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Introduction

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break.

It's a fairly common condition that affects around three million people in the UK. More than 300,000 people receive hospital treatment for fragility fractures (fractures that occur from standing height or less) every year as a result of osteoporosis.

Wrist fractures, hip fractures and fractures of the vertebrae (bones in the spine) are the most common type of breaks that affect people with osteoporosis. However, they can also occur in other bones, such as in the arm, ribs or pelvis.

There are usually no warnings you've developed osteoporosis and it's often only diagnosed when a bone is fractured after even minor falls.

What causes osteoporosis?

During childhood, bones grow and repair very quickly, but this process slows as you get older.

Bones stop growing in length between the ages of 16 and 18, but continue to increase in density until you're in your late 20s.

You gradually start to lose bone density from about 35 years of age. Women lose bone rapidly in the first few years after themenopause (when monthly periods stop and the ovaries stop producing an egg).

Losing bone is a normal part of the ageing process, but for some people it can lead to osteoporosis and an increased risk of fractures.

Other factors that increase your risk of developing osteoporosis include:

  • inflammatory conditions, such as rheumatoid arthritis, Crohn's disease and chronic obstructive pulmonary disorder (COPD)

  • conditions that affect the hormone-producing glands, such as an overactive thyroid gland (hyperthyroidism) or an overactive parathyroid gland (hyperparathyroidism)

  • a family history of osteoporosis, particularly history of a hip fracture in a parent  

  • long-term use of certain medications that affect bone strength or hormone levels, such as oral prednisolone

  • malabsorption problems

  • heavy drinking and smoking

Diagnosing osteoporosis

If your doctor suspects you have osteoporosis, they can make an assessment using an online programme, such as FRAX or Q-Fracture. They may also refer you for a scan to measure your bone mineral density.

This type of scan is known as a DEXA (DXA) scan. It's a short, painless procedure and your bone mineral density can then be used to assess your fracture risk.

Treating osteoporosis

Treatment for osteoporosis is based on treating and preventing fractures and using medication to strengthen bones.

The decision about what treatment you have – if any – will depend on your risk of fracture. This will be based on a number of factors, such as your age and the results of your DXA scan.

Preventing osteoporosis

If you're at risk of developing osteoporosis, you should take steps to help keep your bones healthy. This may include:

  • taking regular exercise

  • healthy eating, including foods rich in calcium and vitamin D

  • making lifestyle changes, such as giving up smoking and reducing your alcohol consumption.

Living with osteoporosis

If you're diagnosed with osteoporosis, there are steps you can take to reduce your chances of a fall, such as removing hazards from your home and having regular sight tests and hearing tests.

To help you recover from a fracture, you can try using:

  • hot and cold treatments such as warm baths and cold packs

  • transcutaneous electrical nerve stimulation (TENS) – where a small battery-operated device is used to stimulate the nerves and reduce pain

  • relaxation techniques

Speak to your GP or nurse if you're worried about living with a long-term condition. They may be able to answer any questions you have.

You may also find it helpful to talk to a trained counsellor or psychologist or other people with the condition.

The National Osteoporosis Society can put you in touch with local support groups, and they also have an online discussion forum.

Symptoms of osteoporosis

Osteoporosis develops slowly over several years.

There are often no warning signs or symptoms until a minor fall or a sudden impact causes a bone fracture.

Healthy bones should be able to withstand a fall from standing height, so a bone that breaks in these circumstances is known as a fragility fracture.

The most common injuries in people with osteoporosis are:

  • wrist fractures

  • hip fractures

  • fractures of the spinal bones (vertebrae)

Sometimes a cough or sneeze can cause a rib fracture or the partial collapse of one of the bones of the spine.

In older people, a fractured bone can be serious and result in long-term disability. For example, a hip fracture may lead to long-term mobility problems.

Although a fracture is the first sign of osteoporosis, some older people develop the characteristic stooping (bent forward). It happens when the bones in the spine have fractured, making it difficult to support the weight of the body.

Is osteoporosis painful?

Osteoporosis isn't usually painful until it causes a fracture.

