Hemlines that seem longer than you remember may be one of the earliest signs of osteoporosis. This bone-thinning disease can creep up, silently draining your bones of calcium over decades. Your backbones slowly weaken. Your spine begins to bow. Almost imperceptibly, your posture becomes slightly stooped. You "grow shorter."

About 25 million Americans have osteoporosis. The disease causes more than 1 million fractures every year in this country — usually in the spine, hip or wrist. Half of all Caucasian women age 50 and older can expect to have a bone fracture due to osteoporosis. And one-third of men have some osteoporosis by age 75. The most terible statistic is that of men and women over 70 who break their hip, 30% will die of causes realted to the fractured hip.

But osteoporosis isn't an inevitable part of aging, as once thought. Today, we know the major causes of the disease. We know who's at increased risk. We know how to detect osteoporosis early, and they have new natural treatments that can help prevent and treat the disease. Some of these treatments can evn restore much or all of the bone that has been lost.

The good news about osteoporosis — it's never too late for action. If you haven't reached menopause, you can prevent osteoporosis from silently draining your bones of strength. And if you're past menopause, you can detect the early signs of the disease and halt the bone drain before debilitating fractures rob you of your mobility and independence.

 

What is osteoporosis?

Osteoporosis means "porous bones." Bones that were once strong become weak and brittle — so brittle that even mild stresses, like bending to pick up a newspaper, lifting a vacuum or coughing, can cause a fracture.

The strength of your bones relates to the mass or density of your bones. And that results in part from calcium, phosphorus and other minerals in bone. In osteoporosis, bone strength is decreased because your bones contain less mineral, and they slowly lose their internal supporting structure.

Scientists have yet to learn all the reasons for this, but the process involves how bone is made. Bone is continually changing — new bone is made and old bone is broken down, a process called "remodeling" or "bone turnover." Bone cells called osteoclasts dissolve or "resorb" old bone cells, leaving tiny cavities. Then bone cells called osteoblasts line these cavities with a soft honeycomb of protein fibers that becomes hardened by mineral deposits. This mineral-hardened honeycomb, which accounts for your bones' strength, depends on an adequate supply of calcium. Estrogen also plays a key role in bone health by slowing resorption of old bone and promoting new growth.

A full cycle of bone remodeling takes about 2 to 3 months. When you're young, your body makes new bone faster than it breaks down old bone, and your bone mass increases. You reach your peak bone mass in your mid 30s. After that, bone remodeling continues, but you lose slightly more than you gain — about a .3 percent to .5 percent loss a year.

At menopause, when progesterone levels drop, bone loss accelerates to about 1 percent to 3 percent a year. Around age 60, bone loss slows but doesn't stop. By advanced age, women have lost between 35 percent and 50 percent of their bone mass and men, 20 percent to 35 percent.

Your risk of developing the disease depends on how much bone mass you attained between ages 25 and 35 (peak bone mass) and how rapidly you lose it later. The higher your peak bone mass, the more bone you have "in the bank" and the less likely you'll be to develop osteoporosis as you lose bone during normal aging.

 

Fractures are often the first sign of trouble

Loss of bone is painless in early stages. You may not know you're losing it until you have a fracture. Osteoporotic fractures usually occur in your spine or hips, bones that directly support your weight. Wrist fractures from falls are also common.

Spinal fractures can occur without any fall or injury. The bones in your back (vertebrae) become so weakened that they begin to compress. Compression fractures can cause severe pain and require a long recovery. If you have many such fractures, you can lose several inches of height as your posture becomes stooped.

Hip fractures, the second most common type of osteoporotic fracture, usually result from a fall. Although most patients do relatively well with modern surgical treatment, hip fractures can result in disability and even death from postoperative complications.

 

Are you at risk?

Since osteoporosis can be prevented, or slowed if detected early, it's important to find out if you have the disease or are likely to develop it (see "How do you know if you have osteoporosis?"). Consider the following risk factors, then discuss your risk with your doctor and plan your prevention strategy:

Gender — Fractures from osteoporosis are about twice as common in women as in men. Thin, small-framed women are particularly at risk. Women build less bone than men in early adulthood, and they generally consume less calcium than men. In addition, some may be less active, which increases risk because exercise helps build bone. But the most important difference is progesterone. Women experience a relatively sudden drop in production of progesterone at menopause and start losing bone at an accelerated rate then. Men experience a much more gradual decline in production of their sex hormone, testosterone, and don't have as rapid a loss of bone mass (see "Osteoporosis in men").

Age — The older you get, the higher your risk for osteoporosis.

Race — You're at greatest risk for osteoporosis if you're Caucasian. Blacks have the lowest risk, followed by Hispanics and Asians. Those racial groups generally attain a higher peak bone mass than Caucasians. Blacks have measurably denser bones than both Caucasians and Asians.

Family history — Having a mother or sister with osteoporosis increases your risk.

