Written by Dr. Sanjana V.B Bhms,dbrm,cdn

Founder & medical director of siahmsr wellness.in

Reviewed by SIAHMSR

All rights reserved with siahmsr digital healthcare[siahmsr wellness]

BONE HEALTH IN WOMEN- OSTEOPOROSIS

   Healthy bones and joints are crucial for maintaining mobility and protecting the vital organs in humans. It is a serious health concern if bone mass and strength start losing with middle age, as weakening of bones can cause fractures eventually. However, bone health of women needs to be prioritized as female sex is more at the risk of osteoporotic fracture particularly after menopause and in old age.

  Bones are continuously changing with new bone formation and old bone resorption or loss and it is a constant process. New bone formation process is faster than bone losing process in younger age and hence bone mass remains good. Most people reach their peak bone mass around age 30. After the middle age, bone mass starts losing.

  Osteoporosis is a condition that makes bones weak and brittle due to decreased bone mass and strength. It develops when bone mineral density and bone mass decreases, or when the structure and strength of bone changes. This reduced strength and bone loss can increase the risk of bone fracture.

 Who are at risk of osteoporotic fracture?

   Postmenopausal and old women

   Bone mineral density decreases with ageing and with decline in estrogen which can weaken bone strength. Women, particularly after menopause is a high risk of osteoporosis.

    Bone mineral density decreases after menopause due to decline in estrogen hormones and this can lead to decreased bone strength and fracture. Estrogen plays a key role in both the formation of bone as well as in the prevention of the resorption of bone.

   Osteoporotic fracture is common in old age. Of the estimated 10 million people affected with osteoporosis, about eight million or 80% are women. Approximately one in two women over age 50 is at risk of osteoporotic bone fracture.

     Woman can lose up to 20% of her bone density during the five – seven years following menopause. If the bone mass loss is in quicker pace, there is greater chance of developing osteoporosis.

·    Some ethnic groups

   Caucasian women, postmenopausal and older women, are mostly at risk for osteoporosis and bone fracture. In the age group of 20 to 80, Caucasian women lose one-third of the bone mineral density in their hip most probably due to deficient absorption of calcium due to lactose intolerance. Calcium is an important mineral required for bone mineralization along with magnesium, copper and phosphorus. Deficiency may weaken the bone strength predisposing to fracture.

  About 20 percent of Asian American women age 50 and older are estimated to have osteoporosis. More than half of all Asian American women age 50 and older are estimated to have low bone density.

· Women with calcium & vitamin D deficiency

   A diet low in calcium may cause decrease in bone density, early bone loss and an increased risk of fractures. Vitamin D is important for bone mineralization and bone strength.

·   Women living a sedentary life style

     Women who are physically inactive have a higher risk of osteoporosis than do their more-active counterparts.

· Tobacco and alcohol using women.

    Studies suggest that tobacco weakens bones. Excessive intake of alcoholic drinks for a long time also may increase the risk of osteoporosis.

 Are younger women at risk of osteoporotic fracture?   

    Although osteoporosis commonly occurs in older people, it sometimes affects young people, including premenopausal women having their regular menstrual periods.

    In premenopausal women osteoporosis may occur from low bone density. Some hormonal diseases such hyperthyroidism [excess production of thyroid hormones] can cause bone loss. Untreated severe hyperthyroidism [over active thyroid state ] also leads to lowered bone mass and increases the probability of high bone turnover osteoporosis.

  Subclinical hyperthyroid state [in which only Thyroid stimulating hormone is low while thyroid hormone production is within normal range] also may eventually lead to osteoporosis.

Subclinical hyperthyroidism may not cause much symptoms but it may affect bone metabolism resulting in decreased bone mineral density (BMD) and increased risk of fracture, particularly in postmenopausal women.

   In women, bone loss increases at menopause due to reducing estrogen levels. Prolonged absence of menstruation before menopause also increases the risk of osteoporosis.

  Eating disorders also may contribute to osteoporosis. Severely restricting food intake may cause deficiencies of elements required for bone growth.  Being underweight also weakens bone in both men and women.

Moreover, gastrointestinal conditions such as celiac disease can reduce absorption calcium, which can adversely affect bone health.

 Women on certain medications for a long-term are at the risk of osteoporosis. Use of corticosteroid medications [prednisone, cortisone, prednisolone and dexamethasone] may have detrimental effects on bones weakening them.

   Some other drugs that might increase the risk of osteoporosis include aromatase inhibitors used for treating breast cancer, selective serotonin reuptake inhibitors, methotrexate, some anti-seizure medications, such as phenytoin (Dilantin) and phenobarbital, and proton pump inhibitors.

Low Bone Density due to family history of osteoporosis &poor diet

   In young women, low bone density is often caused by low peak bone mass by age 30. Sometimes genetic factors cause women to have low peak bone mass. Also, calcium and vitamin D poor diet lead to low bone mass. Such women are at an increased risk of getting osteoporosis later in life. It is often goes unnoticed or undetected as bone density tests are not routinely recommended for young women.