Although not always painful, spinal fractures are the most common cause of long-term (chronic) pain associated with osteoporosis.

Causes of osteoporosis 

Osteoporosis causes bones to become less dense and more fragile. Some people are more at risk than others.

Bones are at their thickest and strongest in your early adult life and their density increases until your late 20s. But you gradually start losing bone density from around the age of 35.

This happens to everyone, but some people develop osteoporosis and lose bone density much faster than normal. This means they are at greater risk of a fracture.

Risk groupsf

Osteoporosis can affect men and women. It's more common in older people, but it can also affect younger people.

Women

Women are more at risk of developing osteoporosis than men because the hormone changes that occur in the menopause directly affect bone density.

The female hormone oestrogen is essential for healthy bones. After themenopause (when monthly periods stop), oestrogen levels fall. This can lead to a rapid decrease in bone density.

Women are at even greater risk of developing osteoporosis if they have:

  • an early menopause (before 45 years of age)

  • a hysterectomy (removal of the womb) before the age of 45, particularly when the ovaries are also removed

  • absent periods for more than six months as a result of overexercising or too much dieting

Men

In most cases, the cause of osteoporosis in men is unknown. However, there's a link to the male hormone testosterone, which helps keep the bones healthy.

Men continue producing testosterone into old age, but the risk of osteoporosis is increased in men with low levels of testosterone.

In around half of men, the exact cause of low testosterone levels is unknown, but known causes include:

  • the use of certain medications, such as oral glucocorticoids

  • alcohol misuse

  • hypogonadism (a condition that causes abnormally low testosterone levels)

Risk factors

Many hormones in the body can affect the process of bone turnover. If you have a condition of the hormone-producing glands, you may have a higher risk of developing osteoporosis.

Hormone-related conditions that can trigger osteoporosis include:

  • hyperthyroidism (overactive thyroid gland)

  • disorders of the adrenal glands, such as Cushing's syndrome

  • reduced amounts of sex hormones (oestrogen and testosterone)

  • disorders of the pituitary gland

  • hyperparathyroidism (overactivity of the parathyroid glands)

Other risk factors

Other factors thought to increase the risk of osteoporosis and broken bones include:

  • a family history of osteoporosis

  • a parental history of hip fracture

  • a body mass index (BMI) of 19 or less

  • long-term use of high-dose oral corticosteroids (widely used for conditions such as arthritis and asthma), which can affect bone strength

  • having an eating disorder, such as anorexia or bulimia

  • heavy drinking and smoking

  • rheumatoid arthritis

  • malabsorption problems, as experienced in coeliac diseaseand Crohn's disease

  • some medications used to treat breast cancer and prostate cancer which affect hormone levels

  • long periods of inactivity, such as long-term bed rest

Diagnosing osteoporosis 

Osteoporosis is often diagnosed after weakened bones have led to a fracture.

If you're at risk of developing osteoporosis, your GP may refer you for a bone mineral density scan, known as a dual energy X-ray absorptiometry (DEXA, or DXA) scan.

Normal X-rays are a useful way of identifying fractures, but they aren't a reliable method of measuring bone density.

DEXA (DXA) scan

DEXA scan can be used to help diagnose osteoporosis. It's a quick, safe and painless procedure that usually takes about five minutes, depending on the part of the body being scanned.

The scan measures your bone mineral density and compares it to the bone mineral density of a healthy young adult and someone who's the same age and sex as you.

The difference between the density of your bones and that of a healthy young adult is calculated as a standard deviation (SD) and is called a T score.

Standard deviation is a measure of variability based on an average or expected value. A T score of:

  • above -1 SD is normal 

  • between -1 and -2.5 SD is defined as decreased bone mineral density compared with peak bone mass

  • below -2.5 is defined as osteoporosis

Although a bone density scan can help diagnose osteoporosis, your bone mineral density result isn't the only factor that determines your risk of fracturing a bone.

Your age, sex and any previous injuries will need to be taken into consideration before deciding whether you need treatment for osteoporosis.

