Let's Talk About Osteoporosis Treatment
When bones are weak, staving off further damage and preventing a fracture are both important. Read up on the moves, meds and other treatments proven to help.by Krista Bennett DeMaio Health Writer
If you’re one of the 10 million Americans with osteoporosis, a condition marked by low bone density and porous, brittle bones, it can be scary walking around thinking that you could very easily suffer a fracture. But know this: the right treatment can significantly lower that risk—by almost half, according to research. So what’s the best treatment plan for you? Can you rebuild bone once osteoporosis sets in? And are there side effects to be prepared for? We know you have questions, and we have the answers you need.
Our Pro Panel
We went to some of the nation's top osteoporosis experts to bring you the most scientific and up-to-date information possible.
Saika Sharmeen, M.D.
Rheumatologist and Assistant Professor
Renaissance School of Medicine, Stony Brook University
Stony Brook, NY
Eliana Cardozo, D.O.
Physiatrist and Assistant Professor
Rehabilitation and Physical Medicine at Mount Sinai Hospital
New York, NY
Stephen Liu, M.D.
Clinical Assistant Professor
UCLA School of Medicine
Los Angeles, CA
Beyond lifestyle upgrades like following a nourishing diet that includes calcium and vitamin D, and doing weight-bearing exercises most days, there are natural remedies that hold promise for osteoporosis. Small studies have suggested acupuncture may increase bone growth in people with the condition. Tai Chi has been noted to reduce falling in elderly folks. Research has also suggested soy isoflavones, which are phytoestrogens, may slow bone loss, but not enough to replace conventional osteoporosis medications.
It’s unlikely that you’ll see a complete osteoporosis reversal or cure, but with medication and lifestyle changes, you may be able to improve your bone density and T-score, getting your bones out of the danger zone for breakage. Doctors say the goal of treating osteoporosis is stability and preventing fractures.
Unlike many other conditions, there’s no one specialist for osteoporosis. Your internist and gynecologist may suggest a routine bone density screening. Osteoporosis can also be diagnosed and treated by endocrinologists because of its hormonal connection, rheumatologists (who treat conditions affecting joints and bones), physiatrists (who treat joints, muscles, bones, nerves, ligaments, and tendons), and orthopedists (who treat fractures).
That’s a no. Current osteoporosis guidelines are to treat with bisphosphonates for up to three years, and if your bone density improves, then take a break—what’s known as a drug holiday. Bisphosphonates linger in your bones after you stop taking it, so you’re still getting protection. More high-risk fracture patients should remain on them for up to ten years. The anabolic agents can only be given for a year or two, depending on the drug, due to the potential side effects of long-term use.
What’s Osteoporosis, Again? Let’s Recap!
Osteoporosis translates to porous, or soft, bones. While healthy bones are pocked with small holes that give them a honeycomb-like appearance, osteoporosis occurs when you lose too much bone mass, developing large holes in your bones (think: Swiss cheese) that make them brittle, weak and prone to breaking.
When does this start to happen? Usually not until mid-life. You spend the first few decades of your life building bone mass. By age 30, you’ve hit your peak bone mass—the max amount of bone you’ll have in your lifetime. For the next two decades, your bone mass will stay pretty stable. You’ll lose some bone, but you’ll also make new bone, a process called remodeling. Around age 50 and beyond though (earlier if you have certain underlying health conditions) bone loss starts to pick up the pace, especially if you’re a postmenopausal woman (when estrogen wanes, bone mass tends to as well).
If your bone loss outpaces bone growth, you have the osteoporosis pathophysiology—the process that leads to the bone-thinning disease. Without treatment (usually in the form of medications), your bone loss and fragility will worsen, leaving you prone to breaks and fractures. It doesn’t take a fall to cause an injury—even twisting a weird way can cause a break when your bones are vulnerable.
Fortunately, with the right treatment, fitness plan and a solid diet, you may be able to improve your bone density to some extent, even after it’s reached the point of osteoporosis, or at least stave off further damage. That’s because (like those folks on HGTV), your bones are always doing some rebuilding and remodeling, so there’s the potential for improvement. Still, doctors define success on osteoporosis treatment as stability: Retaining the bone mass you have, rather than building more of it.
So, How Do I Know If I Have Osteoporosis?
Osteoporosis is a silent disease. There aren’t any symptoms, so many people don’t find out they have it until they fracture a bone. Others get the news during a routine bone mineral density screening (BMD) for osteoporosis called a bone densitometry scan (a.k.a. DXA or DEXA scan). This X-ray-like test uses a small amount of radiation to measure the minerals in your bone, which tells your physician how weak (or strong) it is. The results come in the form of a T-score—a measure of how much your bone density differs from a 30-year-old at peak bone mass. How to read your T-score?