    It is presumed often that premenopausal women with low bone density ,do not have an immediate risk of bone fractures .Therefore it is believed that gathering information about their bone density through testing may only cause unnecessary worry and expense. Thus the condition of bone loss goes undetected on time.

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·    What are the symptoms of osteoporosis?

Osteoporosis is like a silent disease with no apparent symptoms for long time. The only symptom that comes late is a sudden fracture of bone that happens from trivial injury. Normal stresses such as bending, lifting, or even coughing may cause a spontaneous fracture. Fractures may occur in any bone of the body but mostly bones of the hip, vertebrae of spine, wrists are broken.

How to detect  osteoporosis?

Dual-energy X-ray absorptiometry (DEXA) test is the gold standard and can spot low bone density at particular sites of bones.

DEXA tests can underestimate bone density in women who are small and thin. Therefore, the test may indicate that a small person has low bone density, but the bone density is actually normal for the person’s body size.

Diagnosing osteoporosis in women is done by evaluating the medical history, physical examination, bone mineral density (bone density) testing, Lab  tests etc.

Bone density testing

A bone density test shows the amount of bone a person has in the hip, spine or other bones. It is routinely recommended for postmenopausal women and older people.

Bone density tests are not usually ordered for premenopausal women. It is suggested only if they break several bones easily or fracture bones at sites that are unusual for their age, such as bones in the hip or spine. Also, the test is recommended if a disease condition or a medicine intake poses risk for secondary osteoporosis. This test should be done on a DXA machine [DXA - dual energy x-ray absorptiometry].

   One or two years after an initial bone density test, a second bone density test may be done to determine if the low peak bone mass has improved or remains the same. If the bone density is found to be decreased significantly between the first and second test, that means there is bone mass loss and further evaluation by a healthcare provider is mandatory to interpret and manage it.

   A bone density test result shows a Z-score and a T-score. T-scores are used to diagnose osteoporosis in postmenopausal women and men age 50 and older, but not in premenopausal women.

 A Z-score compares your bone density to what is normal for someone of your age. Although a Z-score alone is not used to diagnose osteoporosis in premenopausal women, it can provide important information regarding the bone health.

If the Z-score is above -2.0, the bone density is considered within the ranges expected for normal according to the International Society for Clinical Densitometry (ISCD). For example, a Z-score of +0.5, -0.5 and -1.5 is considered normal for most premenopausal women.

If the Z-score is -2.0 or lower, the bone density is considered below the expected range. Examples are -2.1, -2.3 and -2.5. If the Z-score of a woman is in this range, it is important to consider the health history and evaluate probable  causes of bone loss, including secondary osteoporosis [from drugs etc.] before making a diagnosis of osteoporosis.

In women whose Z-score is normal, but presenting with one or more broken bones from a minor injury or slightest trauma the healthcare provider may consider diagnosing the condition as osteoporosis.

Can pregnancy cause bone loss?

 Various research studies show that some bone mass loss may occur during pregnancy however, a woman usually regains it after child birth. In fact, studies show that having multiple pregnancies and child birth do not increase the risk of occurrence of osteoporosis later in life. Studies further conclude that each pregnancy provides some protection from osteoporosis.

 Does breastfeeding cause some bone mass loss?

 As happens in pregnancy, breastfeeding also may cause some temporary bone loss. However, bone density is regained soon over the course of time and it doesn’t cause any harm to a woman’s bone health. It is recommended that all women pregnant and nursing women need to take calcium, vitamin D rich food or supplements and adequate and moderate exercise to keep their bones healthy.

How to improve your bone health?

·       Include calcium rich food in your diet   

     Calcium is important for bone strength as it is one of the major minerals helping bone mineralization process which imparts strength to bones along with magnesium, phosphorus and copper.

For adults in the age group 19 to 50  the Recommended Dietary Allowance (RDA) is 1,000 milligrams (mg) of calcium a day. The recommendation increases to 1,200 mg a day for women age 51 and older.

 Good sources of calcium include dairy products, almonds, broccoli, kale, fishes such as salmon, sardines and soy products, such as tofu.

Calcium supplements also are available for people who are at risk of bone loss and osteoporosis. Supplements must be used only under the directions of a physician or healthcare provider.

      Improve your vitamin D level.

Your body needs vitamin D to absorb calcium.

 For adults [ages19 to 70,] the RDA or recommended dietary allowance of vitamin D is 600 international units (IUs) a day. The recommendation increases to 800 IUs a day for adults age 71 and older

Good sources of vitamin D include oily fish, such as salmon, trout, tuna and mushrooms, eggs etc.

Vitamin D fortified milk and cereals, are good sources of vitamin D. Sunlight exposure also helps to produce vitamin D by the skin. Vitamin D supplements also help to maintain your vitamin D level adequate.

