Osteoporosis

Overview

Definition

Osteoporosis is a progressive skeletal disease characterized by a reduction of bone mass, which can cause bone fractures and deformity. Osteoporosis affects over 25 million people each year—80% of them are women. Osteoporosis may be secondary to chronic liver or kidney disease, arthritis, or malabsorption diseases, or caused by prolonged use of corticosteroids. Rare forms include idiopathic or juvenile osteoporosis. Most common is postmenopausal osteoporosis, where accelerated bone resorption is the result of reduced estrogen, and involutional osteoporosis, characterized by the imbalance of bone resorption and formation.

Etiology

Most osteoporosis is caused by increasing bone resorption that is due to decreased estrogen and progesterone production following menopause. Additionally, women lose about 15% to 30% of their bone mass on average between the age of 30 and menopause. Decreased testosterone in aging men accelerates osteoporosis as well. Other causes include the following.

• Glucocorticoid and heparin use
• Juvenile osteoporosis—a rare disorder affecting children ages 8 to 14; self-limited, usually resolves in four to five years
• Renal failure
• Hyperthyroidism
• Hyperparathyroidism
• Hyperadrenalism
• Upper intestinal surgery
• Calcium, magnesium, and micronutrient deficiencies
• Low vitamin D intake and/or insufficient sunlight exposure
• Cushing's syndrome
• Anorexia nervosa
• Chronic heparin therapy
• Hypogonadism
• Exogenous glucocorticoid administration
• Thyrotoxicosis
• Hyperprolactinemia
• Low calcium absorption (low gastric acidity)
• Long term diuretic or antibiotic use

Risk Factors

• Women
• Age—25% of women at age 60 and 50% of women at age 75 have vertebral fractures
• Caucasians, Asians more prone to the condition
• Thin women with history of amenorrhea and low body fat
• Smokers; regular alcohol or caffeine drinkers; people whose diets are high in phosphates or low in calcium
• Family history
• Depression—effects hypothalamic–pituitary axis
• Sedentary lifestyle or prolonged immobilization
• Nulliparous women
• Heavy metal toxicity
• Chronic broad-spectrum antibiotic use (destroys normal intestinal flora, leading to malabsorption of nutrients and decreased vitamin K production)

Signs and Symptoms

• Periodontal disease—an early warning sign
• Loss of height
• Hunched back/spinal deformity
• Back pain
• Fracture without trauma

Differential Diagnosis

• Malignancies (e.g., multiple myeloma, lytic metastatic carcinoma)
• Osteomalacia
• Paget's disease
• Skeletal hyperparathyroidism

Diagnosis

Physical Examination

The patient with more established disease may have deformities (e.g., dorsal spine, wrist) and typically appears hunched. Distribution of weight changes in women with thickening in the waist and upper back and thinning of the hips and breasts. Periodic measurements demonstrate loss of height.

Laboratory Tests

• Urinary test—indicates breakdown of bone products
• Tests identify secondary osteoporosis or underlying illnesses but are normal with primary osteoporosis (e.g., serum calcium, phosphate, creatinine, or thyroid)
• Serum assays of bone-specific alkaline, phosphatase, osteocalcin, and C-terminal procollagen peptides help monitor effectiveness of therapy
• Thyroid function usually normal in primary forms of osteoporosis

Pathological Findings

• Decrease in cortical bone thickness and in the size and number of trabeculae of the cancellous bone
• Biochemical indices of bone absorption are usually increased
• Lack of estrogen decreases bone density, sensitivity of bone to parathyroid hormone (PTH), intestinal calcium absorption, and increases calcitonin and osteoclastic bone resorption
• Decrease in 1,25-dihydroxy vitamin D (calcitriol, the active form of vitamin D) causes lower calcium absorption and hypercalciuria

Imaging

Radiographic screening for bone loss may determine the need for treatment. Early changes of intervertebral space and accentuation of cortical plates, and late changes plate fractures and intervertebral compression and deformity will be seen on X ray. Current bone density does not predict future bone density.

• Quantitative digital radiography
• Single-photon absorptiometry of the forearm
• Dual-photon absorptiometry of the 2nd to 4th lumbar vertebrae
• Quantitative computerized tomography and dual energy X ray absorptiometry—measure cortical and trabecular bone and total body bone mineral density levels

Other Diagnostic Procedures

Risk factors are not diagnostic. Physical evidence may be present, and most compelling. The most reliable diagnostic tools are imaging techniques.

Treatment Options

Treatment Strategy

A variety of pharmacological, hormonal, and phytomedicinal treatments slow the effects of osteoporosis. Imaging must be repeated to insure adequate treatment is being given. Diet and exercise, with caution as to any increased mechanical stresses, may be essential to maximize treatment plans.