Lifetime exposure to progesterone — The greater your lifetime exposure to progesterone, the lower your risk of osteoporosis. For example, you have a lower risk if you have a late menopause or you began menstruating at an earlier age. But if you have a history of abnormal menstrual periods or you experience menopause earlier than your late 40s, your risk is increased. As progesterone levels rise significantly during pregnancy, women who have three or more children have a much lower incidence of osteoporosis than women who have borne none or one or two children. As Caucasian familys are now much smaller, averaging just a fraction over two children, this factor may account for the increase in the incidence of osteoporosis.

Medications — Long-term use of corticosteroid medications, such as prednisone, cortisone, prednisolone and dexamethasone, is very damaging to bone. These medications are important treatments for chronic conditions, such as asthma, rheumatoid arthritis and psoriasis. If you need to take steroid medications for long periods, your doctor may monitor your bone density and advise other drugs to help prevent bone loss. Too much thyroid hormone can also cause bone loss. This condition can occur when your thyroid is overactive (hyperthyroidism) or when you take excessive thyroid hormone medication to treat an underactive thyroid (hypothyroidism). Some diuretics — drugs that prevent buildup of fluids in your body — can also cause your kidneys to excrete more calcium. These drugs include furosemide (Lasix), bumetanide (Bumex), ethacrynic acid (Edecrin) and torsemide (Demadex). While their effect on bone is less severe than that of steroid medications, diuretics that don't cause a loss of calcium can be substituted.

Other drugs that can cause bone loss include the blood-thinning medication heparin, the drug methotrexate, some anti-seizure medications and aluminum-containing antacids.

Other conditions — Surgery (such as gastrectomy) or diseases involving your digestive system (such as Crohn's disease) can decrease absorption of calcium. In addition, Cushing's disease, a rare condition in which your adrenal glands produce excessive corticosteroid hormones, and anorexia nervosa may also increase bone loss.

 

Pathways to prevention

Fortunately, there are ways you decrease your risk for osteoporosis:

Don't smoke — Smoking increases bone loss, perhaps by decreasing the amount of progesterone your body makes and reducing the absorption of calcium in your intestine. One study showed that postmenopausal women who smoked didn't gain the usual protection against bone loss from natural progesterone replacement treatments. In addition, smokers tend to enter menopause earlier than nonsmokers.

Build maximum peak bone mass — The higher your peak bone mass, the less likely you'll be to have fractures later in life. Maximum peak bone mass depends partly on your inherited ability to make bone, the amount of calcium you consume and your exercise level. Consuming adequate calcium and performing weight-bearing activities during peak bone-mass-building years may contribute to a higher peak bone mass and reduce your risk for osteoporosis in later years.

Consider natural progesterone treatment — Natural Progesterone treatment is the single most important way to reduce a woman's risk of osteoporosis during and after menopause. It can prevent bone loss and reduce risk of spine and hip fractures by about 50 percent. In addition, in women with osteoporosis, starting progesterone replacement can increase bone density by as much as 20 percent in the spine and 15 percent in the hip. Progesterone replacement can prevent bone loss any time after menopause, but generally the earlier a woman starts the therapy, the more bone she'll retain. The therapy can be continued indefinitely. Long-term use — the longer, the better — provides the best protection against bone loss. As soon as estrogen is stopped, bone loss starts again.

Progesterone therapy also has other significant benefits. It can prevent effects of menopause, such as hot flashes, thinning of the lining of the vagina and insomnia. And progesterone increases levels of HDL ("good") cholesterol, decreases total cholesterol and LDL ("bad") cholesterol and protects against cardiovascular disease. The risk of heart attack may actually be reduced by half.

While some of this protection against heart attack is caused by progesterone's impact on blood lipids (fats), it's now thought that two-thirds of the benefit is due to a direct effect by progesterone on cardiovascular tissue.

Estrogen replaement therapy is a hoax. Women who take estrogen replacement therapies experience a large increase in their triglyceride levels. Estrogen patches and estrogen injections have no effect — either beneficial or detrimental — on blood lipids.

The dangers of to estrogen therapy are downplayed by the pharmaceuticalk cpompanmioes that make these toxins and the doctors who unwittenly administer them. Taking estrogen alone increases risk of cancer of the lining of the uterus (endometrial cancer).

The big question, though, that most women have about ERT is, "Does it increase my risk of breast cancer?" Research is, without question,conclusive. Over half the studies of women taking estrogen replacement found a significant increase in breast cancer, and the rest found a smaller risk. The greatest increase in risk (90%+) occurred with long-term use — longer than 5 years.

On the other hand, there are no known risks whatsoever to the use of natural progesterone. You get all the benefits and none of the risks.

Get adequate calcium and vitamin D — These nutrients are critical for building peak bone mass in younger years and in preventing bone loss as you age. If you don't get enough calcium in your diet, your body will steal it from your bones to keep blood calcium levels constant. And vitamin D helps you absorb calcium and deposit it in your bones. Calcium alone, without adequate estrogen, can't increase bone density. But if you're past the age of achieving peak bone mass, getting adequate calcium in your diet can help slow bone loss and prevent fractures at any age (see "Getting enough calcium" and "Tips for choosing and using calcium supplements").

