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Osteoporosis, Part 2: Testing and Treatments

In our last post, we started to look at osteoporosis, a disease that causes weak and brittle bones, often leading to other health issues and disability. We also examined the various risk factors — and yes, there are a large number of them. In this post, we’ll start turning to what you can do about osteoporosis. First, we’ll look at how your bones can be tested, and then we’ll begin to look at treatments.
Bone Density versus Bone Quality
As we’ve discussed, your bones are alive and dynamic. Even after you’ve reached your full height, you may still be adding to your bone mass (though after the age of 30 or so, it takes much more effort to maintain, let alone build up, bone mass).
In the past, osteoporosis was often only diagnosed after the patient had already experienced a fracture. Today, osteoporosis is often diagnosed with a bone density test. Bone density is measured by looking at x-rays to determine the amounts of calcium and other important minerals that are in a segment of bone. The x-ray images generally focus on areas of the body that are especially susceptible to osteoporosis fractures, including the wrist/forearm, spine, and hips. Scans done using smaller devices, looking at just your wrist, finger, or heel, can often be done at a clinic or pharmacy. More thorough scans of the spine or hips require a larger device, and are generally performed at hospitals.
Bone density tests give you two kinds of results. One is called your T score. This compares your bone density with the average for a healthy young adult of your sex. Your T score shows the number of standard deviations that your bone density is above or below the average. A T score of -1 or higher means you have normal bone density, while a T score between -1 and -2.5 implies you have osteopenia (a condition that is a precursor to osteoporosis). A T score below -2.5 indicates that you have osteoporosis.
Your other score is called your Z score. This also looks at your bone density compared with a norm, but in this case it is more specific. Your Z score compares your bone density with that of someone of your age, sex, weight, and racial or ethnic origin. A Z score less than -2 implies that something other than aging may be the underlying cause of your low bone density.
The updated National Osteoporosis Foundation guidelines include the use of a new algorithm from the World Health Organization (WHO) based on absolute fracture risk called FRAX. The FRAX algorithm takes into account not only your bone mineral density at the hip, but also nine specific clinical risk factors for osteoporosis and related fractures. This algorithm estimates the 10-year hip fracture probability and 10-year probability for all major osteoporosis-related fractures.
The higher the bone mineral content, the more dense your bones are. And the denser your bones are, the less likely you are to endure a fracture. Regular testing is necessary to determine whether you are experiencing active bone loss. Even a diagnosis of osteoporosis does not always mean bone loss is occurring. While low bone density is problematic, low bone density that remains stable is less problematic than low bone density combined with active bone loss.
There are different ways to determine if there is active bone loss or if density is stable. Two bone density exams from the exact same machine can be compared; however, as these are not always covered by insurance, this can be costly. Another test that can be more helpful for revealing active bone loss is a urine test that looks at specific bone markers. The urine NTX test looks at a specific bone marker — N-terminal telopeptide (NTX) — to measure bone turnover. When repeated, if the test shows an increase in NTX levels, this can indicate increased bone turnover. In those who have already been diagnosed with osteoporosis, this can mean that the disease is progressing more rapidly.
Bone density, however, only provides part of the picture. While the test can tell you your bone density, it does not help identify the cause. Further, it is possible for some people who have a low bone density to experience a fracture, while another person with the same bone density will not. This is because of bone quality, which cannot be measured, but is an important factor in determining the severity of osteoporosis. Bone density is part of bone quality, but bone quality is also related to many of the risk factors discussed in our previous post. Your bones, like the other living tissue in your body, are a reflection of what you put into your body. What you eat, the medications you take, the exercise you do (or don’t do), all impact the quality of your bones. While you may be unable to improve your bone density, with lifestyle changes it is possible to improve your bone quality. Better bone quality will reduce your risk of fractures.
Treatments for Osteoporosis
You have probably seen television commercials for many of the prescription medications that are purported to reduce the risk of fractures and increase bone density, featuring celebrities like Blythe Danner and Sally Field. For men as well as women, medications called bisphosphonates are commonly prescribed to treat osteoporosis. These include ibandronate (Boniva), risedronate (Actonel, Atelvia), alendronate (Fosamax, Binosto), and zoledronic acid (Reclast, Zometa). These treatments can be effective, but many people experience unpleasant side effects including nausea, abdominal pain, difficult swallowing, and an increased risk of esophageal ulcers or an inflamed esophagus. Long-term treatment with bisphosphonates has also been linked to rare problems where the femur (thigh bone) cracks or breaks, as well as a condition that causes the jawbone to deteriorate. If you are considering prescription medication for osteoporosis, you should talk with your doctor about the risks and benefits.
Osteoporosis and low bone density can also be treated with hormone replacement. Hormones activate osteoblasts, which are cells that build bones. For women, proper levels of estrogen, progesterone, and testosterone are important, while for men testosterone is key. Of course, as we age, levels of these hormones decrease. To help maintain healthy bones, these hormones should be supplemented. Measuring your hormone levels, which you can do with hormone tests at Rejuvé, is critical. Even though your hormone levels may be in the “normal range,” they may still not be at the optimal levels for promoting healthy bone density. Restoring hormone levels with treatments like bio-identical hormone replacement can help the body regain its ability to maintain bone density.
In addition to the sex hormones, other hormone levels can also impact bone density, and these should be tested as well. Thyroid and DHEA levels tend to decline with age, and are important to maintain for both men and women. With proper hormone testing, these levels can be balanced with supplements. Stress can also have an impact on hormones. High levels of stress can exacerbate the decline of the levels of these hormones, while at the same time flooding the body with cortisol. Cortisol spurs the breakdown of bone; this is another reason why balancing not only hormones, but also finding balance in your life, is key in preventing bone loss.
In our next post, the last in this series, we’ll take a much closer look at lifestyle changes you can make to mitigate the effects of osteoporosis, promote bone growth, and work to maintain a healthy bone density.