Osteoporosis: Causes, Symptoms and Treatment

What is Osteoporosis?

Osteoporosis is a common bone disease, characterised by the loss of bone mass and deterioration of bone tissue. It is often called the “silent disease” because it progresses silently and without symptoms until a fracture or break occurs. Osteoporosis mainly affects older people, especially women after menopause, but it can also occur in younger individuals.

According to the NHS, around 3 million people in the UK have osteoporosis^[1], with the condition being four times more common in women than men^[2].

What is Osteopenia?

Osteopenia is a precursor to osteoporosis and refers to low bone mass that is not severe enough to be classified as osteoporosis. Identifying osteopenia early provides an opportunity to prevent the progression to osteoporosis through lifestyle modifications and medicine.

Forth’s founder, Sarah, shares her story on diagnosing osteopenia, HRT and bone health.

What Causes Osteoporosis and Osteopenia?

Bone density naturally decreases with age, but women can be particularly susceptible to a rapid reduction in bone density (osteopenia) in the first few years after menopause, due to hormonal changes.

Oestrogen plays a major role in protecting your bone density. But, levels decline during menopause, causing reduced bone density and increased risk of fractures.

Other causes include:

Age-related Bone Loss

• Bone Density Decline with Age: After about age 30, bone mass naturally decreases as bone formation slows down and bone resorption (breakdown) increases.

• Menopause: In women, the drop in oestrogen levels after menopause accelerates bone loss, significantly increasing the risk of both osteopenia and osteoporosis.

Hormonal Imbalances

• Sex Hormones: Low levels of oestrogen in women and testosterone in men can lead to bone loss.

• Thyroid Hormones: Excess thyroid hormone, due to an overactive thyroid or thyroid hormone replacement therapy, can accelerate bone loss.

• Parathyroid Hormone (PTH): High levels of PTH (due to hyperparathyroidism) cause bones to release calcium, weakening them over time.

Nutritional Deficiencies

• Calcium: Calcium is essential for strong bones, and a long-term deficiency contributes significantly to bone loss.

• Vitamin D: Vitamin D helps the body absorb calcium; a deficiency leads to lower calcium absorption, which weakens bones.

• Protein and Other Nutrients: Low protein intake, along with deficiencies in other bone-supporting nutrients like magnesium and vitamin K, can also impact bone health.

Sedentary Lifestyle

• Lack of Physical Activity: Regular weight-bearing exercises, such as walking, jogging, or weightlifting, help stimulate bone growth and maintain bone density. When we don’t engage in these activities, our bones may become weaker and more prone to fractures. Research has shown that resistance training (weightlifting) has a direct impact on not only our muscles, but bones too^[3].

Medications

• Drugs like proton pump inhibitors (PPIs), certain cancer treatments, anticonvulsants and long-term use of corticosteroids can lead to bone loss as they interfere with bone formation and vitamin D metabolism.

Lifestyle Factors

• Smoking: Smoking contributes to bone loss by decreasing blood supply to bones and interfering with hormone levels, particularly oestrogen^[4].

• Excessive Alcohol Consumption: Chronic alcohol intake interferes with calcium balance and affects hormones that protect bone health.

• Poor Diet: Diets high in caffeine, sodium, or protein but low in fruits, vegetables, and whole foods can impact calcium balance and overall bone health.

"Regular, weight bearing exercise, as well as strength based exercise is probably the most important thing you can do to look after your bone health. Minimise the time you sit on a daily basis as even standing can be beneficial. The Royal Society of Osteoporosis has some excellent resources regarding exercise if you’ve already been diagnosed with Osteoporosis."

Dr Thom Philips

Symptoms to Look Out For

Osteoporosis is often asymptomatic (it has no symptoms), but there are some signs that may indicate its presence.

• Fractures from Minor Falls or Impact: Often in the hip, spine, or wrist, as bones are weakened and break more easily.

• Loss of Height Over Time: Caused by compression fractures in the spine

• Back Pain: Often due to fractures or collapsed vertebrae.

• Stooped Posture: Known as kyphosis, resulting from spinal bone weakness and fractures.

• Easily Broken Bones: Especially after minor injuries that would not typically cause fractures in healthy bones.

"Fragility fractures (broken bones with underlying bone thinning) are a massive health issue. As well as being hugely inconvenient, often we can use a fragility fracture as a marker of overall health and, perhaps surprisingly, having a fragility fracture doubles the risk of death in the following year for older women and triples the risk in older men^[5]."

Dr Thom Philips

Diagnosing Osteoporosis

Osteoporosis can be diagnosed using:

• Bone Density Scan (DEXA or DXA scan): The NHS recommends dual-energy X-ray absorptiometry as the standard test to measure bone density, particularly in the spine and hip.

• FRAX or Q-Fracture Assessment: These are risk assessment tools used by healthcare providers to estimate a person’s 10-year risk of fracture based on various factors, such as age, gender, and lifestyle.

• Routine X-rays: X-rays are sometimes used if a fracture is suspected, though they typically detect osteoporosis only in advanced cases.

• Blood Tests: Blood tests are used to identify other medical conditions that could affect bone health, including vitamin D and calcium levels. Our Menopause Health Test is an at-home blood test that checks key biomarkers related to muscle and bone health once you've reached menopause.

• Vertebral Fracture Assessment (VFA): Often included during a DEXA scan, this looks specifically for fractures in the spine.

Treating Osteoporosis

Treating osteoporosis involves a combination of lifestyle modifications and medications.

Calcium and vitamin D supplements are commonly recommended to ensure adequate bone nutrition. In some cases, hormone therapy may be used in postmenopausal women to counteract the decline in oestrogen levels.

There are also a variety of medications available to prevent further bone loss and increase bone strength. The choice of medication depends on individual factors, such as the severity of osteoporosis and any underlying medical conditions. Your doctor will be able to advise on what’s best for you.

Preventing Osteoporosis

Preventing osteoporosis begins with a proactive approach to bone health. A balanced diet rich in calcium and vitamin D is essential for bone strength. Good food sources of calcium include dairy products, leafy greens, and fortified foods. Vitamin D can be obtained from sunlight exposure and certain foods like fatty fish and eggs.

Regular physical activity, particularly weight-bearing exercises, helps improve bone health and reduces the risk of fractures. Avoiding tobacco smoking and excessive alcohol consumption can also help maintain bone density.

Why Do Our Bones Get Weaker?

Our bones are not just static structures that provide support and protection to our bodies; they are living tissues that undergo a constant process of remodelling. This remodelling involves the removal of old bone tissue by cells called osteoclasts and the formation of new bone tissue by cells called osteoblasts.

However, sometimes this delicate balance between bone resorption and bone formation can be disrupted, leading to conditions like osteopenia. Osteopenia is often asymptomatic, meaning that it does not cause any noticeable symptoms.

"Bone remodelling is regulated by various cytokines (a type of immune protein), growth factors, and signalling pathways. The most important pathways in the bone remodelling model is the nuclear factor-kappa B (RANKL) pathway, crucial for osteoclast differentiation and activation. Osteoprotegerin (OPG), acts as a brake on excessive bone resorption. Imbalances in the RANKL/OPG ratio can tip the scale towards increased bone resorption.

Up until your 30’s, the balance lies slightly in favour of new bone being laid down, but from around the age of 30 in men and 35 in women this balance begins to shift the other way. If measures such as weight bearing exercise, good diet and avoiding smoking and alcohol are not adopted then this balance can slide to the point that your bone density starts to reduce. Eventually, if this process is not stopped your bones begin to thin."

Dr Thom Philips