Your doctor can help you take positive steps to improve your bone health. If you need treatment, they can also suggest the safest and most effective treatment plan for you. 

The FRAX tool

The World Health Organization (WHO) has developed a 10-yearFracture Risk Assessment Tool to help predict a person's risk of fracture between the ages of 40 and 90.

The tool is based on bone mineral density and other relevant risk factors, such as age and sex.

The algorithms used give a 10-year probability of hip fracture and a 10-year probability of a major fracture in the spine, hip, shoulder orforearm.

Treating osteoporosis 

Treating osteoporosis involves treating and preventing fractures and using medication to strengthen bones.

Preventing falls and fractures

The Department of Health's National Service Framework (NSF) for Older People provides doctors and other healthcare professionals with guidance about caring for older people.

An important objective for health services across England is to try to prevent falls and fractures. This is of particular concern for people who've been diagnosed with osteoporosis and those with risk factors for osteoporosis.

The key messages for older people and their family and carers are:

  • falls are a risk as you get older, but aren't inevitable – there are measures you can take to prevent falls or reduce the harm that might be caused by falling

  • staying active and healthy – for example, through exercise and diet – is likely to keep you independent and reduce your risk of falling

  • if you're unsteady on your feet or fall, speak to your GP so possiblecauses of falls, such as poor eyesight, certain medications, and poor muscle strength and balance, can be identified and treated.

Treatment overview 

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Although a diagnosis of osteoporosis is based on the results of your bone mineral density scan (DEXA or DXA scan), the decision about what treatment you need – if any – will also be based on a number of other factors. These include your:

  • age

  • sex

  • risk of fracture

  • previous injury history

If you've been diagnosed with osteoporosis because you've had a fracture, you should still receive treatment to try to reduce your risk of further fractures.

You may not need or want to take medication to treat osteoporosis. However, you should ensure that you're maintaining sufficient levels of calcium and vitamin D. To achieve this, your healthcare team will ask you about your current diet and may recommend making changes or taking supplements.

NICE recommendations

The National Institute for Health and Care Excellence (NICE) has made some recommendations about who should be treated with medication for osteoporosis.

A number of factors are taken into consideration before deciding which medication to use. These include your:

  • age

  • bone mineral density (measured by your T score)

  • risk factors for fracture

NICE has summarised its guidance for two groups of people:

  • postmenopausal women with osteoporosis who haven't had a fracture (primary prevention)

  • postmenopausal women with osteoporosis who've had a fracture (secondary prevention)

  • NICE guidance: Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women

  • NICE guidance: Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women  

Preventing osteoporosis 

Your genes are responsible for determining your height and the strength of your skeleton, but lifestyle factors such as diet and exercise influence how healthy your bones are.

Regular exercise

Regular exercise is essential. Adults aged 19 to 64 should do at least 150 minutes (2 hours and 30 minutes) of moderate-intensity aerobic activity, such as cycling or fast walking, every week.

Weight-bearing exercise and resistance exercise are particularly important for improving bone density and helping to prevent osteoporosis.

As well as aerobic exercise, adults aged 19 to 64 should also do muscle-strengthening activities on two or more days a week by working all the major muscle groups, including the legs, hips, back, abdomen, chest, shoulders and arms.

If you've been diagnosed with osteoporosis, it's a good idea to talk to your GP or health specialist before starting a new exercise programme to make sure it's right for you.

  • strength exercises

  • balance exercises

  • flexibility exercises

  • sitting exercises

Weight-bearing exercises

Weight-bearing exercises are exercises where your feet and legs support your weight. High-impact weight-bearing exercises, such asrunning, skipping, dancing, aerobics, and even jumping up and down on the spot, are all useful ways to strengthen your muscles, ligaments and joints.

When exercising, wear footwear that provides your ankles and feet with adequate support, such as trainers or walking boots.

People over the age of 60 can also benefit from regular weight-bearing exercise. This can include brisk walking, keep-fit classes or a game of tennis. Swimming and cycling aren't weight-bearing exercises, however.

