Osteoporosis is a disease where decreased bone strength increases the risk of a broken bone. Typical fragility fractures occur in the vertebral column, rib, hip, and wrist (Pic. 1). Osteoporotic fractures are those that occur in situations where healthy people would not normally break a bone. Until a broken bone occurs there are typically no symptoms. Bones may weaken to such a degree that a break may occur with minor stress or spontaneously. Chronic pain and a decreased ability to carry out normal activities may occur following a broken bone, e.g. patients may show a curved back from compression fractures of back bones.

There are two forms of osteoporosis - primary and secondary. The cause of primary osteoporosis is not clearly defined. These include osteoporosis associated with aging, which is a natural loss of bone mass in the elderly (Pic. 2), but also postmenopausal osteoporosis, which develops in about one third of women after menopause.

The secondary form of osteoporosis is caused by increased leaching of calcium from the bones, which are subject to specific causes, e.g. a particular disease, certain medications, or poor nutritional habits.

The emergence of osteoporosis is therefore involved various factors; some of them do not know or are not directly affected. Among those that can affect the most is proper nutrition and exercise.

Osteoporosis may be due to lower than normal peak bone mass and greater than normal bone loss. It is more common in women than men and the likelihood increases after menopause (Pic. 3) due to lower levels of estrogen, while in men, a decrease in testosterone levels has a comparable (but less pronounced) effect. Osteoporosis may also occur due to a number of diseases or treatments including surgical removal of the ovaries and anorexia (secondary osteoporosis). About 15% of white people in their 50s and 70% of those over 80 are affected. 

In addition, osteoporosis is a recognized complication of specific diseases and disorders. Medication use is theoretically modifiable, although in many cases, the use of medication that increases osteoporosis risk may be unavoidable.

The diagnosis of osteoporosis can be made using conventional radiography and by measuring the bone mineral density (BMD; an amount of bone mineral in bone tissue). The most popular method of measuring BMD is dual-energy X-ray absorptiometry (Pic. 4) that uses two X-ray beams aimed at the patient’s bones. In addition to the detection of abnormal BMD, the diagnosis of osteoporosis requires investigations into potentially modifiable underlying causes; this may be done with blood tests. Depending on the likelihood of an underlying problem, investigations for cancer with metastasis to the bone, multiple myeloma, Cushing's disease (an increased secretion of adrenocorticotropic hormone (ACTH) from the anterior pituitary) and other above-mentioned causes may be performed.

BMD is a robust predictor of fracture risk and its evaluation is the first step in determining who needs to be treated. Patients at high risk of fracture are most likely to benefit from treatment to reduce fracture risk. Approaches to identifying patients for treatment vary in different world regions according to fracture incidence, available healthcare resources, economic considerations, political will, and cultural priorities.

Prevention of osteoporosis or low BMD is preferred to treatment. Bone microarchitectural changes associated with bone loss are largely irreversible. Although treatment can increase BMD and reduce the risk of fracture, it is unlikely to fully restore the quality and strength of bone to normal. BMD in adults is determined by peak bone mass (PBM), which is the maximum bone mass achieved in life, and the subsequent rate of bone loss. The prevention of osteoporosis or low BMD is directed to maximizing PBM and minimizing the rate of bone loss, with the ultimate goal of maintaining bone strength and preventing fractures. Stabilizing BMD or reducing the rate of bone loss is the primary objective in the prevention of osteoporosis once PBM has been attained. The Surgeon General's report on Bone Health and Osteoporosis recommends a "pyramid" approach to the prevention and treatment of osteoporosis, with a foundation of lifestyle changes that include nutrition, physical activity, and fall prevention; a second tier of addressing drugs and diseases associated with bone loss or osteoporosis; and a third tier of pharmacological therapy.

