Most midlife-aged women think about their bone health only when a friend or older family member is diagnosed with osteoporosis, a condition impacting more than 10 million women characterized by significantly decreased bone mineral quality and density…enough to predispose them to fractures, some of which end up being deadly. What they don’t realize: There’s a good chance they face a similar future themselves.
The bones of more than 34 million US women in their 40s, 50s and older are silently weakening with age. They have osteopenia, a common precursor to osteoporosis in which bone mass is decreasing but not yet low enough to meet osteoporosis’s diagnostic criteria. Osteopenia has no symptoms…these women often don’t even know they have it until they break a bone.
While you may not be having “osteopenia vs. osteoporosis” debates with your friends over coffee and pastries, knowing the difference between the two similarly named conditions…and understanding how to prevent osteopenia from turning into osteoporosis….is essential to staying strong and vibrant as you age. Bottom Line Personal asked Kristi DeSapri, MD, founding physician of Bone & Body Women’s Health, to explain how these conditions are connected and what to do to stay healthy…
Meaning “bone poverty” in Greek, osteopenia is just that—on the continuum of normal bone mass, women with osteopenia rank lower than those who have what is considered healthy bone mass for their age.
Losing bone mass is a normal part of aging. Bone mass typically peaks during adolescence and remains high through the third decade of life. But even during those peak decades of strength, bone is constantly undergoing remodeling, with old or damaged bone being broken down by cells called osteoclasts and replaced with new bone cells courtesy of osteoblasts. This is nature’s way of ensuring bones are as healthy and robust as possible, with osteoblast activity outpacing that of osteoclasts.
But around age 40, bone mass begins a gradual descent…then drops sharply at menopause. Why? Women’s bones are exquisitely sensitive to the loss of the hormone estrogen, which helps preserve skeletal strength and slows the natural breakdown of bone. In fact, most women lose 10% to 20% of their bone mass during menopause. Other risk factors for low bone mass include…
Any of these risk factors can predispose you to osteopenia. But—and this is a crucial but—there are no osteopenia symptoms. Most people have no idea they’re walking around with weakened bones until one of them fractures, usually from a fall or sudden movement that you wouldn’t typically expect to cause trouble, perhaps tripping over a curb, falling from a short step, falling in the sand or even from twisting at the waist or coughing. These are called low-trauma fractures, and by the time they occur, bone mass is so low that the person has full-blown osteoporosis.
An osteoporosis diagnosis means your bones have started losing mass and strength at such a fast pace that your osteoblasts can’t keep up with your osteoclasts, predisposing you to low-trauma fractures—usually in the wrist, hip and spine, though they also can occur in the arm, ribs and other locations. By age 80, about 30% to 35% of women will have received an osteoporosis diagnosis, but the actual number is likely higher due to underreporting. Beware: A woman’s lifetime risk of experiencing an osteoporosis-related fracture is equal to her risk for breast, ovarian and uterine cancer combined.
The same risk factors that predispose someone to osteopenia also can pave the way toward osteoporosis. Like osteopenia, osteoporosis is often asymptomatic, though some people may experience back pain (from small undiagnosed fractures)…a loss of two inches in height…a hunched back called kyphosis…and low-trauma fractures.
Doctors determine if a patient has healthy bones, osteopenia or osteoporosis with a painless test called dual-energy X-ray absorptiometry (DXA), which assesses bone density (a measure of bone mass and bone strength) in the hips, wrists and spine. The lower the score, called a T-score, the higher the fracture risk. A T-score lower than –2.5 is considered osteoporosis, while a T-score between –1 and –2.5 is osteopenia.
If you have osteopenia, is osteoporosis inevitable? Since you can’t count on osteopenia symptoms to warn you, you must proactively protect your skeletal well-being. The (Bone Health and Osteoporosis Foundation) recommends women at average risk for osteoporosis receive a baseline DXA scan at age 65 (and men at age 70), but having one or more risk factors warrants an earlier DXA. Your internist can help assess your risk and determine the proper DXA schedule for you.
DXA results can yield compelling information. If your T-score indicates osteopenia, you can start making changes to help you avoid osteoporosis. Even though every case of osteoporosis starts as osteopenia, not every case of osteopenia will turn into osteoporosis.
Osteopenia a “yellow light diagnosis”—meaning that you have an opportunity to stop and think, What steps can I take to keep this from turning into osteoporosis? (Osteoporosis is a more serious “red light” diagnosis.) Osteopenia isn’t reversible, but the right lifestyle changes, plus medication in some cases, can have a significant impact.
