Boning Up on Osteoporosis
There’s a “silent disease” you may already have that can create serious problems for your health. Here’s how you can find out if you’re at risk.
By Elena Acoba | Photography by James Patrick
“A lot of women may be walking around with osteoporosis and don’t know it before
they get screened.”
-Yvonne McLemore, FNP-C, Pima Pain Center
“If you have a fracture of the spine, you have osteoporosis unless proven otherwise.”
-Stephen Shiller, M.D., Pima Pain Center
significant relief within the
first week of treatment.”-Lindsey Inouye, M.D., Radiology Ltd.
the source is related to osteoporosis.”Efrain Cubillo, M.D., Pain Institute of Southern Arizona
If you are at least 65 years old and female, you should know by now if you have osteoporosis.
If you’re younger — female or male — you can find out your risk for an osteoporosis-related fracture by answering a questionnaire.
Unfortunately, you may have osteoporosis and not even know it. Some people find out only after they’ve broken a bone. But even that’s not too late to get treatment for the bone-loss disease and avoid further complications.
We spoke with several Tucson health professionals, whose expertise is osteoporosis, to discover what everyone needs to know.
Dangers of Bone Loss
Some 44 million Americans have low bone density and another 10 million have osteoporosis, which weakens a person’s bones and makes them easier to break. The disease occurs when bone density is lost and bone growth has slowed or stopped.
Among those with osteoporosis, one in two women and as many as one in four men will break a bone because of the condition.
Osteoporosis is considered a silent disease because there are no symptoms that indicate one has it. Sometimes the first sign is a fracture from regular activity.
“Osteoporosis in the vertebrae can cause serious problems for women,” says Jennifer Howell, D.O., of Genesis Ironwood OB/GYN. “A fracture in this area can happen during day-to-day activities like climbing stairs, lifting objects or bending forward.”
Fractures along the spine can cause sloping shoulders, a curve in the back, height loss, back pain, breathing difficulty and a hunched posture.
Other common osteoporotic fractures occur in the wrists and hips.
People may limit their daily activity because they fear osteoporotic fractures or feel pain from undiagnosed fractures. That reduces the quality of life, makes osteoporosis worse and can cause disability and early death.
Find Out Your Risk
Post-menopausal women are at particularly high risk because they have very low levels of the bone-building hormone estrogen. But other diseases, lifestyle habits and medication use also can lead to osteoporosis.
Factors that put you at higher risk for osteoporosis include having a small, thin body; being white, Asian American or Latina; having had broken bones in the past, and having a family history of osteoporosis.
High-risk lifestyle habits include smoking, doing little physical activity and drinking too much alcohol.
Medical conditions that can lead to the disease include deficiencies in estrogen, calcium or vitamin D; eating disorders; endocrine abnormalities, and certain cancers.
Medications for treating arthritis, asthma, acid reflux and other long-term conditions also could lead to osteoporosis. So can radiation therapy on the spine.
Every woman at least 65 years old should have a DEXA (dual-energy X-ray absorptiometry) scan to measure bone density. Men ought to get the test by age 70. Anyone with several risk factors should consider getting one earlier.
“A lot of women may be walking around with osteoporosis and don’t know it before they get screened,” says nurse practitioner Yvonne McLemore of Pima Pain Center.
DEXA scans tell you if you have normal bone density, less-than-normal bone density called osteopenia or full-blown osteoporosis that puts you at high risk for fractures.
Often a FRAX score is included in a bone density scan. The FRAX (fracture risk assessment) uses your risk factors to determine your 10-year chances of breaking a bone because of osteoporosis.
You don’t need a DEXA scan to get a FRAX score, but adding the scan provides a clearer picture of your risk.
If you get a fracture, X-rays can reveal if osteoporosis caused it. Often the mere existence of the fracture is enough to make a diagnosis of osteoporosis.
“There’s usually no way normal load-bearing would cause a spinal fracture,” says pain specialist Stephen Shiller, M.D. of Pima Pain Center. “If you have a fracture of the spine, you have osteoporosis unless proven otherwise.”
Doctors will suggest how often scans should be repeated. Dr. Howell says normal DEXA scans in people with low risk can wait up to 15 years to take the next one. DEXA scans also are used to track progress of treatment.
There is no cure for osteoporosis. The best one can do is slow down the loss of bone density and avoid fractures.
Mild osteopenia easily can be addressed by adding more calcium and vitamin D, doing weight-bearing exercises like walking and dancing, ending smoking and reducing alcohol consumption.