Drug Therapies

• Estrogen—slows bone loss and fractures by decreasing resorption, increasing intestinal calcium absorption, and lowering renal calcium excretion. It cannot increase bone growth. Bone loss resumes when treatment is stopped. Many practitioners advocate treating with the lowest dosage possible. Estrogen use may be correlated with an increased risk of breast cancer and uterine cancer, abnormal blood clotting, and gall bladder disease.
• Conjugated equine estrogens (e.g., Premarin 0.625 mg/day)—most commonly used form; can cause metabolic changes in the liver; contraindicated with obesity, smokers, high blood pressure or cholesterol, varicose veins
• Estradiol—most easily metabolized delivering estrogen directly into the blood stream; available in transdermal patch (e.g., Estraderm, 1.0 mg/day of estradiol, 0.05 mg/day of transcutaneous estrogen)
• Progesterone—enhances bone formation; may potentiate estrogen, allowing for lower estrogen dosage (e.g., medroxyprogesterone, 2.5 to 5 mg/day; progesterone, 0.625 mg, such as Provera); eliminates uterine cancer caused by estrogen therapy
• Calcium—1,000 mg/day for postmenopausal women on estrogen and 1,500 mg/day for those not on estrogen; preserves cortical bone mass, no effect on trabecular; taken early in life aids prevention; better absorption if taken with meals; no known adverse effects up to 2,500 mg/day
• Bisphosphonates (e.g., alendronate 10 mg/day)—alternative to estrogen; increases bone density and reduces fractures (take upon rising with eight ounces water; do not lie down or eat for 1/2 hour); side effects: esophagitis, especially with overdose, abdominal pain, heartburn, nausea
• Selective Estrogen Receptor Modulators (SERMS)—estrogen-like effects with reduced breast cancer risk (e.g., raloxifene, 60 mg/day); side effects: hot flashes or blood clotting (uncommon)
• Vitamin D—increases intestinal absorption of calcium and osteoblast activity (800 IU/day); take with calcium

Complementary and Alternative Therapies

Nutritional and herbal support, in particular, can slow bone loss and enhance absorption of essential vitamins and minerals. Weight-bearing exercise and stress management should be part of any program.

Nutrition

• Eliminate refined foods, alcohol, caffeine, tobacco, sugar, phosphorous (carbonated drinks and dairy products), aluminum-containing antacids, and high amounts of sodium chloride (table salt) and animal proteins. Sea salt, soy sauce, tamari, or kelp granules are preferable to table salt because they contain many other trace minerals.
• Increase intake of complex carbohydrates, essential fatty acids (cold-water fish, nuts, and seeds), legumes, and soy. Soy, although is has less calcium than dairy, contains calcium that is more readily absorbed. Isoflavones found in soy may inhibit bone resorption and increase bone building activity. Studies suggest 30 to 50mg/day of soy to optimize bone mass.
• Dark berries (blueberries, blackberries, cherries, and raspberries) contain anthocyanidins which help to stabilize collagen found in bone matrix.
• Mineral-rich foods, especially non-dairy sources of calcium, should be increased. Although dairy is a good source of calcium, it also contains high amounts of phosphorus which inhibits calcium absorption and increases urinary calcium excretion. Non-dairy sources of calcium, although lower in actual calcium content, may provide more bioavailable calcium. Particularly beneficial are almonds, black-strap molasses, dark leafy greens, sardines, sea vegetables, soy, tahini, prunes, and apricots.
• Calcium citrate or aspartate (1,000 to 1,500 mg/day) are the preferred forms of calcium. Calcium requires sufficient stomach acid (HCl) for adequate digestion and this is often low in the elderly. Calcium carbonate buffers stomach acid and may not be the best form. Oyster shell calcium may contain heavy metals or other contaminants and is poorly digested.
• Magnesium (200 mg bid to tid) enhances calcium uptake, is necessary for hormone production, and is cardioprotective. Magnesium may actually increase bone density and may be a more important factor than calcium.
• Vitamin K (100 to 500 mcg/day) is needed to produce osteocalcin, a protein found in bone tissue that increases calcium uptake. Vitamin K is produced by intestinal flora that may become depleted after antibiotic use. Foods high in vitamin K include dark leafy greens. Vitamin K may interfere with coumadin.
• Boron (0.5 to 3 mg/day) is needed for calcium absorption. Women at high risk for breast cancer should use boron with caution as some studies suggest that it increases estrogen metabolism.
• Manganese (5 to 20 mg/day) is a trace mineral that is often low in osteoporosis. It helps produce the collagen matrix onto which calcium is laid down.
• Zinc (10 to 30 mg/day) is needed for normal bone growth. Copper (1 to 2 mg/day) is often low in osteoporosis and is needed with long-term zinc supplementation.
• Chromium (200 to 600 mcg/day) should be used in patients with unstable blood sugars. Poor glucose regulation is associated with increased bone loss.
• Essential fatty acids (1,000 mg bid) are necessary for hormone production.
• B-complex (50 to 100 mg/day) reduces the effects of stress. Elevated cortisol levels from stress increase bone loss. Folic acid (1 to 5 mg/day), B₆ (100 mg/day), and B₁₂ (1,000 mcg/day) should be taken for hyperhomocysteinemia which interferes with collagen crosslinking.