The following non-pharmacological osteopenia treatment strategies can help prevent osteopenia from evolving into osteoporosis…
Enhance your diet. Boost consumption of calcium-rich foods (milk, yogurt, cheese, tofu, almonds and leafy greens like spinach and kale) and vitamin D (eggs, oily fish like salmon and sardines, and mushrooms). Also consider supplementation—the Bone Health and Osteoporosis Foundation recommends 1,200 mg of calcium and 800 to 1,000 IU of vitamin D daily for women over 50.
Build weight-bearing activity into your day. Prioritize strength training, which exerts sufficient pressure on bones to stimulate osteoblasts, as well as higher-impact exercises such as jogging or anything involving jumping (jumping rope, HIIT-style moves, aerobics class). Research shows that moves like these, which exert an impact on bones four times one’s body weight, can improve bone density when done consistently over six to 12 months. These activities are safe for most women with osteopenia, but always clear any new exercise routines with your doctor. It’s also wise to incorporate balance training into your routine to minimize fall risk and, thus, the risk for fractures—nearly 90% of osteoporotic fractures are caused by falling.
Minimize alcohol consumption, and if you smoke, try to quit. Drinking more than seven alcoholic beverages a week raises your fall risk. And according to The Menopause Society, female smokers lose bone faster and have lower bone mass overall than nonsmokers.
Ask your doctor if osteopenia medication may be right for you. Prescription medication can help slow the progression of osteopenia to osteoporosis. These medications include…
Hormone Therapy (HT), also called menopausal hormone therapy (MHT). You likely associate HT with hot flashes, vaginal dryness and other menopausal symptoms, but bone loss is a symptom of menopause, too…and HT can help. Estrogen and progesterone, or estrogen alone in women who’ve had their uterus removed, can reduce bone breakdown, improving bone mineral density by 3% to 7% and reducing fracture risk by about 30% to 40%. HRT comes in many forms, including pills…transdermal patches, creams and gels…and vaginal rings.
Despite the HT backlash that occurred 20+ years ago as the result of the Women’s Health Initiative, we now know that many of those findings were flawed, and HRT is not only safe but also has multiple health benefits for most women in the years leading up to and immediately after menopause…and even into one’s 60s and 70s. Your doctor can explain potential risks, including a small increased risk for blood clots with oral HRT.
Women with a history of estrogen receptor-positive breast cancer…stroke or heart attack…unexplained or abnormal uterine bleeding…or elevated liver functions should not take HRT for osteopenia. Non-hormonal raloxifene (Evista) may be an alternative option. Part of the selective estrogen receptor modulator (SERM) class of medications, the daily pill acts similarly to estrogen in the bones but not in the breasts or uterus. (In fact, it’s prescribed to treat and prevent a type of breast cancer called ER-positive breast cancer.) Hot flashes and leg cramps or swelling are possible side effects.
Bisphosphonates. These intravenous (IV) and oral medications are FDA-approved for osteoporosis treatment and prevention in postmenopausal women. Their effects on bone density are similar to those of HRT. Alendronate (Fosamax), risedronate sodium (Actonel) and ibandronate (Boniva) are taken orally, while zoledronic acid (Reclast) is administered via IV.
Bisphosphonates pose a rare but serious risk. In some people, with prolonged use, they can increase risk for certain fractures, including thighbone fractures, a seemingly paradoxical effect attributed to the fact that bone rebuilt with bisphosphonates’ help tends to be more brittle and delicate than bone rebuilt with HT. To minimize this risk, some doctors recommend a “drug holiday” after three to five years. More common side effects with oral bisphosphonates are stomach upset and acid reflux.
Hearing “You have osteopenia” can take a psychological toll on patients, many of whom are in their 50s and 60s and feel like they’ve done everything right—run marathons, taken yoga classes for decades, eaten well—only to be diagnosed with a condition long-linked with being old and frail. Some patients drastically reduce their activity levels out of fear of a fracture.
Informed awareness is a crucial aspect of osteopenia treatment and includes not blaming yourself for your condition…trying to manage your stress levels (inflammatory chronic stress actually can increase osteoporosis risk)…and adopting the osteoporosis prevention strategies mentioned in this article. Schedule your first DXA by age 65 at the latest (according to Medicare data, less than 25% of US women undergo this vital screening), and follow your physician’s advice for repeat DXAs, usually every two years. You can safeguard the bone you have and avoid the risk for a potentially life-altering fracture. Remember: Not every case of osteopenia is destined to become osteoporosis!
