Osteoporosis

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osteoporosis, disease characterized by the thinning of bones, with a consequent tendency to sustain fractures from minor stresses. Osteoporosis is the most common metabolic bone disease, and its name literally means “porous bone.” The disorder is most common in postmenopausal women over age 50. It is estimated that approximately one-fourth of the world’s population of women over age 60 have some degree of osteoporosis. For these women, fracture is a leading cause of morbidity and mortality.

In affected persons the tiny rigid plates forming the honeycombed matrixes within bone gradually become thinner and rodlike, and the spaces between them grow larger. The bone thus becomes more porous and weaker. These lighter and more fragile bones tend to fracture from minor traumas and stresses that ordinarily would have no ill effects. The gradual progression toward osteoporosis results from changes in the balance between the amount of new bone that is formed within the body and the amount of bone that is resorbed, or broken down and assimilated. Thus, the disease may arise from either decreased bone formation or increased bone resorption. Because there is less bone per unit volume, the decrease in bone density of osteoporosis is great. Measurements of bone density (bone densitometry) define osteoporosis by a T score of –2.5 (2.5 standard deviations below normal peak bone density based on sex and genetic background) or lower.

Bone mass reaches its peak during young adulthood. Then, after a period of stability, there is a slow but steady loss of bone beginning about age 40. In women, normal aging and menopause significantly increase susceptibility to osteoporosis. Bone loss accelerates after menopause as a result of the associated decline in the production of estrogen and other sex hormones. Other causes of osteoporosis include hypogonadism in men and in premenopausal women, primary hyperparathyroidism, hyperthyroidism, glucocorticoid excess, nutritional deficiency (e.g., anorexia nervosa), immobilization, several therapeutic agents (e.g., heparin and anticonvulsants), liver disease, and renal disease. Both genetic and lifestyle factors contribute to osteoporosis. Family history, such as the tendency to fracture, is an important factor in osteoporosis.

Lifestyle choices also influence the development of osteoporosis: risk is higher in people who are physically inactive, have low calcium intake, are very thin, are smokers, or are heavy drinkers, consuming excessive amounts of alcohol. Osteoporotic vulnerability is partly dependent on the bone mass originally present; persons with larger, denser bones can lose more bone without becoming prone to fractures than can persons who had lighter bones as young adults. Since men have heavy bones to begin with, their bones are still proportionally denser (and stronger) after the inevitable loss of bone mass due to aging. Osteoporosis also can result from endocrine and gastrointestinal disorders and from certain cancers.

Most patients with osteoporosis have no symptoms, though some patients have back pain. As the thoracic vertebrae become compressed, the spine bends forward, producing the typical “dowager’s hump,” with an accompanying loss of height. A compression fracture of a vertebra may be signaled by a sudden sharp pain in the affected area after minimal or no trauma or by a sudden loss of height. It is common, however, for the patient not to recall pain or trauma and for vertebral compression fractures to be detected as incidental X-ray findings. Fractures of the femur after little or no trauma are quite common and are a major cause of morbidity and mortality in postmenopausal women.

In most cases, osteoporosis can be prevented. The most effective measures for preventing osteoporosis include good nutrition and a liberal intake of calcium and vitamin D throughout life, particularly in the early postmenopausal years. Moderate, regular physical activity, especially weight-bearing exercise such as walking, running, and weightlifting, also protects against bone loss. There are several therapeutic agents that play different roles in preventing bone loss, reducing fracture risk, and rebuilding bone. Estrogen replacement therapy (see hormone replacement therapy) may be used to prevent osteoporosis in postmenopausal women; however, it is typically used as a last resort when other medications prove ineffective. Raloxifene (an estrogen-like drug), bisphosphonate drugs (such as risedronate and alendronate), and calcitonin decrease bone resorption. Calcium and vitamin D supplements decrease bone resorption and stimulate bone formation. Experimental studies of nitroglycerin revealed that this substance, which is used in the treatment of certain cardiovascular diseases, has similar density-increasing effects on bone. In addition, parathormone, when given intermittently, increases bone formation.