We all take our health and bone structure for granted. Most of us understand that our bones are very supportive... until they are not.
Osteopenia and osteoporosis which means "porous bone" are silent diseases and don't usually become noticeable until we accidentally fall and break a bone. People with severe osteoporosis can break bones just by stepping off a curb, sneezing, or even hugging. While osteopenia means reduced bone mass, it is actually a precursor to osteoporosis which is a medical condition in which the bones become brittle and fragile due to loss of bone tissue matrix, typically as a result of hormonal changes with aging or a deficiency of calcium and vitamin D.
We actually reach our peak bone mass at approximately 25-30 years of age. Both men and women will lose 2-3 percent of our bone mass every decade after that. However, during and following menopause, there is a significant acceleration of this process and women can begin losing 2-3% of their bone mineral mass density each year. One in three women and one in five men will develop osteoporosis after age 50.
Of the nearly 300,000 people in the United States who fracture their hip every year, one out of four end up in nursing homes and nearly 50% never regain their previous function. That first injury often sets off a cascade of health problems that can lead to severe disability and a decline of their quality of life. Studies show that 30% of Medicare patients who fracture their hip will die within one year.
Most of us have an out-of-sight, out-of-mind relationship with our bones. We know they are there to support us, and we know they're vital to our health and mobility, but we don't really think about them until they start to let us down, causing our health to be devastated.
The truth of the matter is that bones are not truly solid but are living tissue made up of an intricate honeycomb bone matrix of collagen and minerals, especially calcium along with living bone cells. Bone tissue is continuously remodeled through the concerted actions of bone cells. Specialized cells called osteoclasts break down old bone. Osteoblasts rebuild healthy bone. Other cells on the surface of the bone periosteum act as mechanosensors and orchestrate the bone remodeling process. This process of removing old weak bones and creating new, strong, and healthy bones is what keeps our skeletal system at peak performance. When we are young, bone is formed faster and we grow taller. Our bones become denser until our mid to late 20s when we reach our peak bone mass - the most bone tissue we will ever have. After that, we start losing bone faster than new bone is built.
There are two types of bones including cortical bone which is dense and trabecular bone which is surrounded by a shell of cortical bone. Trabecular bone is more metabolically active and the first to leave us as we age. This is the bone that we find more in the vertebrae and the neck of the femur which is why bone density or DEXA is concentrated on those areas. Trabecular bone is more like struts of bone similar to the scaffolding of a building. As these struts begin to break down with age and hormonal decline, or disease, or disuse, the trabecular bone matrix begins to break away and bone is weakened. Bone density scans may appear to be more dense but the strength and quality of the bone may be lacking.
So our goal is to maintain a healthy skeleton because it is easier to maintain our bone structure than to lose it and try to rebuild it. We should not think of bone as a dried out stagnant support system for our body. Rather, it is an amazingly sophisticated system that constantly breaks down old bone and rebuilds with new healthy bone cells. There are also cells called osteocytes which are sponge-like cells that are interconnecting the cells within the bone tissue. In addition, encased within the bone is the bone marrow which is key to the health of many other systems because these contain stem cells within the bone marrow that produce B and T cells that are critical to our immune system to fight disease.
Aging is the most common risk factor for osteopenia and osteoporosis. After our bone mass peaks at age 25-30, our body breaks down old bone faster than it builds new bone.
In both men and women, hormones help activate bone cells to make new healthy bones. Men have a higher peak bone mass than women. Because women have smaller bones with a thinner cortex and smaller diameter, they are more vulnerable to developing osteoporosis. After menopause, bone loss sets in with a vengeance. In fact, in the 10 years after menopause, women can lose 40% of their spongy inner bone and 10% of their hard outer bone.
Other risk factors for osteopenia and osteoporosis include a family history of low bone mineral density, being older than age 50, menopause before age 45, a diet lacking calcium and vitamin D, lack of resistance exercise, smoking or other forms of tobacco, drinking too much alcohol or caffeine, taking prednisone, anorexia, and several other medical conditions.
DEXA, which stands for dual energy x-ray absorptiometry, is the most common way to measure bone mineral density.
Testing recommendations include the following groups:
The goal of treatment is to prevent osteopenia from progressing into osteoporosis. The first part of treatment involves diet and exercise. Although calcium and vitamin D supplements may sometimes be necessary, dietary consumption of these vitamins and minerals are best.
Walking, jumping, running, and weight-bearing exercises are the most effective for building and maintaining bone.
Lifestyle measures to improve bone density should be first line therapy but hormones should be considered if no improvement is noted on bone density scans.
Nutritional supplements that may raise bone density are:
There have been multiple hormonal treatments developed over the last several decades which are highly advertised. Treatments may include tablets, injections, or infusions that can be taken daily, weekly, monthly, semi-annually or annually. These medications work primarily by slowing down the bone resorption which does maintain or increase bone density but does not necessarily create healthy bone strength.
One unquestionable benefit of hormone replacement is the preservation and restoration of bone density. Studies have shown that it is possible for most patients to raise and improve bone density with the use of specific supplements and hormones. Both estrogen and testosterone improve bone density. Higher doses have greater effect but lower doses will still be effective. Spinal bone density tends to improve more rapidly than hip bone density. Bisphosphonate drugs such as Fosamax, Boniva, Actonel, Reclast, and Prolia may increase bone density on bone scans but the quality and strength of retaining older, denser bone does not equate to healthier stronger bone and may even increase the risk of difficult to treat spiral fractures, destruction of the jawbone, and esophageal problems including trouble swallowing.
By far the most effective method of hormone replacement for increasing bone density is implantation of hormone pellets. This is because the pellets release a constant amount of hormone throughout the day, every day, for several months. With bio-identical hormone pellet therapy, there is no significant fluctuation of hormone levels. In some women who had previously been using transdermal hormone creams, bone density increased significantly in the lumbar spine after changing to bio-identical hormone pellet therapy.
Bone density in men also responds to hormonal changes. All men with osteoporosis, with height loss, or history of vertebral, hip or wrist fracture, should have DEXA bone density testing. If bone density is low or low normal, the testosterone level should be obtained. A total testosterone level below 320 ng/dl justifies treatment with testosterone. Again, pellets are the most effective method of hormone administration but sublingual, transdermal or intramuscular preparations are still effective. Bone density should be retested every year until a desirable result is achieved, and every two years after that.
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