A program of physical exercises for osteoporotic people should include: strength exercises, weight bearing and impact exercises, flexibility, coordination and balance activities and cardiovascular conditioning. These factors are important because they contribute directly to a better quality of life for osteoporotic patients, decreasing the risk of falls and providing them with the opportunity of having a more active life style, therefore avoiding, greater bone loss caused by inactivity. These recommendations indicate that not only highly osteogenic exercises (e.g. strength training and running) are indicated in the treatment and prevention of osteoporosis. The development of balance and coordination leads the subject to have more body consciousness, with a reduced fall risk. Aerobic exercises also benefit osteoporotic patients by giving them more determination for daily activities, allowing them to develop the habit of a more active lifestyle.

Kallmann syndrome

Kallmann syndrome (KS) is a rare genetic condition that is characterized by a failure to start or a failure to complete puberty. Kallmann syndrome occurs due to a failure of the hypothalamus to release gonadotropin-releasing hormone (GnRH) at the appropriate time.

One possible side effect of having KS is the increased risk of developing secondary osteoporosis or osteopenia (weak bones that are still strong enough that they wouldn't break easily during a fall). Estrogen (females) or testosterone (males) is essential for maintaining bone density. Deficiency in either testosterone or estrogen can increase the rate of bone resorption while at the same time slowing down the rate of bone formation. Overall this can lead to weakened, fragile bones which have a higher tendency to fracture.

Anorexia nervosa

Anorexia nervosa is a serious psychiatric illness characterized by failure to maintain a minimally normal weight, intense fear of gaining weight or becoming fat, and preoccupations about body shape and weight. Due to insufficient food intake in patients anorexia can lead to malnutrition (diet doesn't contain the right amount of nutrients) or hypovitaminosis (deficiency of one or more vitamins). Nutrition has an important and complex role in maintenance of good bone. High blood acidity may be diet-related, and is a known opposition against the bones. 

Probably more than half of young women with anorexia nervosa develop osteoporosis, and relatively quickly. Males with anorexia nervosa also have osteopenia and osteoporosis. Weight restoration is by far the most effective and evidence-based approach for prevention and treatment of low bone density. Weight gain normalizes hormone levels which play important roles in regulating bone health.

Premature ovarian failure

Premature ovarian failure (POF) is the loss of function of the ovaries before age 40. Hormonally, POF is defined by abnormally low levels of estrogen and high levels of follicle-stimulating hormone (FSH), which demonstrate that the ovaries are no longer responding to circulating FSH by producing estrogen and developing fertile eggs. Generally, osteoporosis or decreased bone density affects almost all women with POF due to an insufficiency of estrogen. 

Menstrual cycle disorders

Amenorrhoea is the absence of a menstrual period in a woman of reproductive age. When a woman is experiencing amenorrhoea, an eating disorder, and osteoporosis together, this is called female athlete triad syndrome. A lack of eating causes amenorrhoea and bone loss leading to osteopenia and sometimes progressing to osteoporosis.

Menopause

Women lose bone mass more quickly than men starting at about 50 years of age. This occurs because 50 is the approximate age at which women go through menopause. Not only do their menstrual periods lessen and eventually cease, but their ovaries reduce in size and then cease the production of estrogen, a hormone that promotes the production of bone mass.

Ovariectomy

Ovariectomy is the surgical removal of an ovary or ovaries. Ovariectomy is associated with an increased risk of osteoporosis and bone fractures. A potential risk for ovariectomy performed after menopause is not fully elucidated. 

Reduced levels of testosterone in women are predictive (foretelling) of height loss, which may occur as a result of reduced bone density. In women under the age of 50 who have undergone oophorectomy, hormone replacement therapy (HRT) is often used to offset the negative effects of sudden hormonal loss (for example early-onset osteoporosis) as well as menopausal problems like hot flushes (also called "hot flashes") that are usually more severe than those experienced by women undergoing natural menopause.

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Sources

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DEXA scanner in use ALSPAC ―by Nick Smith photography licensed under CC BY-SA 3.0
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