Osteoporosis is a disease of thinning bones that predisposes women to fractures caused by low
bone mass and disordered bone architecture. 10 million Americans are affected by osteoporosis,
most of whom are women. 1.5 million fractures occur every year in those suffering from
osteoporosis. 50% of women over fifty years of age will suffer an osteoporotic fracture in their
lifetime leading to pain, disability and even death. Hip fractures double the risk of death for women.
Osteopenia – a bone density T-Score between -1.0 and -2.5
Osteoporosis – a bone density T-Score at or below -2.5. Osteoporosis is a disease of the
bone characterized by a predisposition to fractures caused by low bone mass and
disordered bone architecture. Osteoporosis is also diagnosed by proving the presence of a
low-impact fracture of the hip, vertebrae or wrist.
DEXA Scan – (Dual Energy X-ray Absorptiometry) is the form of x-ray testing to determine a
woman’s (or man’s) bone mineral density (BMD).
T-Score – the score given by bone mineral density (BMD); the score is calculated by
comparing a woman’s BMD as compared to the normal bone density of a woman aged 25-
FRAX – a risk assessment tool offered by the World Health Organization (WHO) that helps
clinicians decide which patients with osteopenia should be offered medical treatment to
avoid an osteoporotic fracture. Components of the FRAX include the T-score at the hip, age,
personal history of a previous fracture, weight, height, history of glucocorticoid (steroid) use,
cigarette use, consumption of more than 3 alcoholic beverages per day, history of
rheumatoid arthritis, history of a parent with a hip fracture and history of disease that causes
osteoporosis (e.g. hyperthyroidism, parathyroid tumor). The FRAX score can be calculated
online at http://www.shef.ac.uk/FRAX/. This tool calculates the 10-year risk of sustaining
either an osteoporotic hip fracture or an other osteoporotic fracture (i.e. of the spine or wrist).
Who should have a DEXA Scan to determine her BMD?
1. Women 65 and older
2. Women 50 to 65 if risk factors or clinical concerns are present
3. Any woman who sustains a low-trauma fracture.
Lifestyle modifications for prevention and treatment:
1. Calcium 1500 mg daily
2. Vitamin D3 1000 IU
3. Daily weight-bearing and muscle strengthening exercises
4. Stop smoking
5. Decrease alcohol consumption to no more than 1 drink per day (i.e. 12 oz. of beer, 5 oz.
of wine or 1.25 oz of hard liquor)
Who should be considered for medical treatment?
1. Women with osteoporosis (BMD less than or equal to -2.5)
2. Women with osteopenia whose FRAX score indicates a hip fracture risk of greater than
or equal to 3% or an overall osteoporotic fracture risk of 20% over the next ten years.
Medical treatment options
1. Bisphosphonates (most common medical treatment).
Bisphosphonates must be taken with plain water (tablets 6-8 oz; oral solution follow with 2
oz) first thing in the morning and ≥30 minutes before the first food, beverage, or other
medication of the day; remain elevated fro 30-60 minutes after taking.
Most common side effects: abdominal pain, reflux, diarrhea, headache, body aches, rash,
Severe side effects: Atrial fibrillation, ulcer formation, hypertension, low serum calcium, low
serum phosphate, severe joint and muscle pain, osteonecrosis of the jaw. . (Women who
have taken bisphosphonates for three or more years should discontinue the medication for
three months prior to invasive dental surgery.) The bisphosphonate can be restarted once
the bone is healed.
Contraindications: kidney disease, underlying GI disease
- Fosamax (alendronate) taken daily, weekly
- Boniva (ibandronate) taken daily, monthly or I.V. every 3 months
- Actonel (risedronate) taken daily, weekly or monthly
2. Hormone therapy (estrogen or estrogen + progesterone)
Daily oral dose
Not recommended for primary treatment of osteoporosis or osteopenia. Possible
complications with hormone therapy include clot formation, stroke, heart attack, Alzheimer’s
3. Evista (raloxifene) is a Selective Estrogen Receptor Modulator (SERM)
Daily oral dose
Most common side effects: hot flashes, swelling, muscle aches, headaches, flu-like
symptoms and infections including bronchitis.
Rare but serious side effects: increased clotting, stroke, elevated triglycerides
Contraindicated in women with clotting disorders, kidney disease, heart disease, abnormal
uterine bleeding, pregnancy and breastfeeding
4. Teriparatide (parathyroid hormone)
Daily nostril spray
Most common side effects: rhinitis, back pain
Suggested follow up:
1. Reassess BMD in 1-2 years. If bone density is stable or improving, continue therapy. If
not, consider a new regimen and reassess in 1-2 years.
2. Measure fasting cross-linked N-telopeptides of type I collagen (NTX) or serum type I
collagen C-telopeptides (CTX) before and 6 months after initiating therapy. Therapy is
adequate if markers are reduced by 50%.
1. Barbieri RL. Are you assessing risk and discussing new treatments for osteoporosis? Sexuality,
Reproduction & Menopause 2008;6(3):8-11