Herbs

Herbs are generally a safe way to strengthen and tone the body's systems. As with any therapy, it is important to ascertain a diagnosis before pursuing treatment. Herbs may be used as dried extracts (capsules, powders, teas), glycerites (glycerine extracts), or tinctures (alcohol extracts). Unless otherwise indicated, teas should be made with 1 tsp. herb per cup of hot water. Steep covered 5 to 10 minutes for leaf or flowers, and 10 to 20 minutes for roots. Drink 2 to 4 cups/day. Tinctures may be used singly or in combination as noted.

• Some herbs have phyto-estrogen/progesterone properties. These can be used to support hormone levels which may minimize bone loss. Natural progesterone may be more effective at increasing bone density than synthetic progestins. It is important to note that natural progesterone may not be strong enough to offset the risk of uterine cancer posed by conventional estrogen replacement therapy. Other herbs can be used in osteoporosis to provide minerals and enhance digestion. Liver support is also recommended to help with metabolizing hormones and normalizing ratios. Chaste tree (Vitex agnus-cactus) and black cohosh (Cimicifuga racemosa) help to normalize pituitary function. Chaste tree must be taken long term (12 to 18 months) for maximum effectiveness. Standardized black cohosh is commercially available as Remifemin (one tablet bid) through Enzymatic Therapies. Use only under physician supervision with hormone therapy. Re-evaluate after six months of use.
• Black cohosh, licorice (Glycyrrhiza glabra), and squaw vine (Mitchella repens) help to balance estrogen levels. Licorice is contraindicated in hypertension.
• Chaste tree, wild yam (Dioscorea villosa), and lady's mantle (Alchemilla vulgaris) help to balance progesterone levels.
• Tea brewed from nettles is high in calcium.
• Kelp (Nereocystis luetkeana), bladderwrack (Fucus vesiculosis), oatstraw (Avena sativa), nettles (Urtica diocia), and horsetail (Equisetum arvense) are rich in minerals and may also help support a sluggish thyroid.
• Milk thistle (Silybum marianum), dandelion root (Taraxacum officinalis), vervain (Verbena hastata), and blue flag (Iris versicolor) support the liver and may help restore hormone ratios. Taken together as a tea before meals, they are slightly bitter and enhance digestion.
• Topical applications of natural progesterone may vary in the amount of active hormone they contain. Usually composed of wild yam, the natural progesterone sterols are converted in the laboratory to make them bioavailable. Progesterone levels should be checked periodically with natural progesterone use. Natural estrogen, an 80-10-10 mixture of estriol, estradiol, and estrone also works well as a substitute for premarin in doses of 2.5 to 10 mg/day. It may have less cancerogenic activity for the uterus and breast.

Homeopathy

An experienced homeopath should assess individual constitutional types and severity of disease to select the correct remedy and potency. For acute prescribing use three to five pellets of a 12X to 30C remedy every one to four hours until acute symptoms resolve. A combination of homeopathic tissue salts such as Calcarea carbonicum, Calcarea fluoricum, and Silica may be helpful. Take as directed.

Acupuncture

Acupuncture may be helpful in treating concurrent pathologies such as hormone imbalances and poor blood sugar control.

Massage

Therapeutic massage may be beneficial in enhancing circulation and increasing overall sense of well-being.

Patient Monitoring

Patients with identified osteoporosis, after stabilization, are seen yearly to assess and adjust therapy as necessary.

Other Considerations

Fluoride treatments increase cancellous bone at the expense of cortical bone (i.e., increases both bone density and bone fragility).

Prevention

Thirty percent of women will not be identified with osteoporosis without bone density tests, allowing initiation of treatment. Prevention of bone fracture is key to osteoporosis treatment. Weight bearing exercise before onset with proper diet and increased calcium and vitamin D, as well as many factors listed under "Drug Therapies" are actually preventive measures. Osteoporosis is thought to be a teenagers' disease as this is when its onset takes root. Adequate calcium/magnesium intake and proper nutrition, coupled with weight-bearing exercise throughout childhood and adulthood are the primary preventative measures for osteoporosis.

Complications/Sequelae

Fractures, the most common complication, are a significant cause of debility and death (e.g., 25% within a year of a hip fracture). Acute and chronic pain can be disabling, and result in associated depression and anxiety.

Prognosis

Osteoporosis will progress more rapidly without estrogen treatment but will progress regardless. Nearly 1.5 million fractures result each year, often causing chronic care status or death. In most patients, stabilization of skeletal manifestations and reduced pain should be predicted with aggressive therapy.

Pregnancy

The etiology is unknown for osteoporosis appearing during or just after pregnancy.

References

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