-1 and higher is considered normal—you’ve got healthy bones
-1.0 to -2.4 is indicative of low bone density, or osteopenia (a potential precursor to osteoporosis).
-2.5 and below means you have osteoporosis.
Your physician may recommend a bone density scan if you’re at risk for osteoporosis. For example, you’re a postmenopausal woman with a family history of osteoporosis or you have a history of taking steroids, which can deteriorate bone health, or if you’ve recently fractured a bone. Otherwise, the recommendation is to screen women over 65 and men over 70.
What Kind of Fractures Does Osteoporosis Cause?
Your diagnosis might not come from a screening or scan, but in the sudden pain of a snap. A fracture, the medical term for a broken bone, is often the wake-up call that your bones are weak. Typically, bones break from trauma (like, say, that fall off the elementary school monkey bars that landed you in a cast all summer), but if you have an underlying condition such as osteoporosis that erodes your bones, you can fracture from very little force—a stumble or even twisting the wrong way. Areas like the hip and spine are particularly susceptible. Here’s a look at the fractures you may face.
Most commonly associated with osteoporosis:
Compression fracture: The bones crush and flatten. When you have osteoporosis, this is common in the vertebrae in the spine, and known as a collapsed vertebrae. Some people walk around not even knowing they have an injury. They may have a nagging back ache. More advanced signs can include loss of height and a curved spine.
Fragility fracture: This is a fracture that occurs from standing height or less, meaning with very low trauma. Because a fall from this height is typically not enough to cause a break unless bones are already weak, a fragility fracture is often a red flag for your physician that osteoporosis is at play.
Other fractures linked to osteoporosis:
Linear fracture: When the bone break runs in a straight line, along the bone shaft.
Open vs. closed fracture: An open fracture means the skin is broken too (and the bone is protruding). It’s also called a compound fracture. With a closed fracture, the skin is still intact.
Stress fracture: This is a hairline crack in the outer layer of the bone, typically due to repetitive movements such as running. It’s also known as a bone fissure.
Partial fracture: This occurs when the bone didn’t break all the way through as it does with a complete fracture.
How to know if you could have a fracture? The following are signs:
loss of mobility
If you’re nursing any of these symptoms, call your doc, who will confirm a fracture with imaging. Typically, your doc will do an X-ray, but magnetic resonance imaging (MRI), computed tomography (CT scan), and a bone scan can detect fractures, too.
How Are Fractures Treated?
As you might suspect, the hip and spine aren’t easy areas to cast, so how do bones heal? In some cases, rest, pain medication, hot and cold therapy, a brace, and/or physical therapy does the trick. If your pain is gradually lessening and you’re regaining your range of motion, you’re on the road to recovery, which takes about six to eight weeks on average.
Other times, surgery is required for more complex bone repair. If there are bone fragments involved, or if resetting the bone is particularly difficult, your physician may need to put in screws, pins, plates, or rods to hold the bone in place. A hip fracture, for instance, may require a partial or full hip replacement.
If a spinal fracture doesn’t heal on his own, surgery such as kyphoplasty may be needed. With this procedure, the doctor uses small balloons to expand the space between the collapsed vertebra. The balloons are removed and that space is cemented. Similarly, a vertebroplasty involves injecting cement into the cracked vertebra, although a study published in the British Medical Journal suggested the latter isn’t effective and doesn’t improve quality of life.
What Are the Medications For Osteoporosis?
So, if you do have osteoporosis, what are your treatment options? That will depend on just how severe your condition has become. If you’ve been diagnosed after a fracture, drugs are the go-to to prevent a future break. If you have not had a fracture, but your score on a fracture risk assessment tool (known as a FRAX Test) indicates a moderate-to-high risk of fracture within the next 10 years, you may also require drug therapy. On the other hand, if you’re in your 50’s, active, at low risk of a fracture and otherwise healthy, you may not be given treatment at all, but just monitored and encouraged to make certain lifestyle changes. (More on what those changes are in a moment.)
