the most important question on this page. A fracture from a fall at standing height or less is a fragility fracture, and it should prompt bone assessment — at any age. It roughly doubles the risk of the next one, and the highest-risk period is the two years afterwards. Vast numbers of these are treated as accidents and never followed up, which is exactly how the hip fracture arrives later.

I've been told I have osteopenia. Is that osteoporosis?

No. Osteopenia means bone density is lower than average but above the osteoporosis threshold, and for most people it is a prompt to attend to bone health — exercise, calcium, vitamin D, smoking, alcohol — and reassess later, not to start drug treatment. Whether treatment is warranted depends on your whole risk picture, not the number alone. It causes far more alarm than it warrants.

Why do I have to take the tablet standing up on an empty stomach?

Because absorption is extremely poor and the tablet can irritate the gullet. First thing, plain tap water, upright for 30 minutes, nothing else to eat or drink. These are not optional refinements — taken with tea, or lying down, the drug either does not get absorbed or causes real problems. Most people who say they could not tolerate it were taking it wrongly.

I'm on denosumab and want to stop. Can I just not have the next injection?

No — and this genuinely matters. Stopping denosumab abruptly causes a rebound surge in bone breakdown, with a real risk of multiple spinal fractures within months. It must be followed by another treatment, usually a bisphosphonate, arranged in advance. If you are thinking of stopping, or have missed a dose, speak to us first rather than simply not booking the next one.

Aren't these drugs dangerous? I've read about jaw and thigh problems.

Both are real and both are rare — and the fear of them keeps far more people from effective treatment than they ever harm. Set against them: a hip fracture in an older adult carries a substantial risk of death within the year and of never living independently again. The balance is not close. Keep your dental care up to date, mention the treatment before dental surgery, and report new thigh or groin pain.

Does swimming build bone?

No, and this surprises people. Swimming and cycling are excellent for fitness but do not load the skeleton, so they do not build bone. What does: weight-bearing impact exercise — brisk walking, jogging, dancing, stairs — and resistance training two or three times a week. Add balance work, which prevents the fall in the first place.

Can men get osteoporosis?

Yes — around a third of hip fractures occur in men, who are much less likely to be assessed or treated for it. Men are also more likely to have an identifiable underlying cause, such as low testosterone, steroid use, alcohol or coeliac disease, so a diagnosis in a man should always prompt a search for the reason.

Could my thyroid tablets be affecting my bones?

Possibly, and it is worth checking. Levothyroxine at a slightly higher dose than you need causes bone loss over years, and it is entirely avoidable with proper monitoring. If you have been on the same dose for a long time without a blood test, that is a reasonable thing to review — particularly after the menopause.

Is it too late if I already have osteoporosis?

Not at all. Treatment substantially reduces fracture risk even in people who have already broken a bone, and the benefit begins within the first year. Exercise, falls prevention, and correcting vitamin D and calcium all continue to help at any age. The highest-benefit group is precisely the people who have already fractured — which is why that first fracture should never be allowed to pass unexamined.