Osteoporosis is a generalized bone disease, characterized by a decrease in bone mass and alteration of its microstructure, so that bones become more porous, increasing the number and size of the cavities or cells that exist in its interior, and this causes bone fragility and an increased risk of fractures.
Bone mass and bone quality, factors in bone fractures
Throughout life, numerous metabolic changes take place inside the bone, alternating phases of destruction and formation. These phases are regulated by different hormones, physical activity, diet, toxic habits and vitamin D, among other factors. Under normal conditions, a person reaches a maximum amount of bone mass, what we call “peak bone mass”, at the age of 30-35 years. From the moment the peak value is acquired, there is a natural loss of bone mass, which is usually slow and lasts for the rest of life.
Peak bone mass is perhaps the most important determinant of skeletal health for the rest of life. Genetic factors play a predominant role in the achievement of peak bone mass; to a lesser extent, nutritional factors (essentially calcium intake), hormonal factors (puberty, menopause, gonadal insufficiencies) and the degree of physical exercise also play a role.
Bone quality refers to those skeletal factors other than bone mass that are also involved in the production of bone fracture. The most important are:
- The shape (length and angulation of the femoral neck) and the microarchitecture of the bone (cortical porosity, connection between trabeculae, abnormalities in matrix collagen).
- The degree of remodeling
- Accumulated bone damage (microfractures due to fatigue).
- Mineralization
All these factors are very important in bone strength. However, we do not have objective tests to measure bone quality in clinical practice.
Symptoms of Osteoporosis
Osteoporosis is called the “silent disease”, because no symptoms appear until the bone has weakened so much that a fracture occurs, the most frequent being at the vertebral level, in the hips and wrists, although they can appear in any location. A fundamental characteristic of these fractures is that they occur spontaneously (without previous trauma), or with a slight trauma that would not produce a fracture under normal conditions.
Pain appears when the fracture occurs. But it is important to know that some vertebral fractures may occur without symptoms and go unnoticed, being discovered when an X-ray is taken.
Depending on the location of the fracture, in addition to pain, other symptoms may appear such as deformity, swelling, nerve compression, vascular rupture, etc.
Hip fractures are of particular importance as they require surgery, hospitalization and a loss of quality of life for the patient, even if only for a short period of time.
Osteoporosis in menopausal women
Osteoporosis mainly affects women after menopause, although it can also occur before menopause, or affect men, adolescents and even children, although in these cases it is usually associated with other diseases or their treatments, for example: corticoids, antiepileptics, hyperthyroidism, malabsorption problems or liver disease; this is known as secondary osteoporosis.
In the case of women, in the first place, their peak bone mass is lower than in men, to which is added that when menopause arrives, when the production of female sexual hormones by the ovary ceases, in some women there is a more accelerated and rapid loss of bone, and as a consequence postmenopausal osteoporosis appears.
In addition, there are other risk factors such as tobacco and alcohol consumption, low weight, a history of family members with osteoporotic fractures or treatment with glucocorticoids, among others, which must be taken into account when assessing the risk of fracture in a patient with osteoporosis.
Can osteoporosis be prevented?
To prevent osteoporosis and its consequences (fractures) we have 2 pillars of action: hygienic dietary measures and drugs.
As regards hygienic dietary measures, although the peak bone mass of each person is mainly conditioned by his or her genetic load, and we cannot act on this, it is important to make the young population, especially women, aware of the need to ingest an adequate amount of calcium during adolescence and young adulthood. They should also exercise correctly and eliminate harmful habits, such as alcohol and tobacco, in order to obtain a good amount of bone mass, that is to say, that the “peak bone mass” be as high as possible, since it will be the bone capital that they will have for the rest of their lives.
The necessary amount of calcium varies with age, being the highest needs in the stages of growth and menopause. In menopause, a Calcium intake of 1,000 to 1,500 mg per day is required. This intake can be made with natural foods rich in calcium (especially milk and its derivatives) or with supplements in the form of medicines (calcium salts). In the latter case, there should be a control by your physician on the amount and the administration schedule.
Similarly, vitamin D is an essential substance for bone. The vitamin D content of most foods, with the exception of some fatty fish, is very low; fundamentally, vitamin D supply to the body is achieved through the skin; if there is low sun exposure, supplements should be used to ensure daily requirements.
Densitometry, blood tests and X-rays for the diagnosis of osteoporosis
Although it is a silent disease, rheumatologists currently have a wide range of tools for early diagnosis and thus adapt the treatment, either to prevent the loss of bone mass or to combat osteoporosis.
Densitometry is the technique used to assess bone mineral density, but this is not sufficient to reach a diagnosis, as it is also necessary to assess the various risk factors that the patient presents, such as the medications taken, family history, toxic habits, presence of any osteoporotic fracture, body mass index, among the most important.
A basic analysis should also be carried out to detect any possible alteration in calcium metabolism, determining calcium, phosphorus, vitamin D, PTH hormone…
It is also very important to determine whether there is any asymptomatic vertebral fracture, for which a dorsolumbar spine X-ray should be performed.
There are other complementary tests, which will have to be individualized for each patient.
Treatment for osteoporosis: preventing fractures
The aim of osteoporosis treatment is to prevent fractures due to this disease.
The pharmacological treatment for osteoporosis will depend on several factors such as sex, age, severity of the disease, cause of the osteoporosis, clinical history and associated diseases, among others:
- First, there are a series of non-pharmacological measures aimed at correcting nutritional deficiencies, modifying lifestyles that are harmful to the bone (no smoking, no alcohol, exercise adapted to the patient’s possibilities), avoiding falls and minimizing the intensity of the impact.
- Secondly, an adequate supply of calcium and vitamin D should be achieved, if possible through diet, and if this is not sufficient, by taking pharmacological supplements, always under medical prescription.
- Thirdly, we have the drugs that slow down the loss of bone mass, and can even increase it. Among the most widely used are bisphosphonates, Denosumab, raloxifene, hormonal treatment (estrogens) and parathormone. All of them have demonstrated, to a greater or lesser extent, the ability to prevent vertebral, hip and other long bone fractures.
If all these measures are taken, we can avoid the majority of osteoporotic fractures, and with it, the loss of quality of life that suffering a fracture would entail.