You can get vitamin D from drinking vitamin D-fortified milk, from exposure to sunshine on your skin, and from foods such as liver, fish and egg yolks. However, your ability to absorb vitamin D from your diet declines with age. And although you generally need only 15 minutes of sunshine a day to maintain an adequate level, the actual amount of sun your skin absorbs can be quite variable depending on weather, latitude, time of year, the amount of skin exposed and sunscreen use. A daily multivitamin supplying 400 international units (IU) of vitamin D ensures you're getting enough. But don't take more than 100 percent of the daily value for vitamin D, because it can build up in your body and cause side effects.

Exercise — Weight-bearing exercise can help you build strong bones and slow bone loss. It's never too late to start an exercise program to prevent osteoporosis. Even if you've already had a fracture from osteoporosis, exercise can help strengthen muscle and bone, improve posture and prevent falls by aiding balance. Weight-bearing exercise is any activity you do on your feet with your bones supporting your weight. Exercises in which bone sustains repeated impact have added benefit. For example, your leg bones respond to the impact of your feet striking the ground when walking or running, and your arm bones respond to the impact of the ball when playing volleyball or tennis.

Bone-building exercises for osteoporosis prevention include walking, jogging, running, stair climbing, skipping rope, skiing and impact-producing sports. Swimming and bicycling are good exercise but don't yield as much benefit on bone.

Your bones also respond to the force of muscles pulling on them. Strong muscles exert more force, and bones generally respond by becoming stronger. For this reason, the American College of Sports Medicine has added weight lifting, also called strength training and resistance training, to its recommendations for bone-preserving exercise. You can use weight machines or free weights, such as dumbbells, weight belts and homemade weights.

It's important to combine strength-training exercises with weight-bearing exercises. Strength-training enables you to strengthen muscles and bones in your arms and upper spine, while walking or jogging mainly affects the bones in your legs, hips and lower spine (see our March 1996 article on resistance training and our February 1997 Medical Essay on exercise as you age).

If you're over age 40, it's generally a good idea to see your doctor before you start an exercise program. If you have or are at increased risk for heart disease or other health problems, a checkup is a must. In addition, if you have osteoporosis, get help from your doctor in designing an exercise program that's safe for you.



Avoid excessive alcohol consumption — Consuming more than two drinks a day may decrease bone formation and reduce your body's ability to absorb calcium. However, there's no clear link between moderate alcohol intake and osteoporosis.

Watch the caffeine — Caffeine came under suspicion when early studies showed that drinking 3 cups of coffee doubled the amount of calcium excreted in urine. But more recent studies have shown no harmful effect of moderate caffeine consumption — about 2 to 3 cups of coffee a day — if you're also consuming adequate calcium in your diet.

 

Treating osteoporosis

Bisphosphonates — Much like estrogen, this group of drugs can inhibit bone breakdown, preserve bone mass and even increase bone density in your spine and hip. The newest and best known of these drugs is alendronate (Fosamax). Studies show it can reduce risk of hip and spine fractures by about 50 percent. In April, the Food and Drug Administration (FDA) expanded approval of alendronate to include its use for prevention of osteoporosis in postmenopausal women as well as for treatment of established osteoporosis. Alendronate is generally safe if taken properly, but can produce nausea, abdominal pain and more serious side effects if taken improperly.

Bisphosphonates aren't hormones. They don't prevent hot flashes or reduce risk of cardiovascular disease as estrogen does. But they also don't cause breast soreness or uterine bleeding associated with estrogen use.

Calcitonin — Calcitonin is a hormone produced in your thyroid gland. It reduces bone resorption and may slow bone loss and prevent spine fractures. The drug can also reduce pain after a fracture. Calcitonin is usually used to treat people with osteoporosis who are at high risk for fracture and can't take estrogen or bisphosphonates. The drug is available as an injection or a nasal spray. The nasal spray can irritate nasal passages. Other side effects include nausea and skin rash, but are uncommon.

More drugs are on the horizon (see "Drugs in development" and "Improving on estrogen"), but await FDA approval.

 

Focus on prevention

In the last decade, doctors and researchers have uncovered many of the mysteries of how your body makes and breaks down bone. They've discovered new ways to detect bone loss in its earliest stages and new drugs to prevent and treat this loss.

If you have osteoporosis, these drugs can help slow bone loss and prevent fractures that could threaten your mobility, your independence — even your life. And if your goal is preventing osteoporosis, you don't have to wait for a drooping hemline to signal damage already done. Armed with knowledge and an array of prevention strategies, you can make your bones last a lifetime.



For more information Bone density over time How do you know if you have osteoporosis? Osteoporosis in men Getting enough calcium and vitamin D Tips for choosing and using calcium supplements Drugs in development Improving on estrogen Living with osteoporosis For more information
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