The National Osteoporosis Foundation recommends starting drug therapy in the following three groups of postmenopausal women, as well as men under 50, who:
Have a history of hip or vertebral fracture
Have a T-score from a bone density scan under -2.5 at the femoral neck or spine, after a doctor rules out any other possible causes
Have a T-score from a bone density scan between -1 and -2.5 at the femoral neck or spine, and a 10-year probability of hip fracture under 3%, or a 10-year probability of any major osteoporosis-related fracture less than 20%
For patients falling into any of these three categories, the different classes of osteoporotic drugs include:
These drugs, taken orally or intravenously, are usually the first line defense for moderate osteoporosis in postmenopausal women and men. They work by slowing cells called osteoclasts, which break down bone. Bisphosphonates come with side effects like nausea, heartburn, esophageal irritation, gastric ulcers, bone, joint, and muscle pain. If you take them through IV, you may experience flu-like symptoms. Bisphosphonates can also cause osteonecrosis to the jaw, which is low blood supply to the jaw bone. However, it’s mostly linked to the high doses given to cancer patients. People who have reduced kidney function may also need careful monitoring by their doctor. The most common bisphosphonates include:
Binosto (Alendronate), taken orally
Actonel and Atelvia (Risedronate), taken orally
Boniva (Ibandronate), taken orally
Reclast (Zoledronic acid), taken intravenously
If you can’t tolerate the side effects of a bisphosphonate, your doctor may suggest Prolia or Xgeva (denosumab), an injection given every six months to slow bone loss. One effect to watch out for: increased risk of vertebral fractures after discontinuation of therapy, which has been associated with accelerated bone loss. One strategy to combat this is to take a bisphosphonate upon termination of RANKL inhibitor therapy.
Estrogen and Estrogen-like Treatments
Hormone replacement therapy (HRT) isn’t the go-to for osteoporosis because it’s associated with serious health concerns including breast cancer, blood clots, and heart disease. But if you’re dealing with severe menopausal symptoms and osteoporosis, it’s nice to know that estrogen replacement is an available option.
For a woman who has a high risk of breast cancer, selective estrogen receptor modulators (SERMs) are an alternative. SERMS act like hormones, but don’t carry the same risk, though you may experience hot flashes, flu-like symptoms and an increased risk of blood clots. Examples of SERMS include:
Duavee (Bazedoxifene), which combines estrogen with an estrogen antagonist to treat menopause symptoms; shown to boost bone density in the hip and lumbar spine
For more severe cases of osteoporosis, your physician may move to an injection that stimulates osteoblasts, cells that build new bone. While on treatment, you may experience headaches, nausea and fatigue. Anabolic agents can only be given for one to two years, depending on the specific drug, to limit serious side effects, including the development of osteosarcoma, a type of bone cancer. After that, you may go on an anti-resorptive to maintain new bone growth. Anabolic agents include:
There have been attempts at combining anabolic agents with other treatments for osteoporosis, like bisphosphonates. The concept is simple: Bisphosphonates prevent bone resorption, and anabolic agents induce new bone formation. Theoretically, a combination should be more potent. However, in reality, this approach hasn't borne out as some researchers had hoped. Studies have either not shown any additive benefit (like with bisphosphonates), or the benefit is quite small (like with SERMs, estrogen, or denosumab). Therefore, a combination therapy is currently not recommended.
Are Osteoporosis Drugs a Lifelong Commitment?
Not necessarily. Women with a high risk of fractures should be treated with meds, but then reassessed after three to five years, according to new osteoporosis treatment guidelines for postmenopausal women from the Endocrine Society, published in The Journal of Endocrinology & Metabolism, If they’re no longer at risk, women can take what’s known as a drug holiday while being monitored by their physician.
For how long should you stay on hiatus? A Loyola Medicine study found that about 15% of patients on a break from treatment experienced fractures, with the majority of them occurring in the fourth and fifth years off meds. Your physician will track changes in your bone density every two years or so.
Eat For Better Bones
Changes to your diet can help boost bone strength, whether you have a mild case of low bone density and you’re not being treated with medication, or you’re on osteoporosis drugs. How to eat smarter?
Prioritize calcium: This is the biggest bone-builder, and women should aim for 1200 mg a day; men should get 1,000 mg. If you think you’re falling short of this number, then you should consider a supplement. Take no more of 500 mg at a time (you can take it a couple of times a day) until you meet that magic number. Foods rich in calcium include:
Fortified foods such as cereals and juices
Say “yes” to Vitamin D: You need an adequate amount to absorb calcium. In addition to sunlight, of course, you can get your lot through foods such as vitamin-D fortified milk and fatty fish. If your vitamin D levels are low (your doctor can check with a blood test), you can take a supplement. Adults over 50 need 800 to 1,000 IUs of vitamin D a day.
