Osteoporosis

Overview

Osteoporosis is a condition in which the bones lose density and their internal structure becomes thinner and more fragile, so that they break more easily than they should. A fracture that would not happen in a healthy bone — after a minor fall from standing height, or sometimes with no obvious injury at all — is the hallmark of the condition.

Bone is living tissue that is constantly renewed throughout life, with old bone removed and new bone laid down. Up to early adulthood, bone is built up to a peak; later, the balance gradually shifts towards loss. Osteoporosis develops when this loss is enough to leave the bones fragile. It is common, especially after the menopause and in later life, and the fractures it causes — most often of the wrist, hip, and spine — are a major cause of pain, lost independence, and, in the case of hip fractures, serious ill health.

The encouraging point is that osteoporosis can be measured before a fracture happens and effectively treated, so much of the harm it causes is preventable.

Symptoms

Osteoporosis itself is silent. It causes no pain or outward sign until a bone breaks, which is why it is sometimes called a hidden condition. Many people first learn they have it only after a fracture from a minor fall.

Fractures in the spine can occur without a fall and may be missed at first. Over time, several such fractures can cause a gradual loss of height, a stooped upper back, and persistent back pain. Because there are usually no warning symptoms, identifying people at risk and testing them — rather than waiting for a fracture — is central to managing osteoporosis well.

Causes and risk factors

Bone density naturally falls with age, and in women the fall in oestrogen after the menopause markedly speeds bone loss, which is why osteoporosis is particularly common in older women. Men are affected too, especially at older ages.

Many other factors raise the risk: a previous fragility fracture, a family history of osteoporosis or hip fracture, low body weight, smoking, and heavy alcohol use. Long-term use of steroid tablets is an important and common cause. Several medical conditions — including overactive thyroid or parathyroid glands, inflammatory rheumatic diseases, coeliac disease, and early menopause — weaken bone, as do low calcium and low vitamin D. Some of these risks can be changed, which is part of what treatment addresses.

Diagnosis

Osteoporosis is diagnosed by measuring bone density with a DEXA scan — a quick, painless, low-dose X-ray, usually of the hip and spine. The result is expressed as a score that compares the bone with that of a healthy young adult, and defines whether bone density is normal, mildly reduced, or in the osteoporosis range.

Because fractures depend on more than density alone, doctors combine the scan with a person’s overall risk, often using a fracture-risk calculator that takes account of age, previous fractures, steroid use, and other factors. This gives a fuller estimate of the chance of a fracture and helps decide who will benefit from treatment.

Investigations

The main investigation is the DEXA bone density scan. Blood tests are usually done to look for treatable contributors and to exclude other causes of weak bones — typically checking calcium, vitamin D, kidney and liver function, thyroid function, and, where relevant, tests for conditions such as coeliac disease or hormonal problems.

If a spinal fracture is suspected, X-rays or a specialised scan can confirm it. In selected cases, further tests are arranged to investigate an underlying cause, particularly in younger people or when bone loss is more severe than expected.

Treatment

Treatment aims to strengthen bone and prevent fractures, and combines lifestyle measures with medicines where the fracture risk warrants them. Everyone benefits from enough calcium and vitamin D, weight-bearing and muscle-strengthening exercise, stopping smoking, moderating alcohol, and steps to reduce the risk of falls.

When the fracture risk is high, bone-protecting medicines make a substantial difference. The most commonly used are the bisphosphonates, which slow bone loss and are taken as tablets or given by drip; other options, including medicines that actively build bone, are used for higher-risk situations or when bisphosphonates are unsuitable. These treatments meaningfully reduce the chance of future fractures, and the choice and duration are tailored to the individual and reviewed over time.

Living with osteoporosis

Bone-friendly habits support any treatment: a diet with enough calcium, adequate vitamin D, regular weight-bearing and strengthening exercise, not smoking, and limiting alcohol. Exercise also improves balance and muscle strength, which helps prevent the falls that lead to fractures.

Making the home safer is one of the most practical steps — good lighting, removing loose rugs and trailing cables, using non-slip mats, and fitting grab rails where needed. Having an eyesight check and reviewing any medicines that cause dizziness also reduce falls. With treatment and these measures, most people with osteoporosis substantially lower their risk of fractures and keep their independence.