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       Physical exercise improves your bone health.

Include physical exercise in your daily routine. Exercises such as brisk walking, jogging and climbing stairs, can help to strengthen your bones and slow bone loss. Moderate intensity strength trainings like exercise with dumbbells, Push ups, aerobic exercises are recommended.

Weight-bearing physical activity may reduce the risk of osteoporosis in women by increasing bone mineralization during the early adult years  producing peak bone mass and reducing the loss of bone after menopause.

High-intensity activities, such as resistance training, seems to provide the best stimulus for improving bone mineralization process.

Repetitive  activities, such as walking, may have a positive impact on bone mineral when performed at higher intensities. In addition, physical activity improves muscular strength, endurance, and balance  can reduce fracture risk, preventing falls.

·       Avoid substance abuse, smoking and limit alcohol consumption.

Role of Calcium and vitamin D supplementation in menopausal women

Calcium intakes in women are generally low and many elderly have poor vitamin D status too. The synergistic effect of poor calcium and vitamin D on bone density along with estrogen deficiency in menopause can lead to osteoporosis.

  Supplementation of calcium and vitamin D can significantly help bone mineralization and density reducing fracture risk in women.  Supplementation with calcium (approximately 1000 mg) can reduce bone loss in premenopausal and postmenopausal women, especially at sites that have a high cortical bone composition.

Vitamin D supplementation slows bone loss and reduces fracture rates in late postmenopausal women.

How is osteoporosis  managed?

 Treatment options are decided according to the severity and risk associated in each patient.

· Prevention is better

 Health education of women regarding the possibility of bone loss and osteoporosis is very important from the very young age as the disease can affect premenopausal and postmenopausal age groups.

  They must be advised to follow a healthy lifestyle through the practice of a proper diet and exercise routine.

 Smoking and drinking alcohol should be limited, and calcium and vitamin D supplementation should be started in all women of the postmenopausal age group with or without osteoporosis.

· Drugs or pharmacological intervention

In patients who have been diagnosed with the disorder, medicinal treatment is followed. Drugs should be selected based on their side effects and contradictions. Follow-up is essential, and patient compliance should be carefully monitored.

Your doctor may prescribe medicines when:

a)    A bone density test shows you have osteoporosis, even if you have not had a fracture before, but your fracture risk is high.

b)    If a bone fracture occurs and a bone density test shows you have thinner than normal bones, but not osteoporosis.

c)     You get a bone fracture that occurs from slight trauma or injury which is usually not sufficient to cause a fracture.

Osteoporosis medicines are not approved or advised for most premenopausal women considering their contraindications and younger age. Bone density tests are used to help guide decisions about treatment.

 According to medline plus website Medicines used for osteoporosis include :

·       Bisphosphonates

·       Raloxifene

·       Estrogen, or hormone replacement therapy (HRT).

·       Romosozumab

For details  on medications click the link of medlineplus below:

https://medlineplus.gov/ency/patientinstructions/000502.htm

Caution: All these medicines are to be taken only under the directions of a specialist for bone health. 

Alternative &complementary medicines

These therapies have preventive and supportive role only in osteoporosis management.

·       Yoga

Study shows that integrated yoga is a safe mode of physical activity which includes weight bearing as well as not weight bearing asanas, Pranayama, and suryanamaskar, all of which helps induce improvement in  bone mineral density [BMD] and strength in postmenopausal osteoporotic females[4].

· Homeopathy

Calcarea phos, calcarea carb, merc sol, phosphorus, silicea, symphytum are some medicines used to reduce bone pains. Some of the medicines help fracture healing also. They have a role as an adjuvant therapy along with vitamins and mineral supplementation.

Conclusion

The best and most important ways to improve bone health in women are well balanced diet, sunlight exposure for 15-20 minutes a day ,physical exercise and calcium &vitamin D supplementation in risk groups such as post-menopausal and older women.

References

1.    https://www.bonehealthandosteoporosis.org/preventing-fractures/general-facts/what-women-need-to-know/#:~:text=Women%20tend%20to%20have%20smaller,increases%20as%20women%20reach%20menopause.

2.    https://www.mayoclinic.org/about-this-site/health-information-policy

3.    https://pubmed.ncbi.nlm.nih.gov/9738135/

4.    https://pubmed.ncbi.nlm.nih.gov/26865770/

5.    https://pubmed.ncbi.nlm.nih.gov/36299953/

6.    https://medlineplus.gov/ency/patientinstructions/000502.htm

7.    https://www.niams.nih.gov/health-topics/osteoporosis#:~:text=Osteoporosis%20in%20Men-,Osteoporosis%20is%20a%20bone%20disease%20that%20develops%20when%20bone%20mineral,Pregnancy%2C%20Breastfeeding%2C%20and%20Bone%20Health

8.    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230461/