Don’t forget other key vitamins and minerals: Play favorites with these when you’re filling your plate:
Magnesium (spinach, collard greens, sweet potatoes)
Potassium (bananas, tomatoes, raisins)
Vitamin C (citrus fruits, strawberries, red peppers)
Vitamin K (kale, Brussel sprouts, collard greens)
Consider a Mediterranean-based diet: Research suggests a Mediterranean diet—one rich in fruit, vegetables, nuts, unrefined cereals, olive oil, and fish—may support bone health This approach to eating can reduce bone loss in those with osteoporosis in just 12 months, a study of more than 1,000 participants between the ages of 65 and 79 showed.
Work in Weight-Bearing Exercise
Exercise builds strong muscles and bones, of course, so breaking a sweat is key when you’re trying to shore up bone density. Choose weight-bearing exercises—those that require you to support your body weight such as walking, jogging, dancing, tai chi, etc., as well as strength and resistance training. These exercises put just enough stress on your bones to stimulate new growth. You’ll want to get your heart pumping at least three times a week to maintain bone density or even improve it.
Yoga in particular can be a boon for your bones. A study published in Topics in Geriatric Rehabilitation tracking 741 participants for 10 years showed that 227 of those participants (with an average age of 68 and low bone density) who practiced yoga every other day for two years, showed significant improvement in spinal bone density by the end of the study. You’ll want to avoid spinal twists though. Poses that flex the spine beyond its limits can increase the risk of compression fracture in those with low bone density, according to a study in Mayo Clinic Proceedings. Not exactly a Zen move!
Avoid a Fall
To state the (very) obvious: If you don’t fall, you’re less likely to fracture a bone. You can also see a physical therapist or personal trainer to work on your balance and core strength, but daily lifestyle and environment tweaks are just as important. Shore up your chances of staying safely upright by:
Removing tripping hazards in your home (loose rugs, furniture, etc.)
Wearing low-heeled shoes with rubber soles for better grips
Always holding handrails when going downstairs
Making all of these changes—cleaning up your diet, moving more, making your environment safer, taking medication—may seem overwhelming. But by focusing on just one positive tweak at a time, you’ll be closer and closer to your end goal: Living a full life with osteoporosis.
Stubbing out a smoking habit is crucial. A recent clinical study evaluated a set of female twins, one of whom smoked a pack of cigarettes per day throughout her adult life. The smoking sibling was found to have 5% to 10% reduced bone density compared to her twin, who never smoked. What's more, among post-menopausal women who take estrogen for bone health but also light up, smoking reduces the levels of protective estrogen in the body, potentially negating any gains made. If you smoke, do everything in your power to quit. For tips and support, check out the American Heart Association for help to stop smoking.
- Osteoporosis Facts and Figures: National Osteoporosis Foundation. (n.d.). cdn.nof.org/wp-content/uploads/2015/12/Osteoporosis-Fast-Facts.pdf
- Vertebroplasty and Pain Relief: British Medical Journal. (2018). “Vertebroplasty Versus Sham Procedure For Painful Acute Osteoporotic Vertebral Compression Fractures.” bmj.com/content/361/bmj.k1551
- Combining Osteoporosis Drug Therapies: Journal of Bone and Mineral Research. (2011). “Effects of Intravenous Zoledronic Acid Plus Subcutaneous Teriparatide [rhPTH(1-34)] in Postmenopausal Osteoporosis.” ncbi.nlm.nih.gov/pubmed/20814967
- Drug Holidays and Fracture Risk: Loyala University Medical Center (2018). “Osteoporosis Patients Who Take ‘Drug Holidays’ Suffer Bone Fractures. loyolamedicine.org/news/osteo-drug-holidays-bone-fractures
- Mediterranean Diet and Osteoporosis: Nutrients. (2019). “Adherence to a Mediterranean Diet and Bone Mineral Density in Spanish Premenopausal Women.” ncbi.nlm.nih.gov/pmc/articles/PMC6470744/
- Yoga for Osteoporosis: Topics in Geriatric Rehabilitation. (2016). “Twelve-Minute Daily Yoga Regimen Reverses Osteoporotic Bone Loss.” ncbi.nlm.nih.gov/pmc/articles/PMC4851231/
- Yoga Exercises to Avoid for Osteoporosis: Mayo Clinic Proceedings. (2019). “Soft Tissue and Bony Injuries Attributed to the Practice of Yoga: A Biomechanical Analysis and Implications for Management.” mayoclinicproceedings.org/article/S0025-6196(18)30940-6/fulltext
- Soy and Osteoporosis: Clinical Calcium. (2005). “Recommended Soy and Soy Products Intake to Prevent Bone Fracture and Osteoporosis.” ncbi.nlm.nih.gov/pubmed/16062011