Treatment of both severe osteopenia and osteoporosis usually includes medication. There are several that variously slow down bone loss and increase the ability to grow bone. Some are taken orally while others are injected.
Currently, the most commonly prescribed class of drugs are bisphosphonates such as Fosamax and Boniva. Denosumabs like Prolia and Xgeva are injected. Raloxifene is a selective estrogen receptor modulator (SERM) that blocks bone resorption.
Calcitonin is a hormone that stops cells from breaking down bone. Teriparatide andabaloparatide are synthetic versions of a hormone that promotes bone growth.
The same lifestyle changes suggested for osteopenia patients apply for osteoporosis patients. Patients also are encouraged to avoid falls by doing exercises to improve balance and eliminating hazards around the house that can cause falls.
When a Fracture Happens
Osteoporosis does not cause pain, but people with it feel pain because of fractures, some of which aren’t diagnosed for a while.
“We find that in one to three percent of patients who have back pain, the source is related to osteoporosis,” says pain specialist Efrain Cubillo, M.D. of the Pain Institute of Southern Arizona. “The source technically is a compression fracture of the thoracic or lumbar spine. People are surprised to hear they have this because of osteoporosis.”
Dr. Cubillo and other doctors find they end up treating two conditions when dealing with patients with pain from osteoporosis-related fractures.
“We formulate a comprehensive, multi-disciplinary plan,” he says, “not only to treat the current osteoporotic condition, but to prevent further fractures from occurring.”
This involves several steps: Treat the pain from the fracture, repair the fracture, order a DEXA scan, prescribe medication to slow the osteoporosis, encourage physical therapy for bone strengthening, and follow-up with additional scans.
Fractures of the vertebra, hip and wrist are the most common injuries among people with osteoporosis. They are called fragility fractures because they are caused by fragile bones.
“The most concerning of these is the hip fracture because it substantially increases the risk of morbidity and death,” says Suezie Kim, M.D. of the Tucson Orthopaedic Institute. “Most hip fractures require surgery to prevent morbidity from prolonged immobilization.”
Hip and wrist fractures are challenging to fix because the weakened bone makes it hard to stabilize the break. Bone grafting, special plates and cement are some ways to get around the challenges.
Cement also plays a role in repairing painful spinal compression fractures in fragile vertebrae that could cause debilitating chronic pain.
Vertebroplasty is used to turn a cracked vertebra into a solid form.
Kyphoplasty inserts a balloon into a vertebra to create a space that is filled with cement. This not only solidifies the bone, but adds height to the vertebra. This helps straighten and lengthen the spine.
In Kivaplasty, doctors use a coil instead of cement to lengthen the spine and give it flexibility. All of these spinal treatments are minimally invasive and can be done on an outpatient basis.
“Approximately 70 to 90 percent of our patients have significant relief within the first week of treatment,” says interventional radiologist Lindsey Inouye, M.D. of Radiology Ltd. “Most resume their activities and reduce pain meds.”
Getting Ahead of Osteoporosis
Prevention is key when it comes to osteoporosis. “The risk for developing osteoporosis is higher if you did not develop strong bones when you were young,” says Dr. Howell.
Doing weight-bearing exercise, eating a good diet, taking in adequate calcium and vitamin D, not smoking and limiting alcohol to one drink a day can help keep the disease at bay.
Discovering osteoporosis early also is crucial. Talk with your primary care physician or gynecologist about appropriate tests and assessments.
“Our most pressing problem seems to be getting the patient diagnosed and treated expeditiously,” says Dr. Inouye. “There are delays in scheduling, insurance authorizations and imaging that need to be addressed.”
Even if you get a diagnosis of osteoporosis only after you’ve suffered a fracture, immediate attention to the disease will go a long way to avoiding another fracture. Specialists are recognizing their role in this.
“Often, the orthopedic surgeon is the first provider to see a patient with osteoporosis,” says Dr. Kim. “There has been an increased awareness that our role needs to be larger than just fracture management.” TL
These Tucson health professionals shared their expertise in osteoporosis for this story:
Efrain I. Cubillo IV, M.D., Pain Institute of Southern Arizona
Jennifer Howell, D.O., Genesis Ironwood
Lindsey W. Inouye, M.D., Radiology Ltd.
Suezie Kim, M.D., Tucson Orthopaedic Institute
Yvonne McLemore, FNP-C, Pima Pain Center
Stephen A. Shiller, M.D., Pima Pain Center