Resistance exercises

Resistance exercises use muscle strength, where the action of the tendons pulling on the bones boosts bone strength. Examples include press-ups, weightlifting or using weight equipment at a gym.

If you've recently joined a gym or haven't been for a while, your gym will probably offer you an induction. This involves being shown how to use the equipment and having exercise techniques recommended to you.

Always ask an instructor for help if you're not sure how to use a piece of gym equipment or how to do a particular exercise.

Healthy eating

Eating a healthy balanced diet is recommended for everyone. It can help prevent many serious health conditions, including heart disease, diabetes and many forms of cancer, as well as osteoporosis.

Calcium is important for maintaining strong bones. Adults need 700mg a day, which you should be able to get from your daily diet. Calcium-rich foods include leafy green vegetables, dried fruit, tofu and yoghurt.

Vitamin D is also important for healthy bones and teeth because it helps your body absorb calcium. Vitamin D can be found in eggs, milkand oily fish.

However, most vitamin D is made in the skin in response to sunlight. Short exposure to sunlight without wearing sunscreen (10 minutes twice a day) throughout the summer should provide you with enough vitamin D for the whole year.

Certain groups of people may be at risk of not getting enough vitamin D. These include:

  • people who are housebound or particularly frail

  • people with a poor diet

  • people who keep covered up in sunlight because they wear total sun block or adhere to a certain dress code

  • women who are pregnant or breastfeeding

If you're at risk of not getting enough vitamin D through your diet or lifestyle, you can take a vitamin D supplement. For adults, 10 micrograms a day of vitamin D is recommended.

The recommended amount for children is 7 micrograms for babies under six months, and 8.5 micrograms for children aged six months to three years. Talk to your GP for more information.

Other factors

Other lifestyle factors that can help prevent osteoporosis include:

  • quitting smoking – smoking is associated with an increased risk of osteoporosis

  • limiting your alcohol intake – the recommended daily limit is 3-4 units of alcohol for men and 2-3 units for women; it's also important to avoid binge drinking

Get some sun!

Between May and September, sunlight triggers the production ofvitamin D, which helps your body absorb calcium.

This process helps strengthen teeth and bones, which in turn helps prevent conditions such as osteoporosis.

Living with osteoporosis 

Having osteoporosis doesn't mean you'll definitely have a fracture.

There are measures you can take to reduce your risk of a fall or break.

Preventing falls

Making some simple changes at home can help reduce the risk of fracturing or breaking a bone in a fall. 

Check your home for hazards you may trip over, such as trailing wires. Make sure rugs and carpets are secure, and keep rubber mats by the sink and in the bath to prevent slipping.

Have regular sight tests and hearing tests. Some older people may need to wear special protectors over their hips to cushion a fall. Your GP can offer help and advice about changes to your lifestyle.

The National Institute for Health and Care Excellence (NICE) has also produced guidance called Falls: the assessment and prevention of falls in older people.

Healthy eating and exercise

Regular exercise and a healthy diet are important for everyone, not just people with osteoporosis. They can help prevent many serious conditions, including heart disease and many forms of cancer.

You should ensure you have a balanced diet that contains all the food groups to give your body the nutrition it needs. Exercising regularly can increase bone strength, relieve stress and reduce fatigue.

The National Osteoporosis Society has produced leaflets about Exercise and osteoporosis (PDF, 1.6Mb) and Healthy living for strong bones (PDF, 2.37Mb) that give further information and advice about diet and exercise.

Getting support 

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Your GP or nurse may be able to answer any questions you have about living with osteoporosis and can reassure you if you're worried.

You may also find it helpful to talk to a trained counsellor or psychologist, or to someone at a specialist helpline. Your GP surgery will have information about these.

Some people find it helpful to talk to others with osteoporosis, either at a local support group or in an internet chat room.

Osteoporosis support

The National Osteoporosis Society provide a helpline service run by nurses with specialist knowledge of osteoporosis and bone health.

Call 0845 450 0230 or 01767 472 721. You can also email them at nurses@nos.org.uk.

They can provide you with details of local support groups and also have an online discussion forum.

Fragile bones

Fragile bones