INTRODUCTION TO OSTEOPOROSIS

Udi Herunefi

Sub division of Orthopaedic & Traumatology

Dr. Moewardi Hospital / Faculty of Medicine

University of Sebelas Maret

Osteoporosis means porosity/thinning of bone regardless of the cause. It is present in most elderly people. Bone loss with aging is a universal phenomenon but is considered a disease when bone mass falls to a level at which a fracture is likely to occur.

How does osteoporosis develop?

Bone, a living structure made up of protein (collagen) and minerals (calcium), constantly destroyed and replaced to maintain its strength. Osteoporosis usually occurs as a result of the normal aging process, when the rate of destruction increases and the creation decreases, causing the bones to become thin and brittle.

Normal bone structure

The outer part is called cortex or compact bone, composed of a shell or compact or solid bone that surrounds plates and rods of bone (spongy bone) within which lies the bone narrow. There are 2 main types of bone cells, osteoclast : destroy the bone & osteoblast : formation of new bone.

Bone mass changes

During childhood & adolescence, bones not only growing but also become more solid. By the age of 25 years, amount of bone in the skeleton has reached its maximum level, known as “peak bone mass”. Peak bone mass is very important in determining whether an individual is at risk of osteoporosis later in life.

Who developes osteoporosis?

Genetic factors:

Peak bone mass mostly genetically determined. People with a very slight body build, has the risk of osteoporosis is genetically inherited. The family history with osteoporosis is a strong risk factor for osteoporosis.

Strong risk factors may increase of developing osteoporosis: Premature menopause. Amenorrhea. Steroid therapy. History of osteoporotic fracture. Overactive thyroid. Cancer (ex. Myeloma). Chronic liver, bowel and kidney disease. Vitamin D deficiency.

Life style risk factors

            Dietary factors (calcium & vitamin D deficiency), excessive alcohol use, smoking, and physical activity can lead to osteoporosis. High intake of protein/caffeine/salt increase the risk of osteoporosis.

Symptoms and Signs of Osteoporosis?

            Osteoporosis only causes symptom when there is a fracture. Bone loss doesn’t cause pain/other symptom.

Diagnosis of osteoporosis

Measuring bone mass to provide information about the likely hood of fracture, just as blood pressure to predict the risk of stroke, or blood level cholesterol to predict the risk of heart disease.

Ways to measure bone mass

Using DEXA (dual energy x-ray absorptiometry): for hip and spine. Value of bone mass is known as bone mineral density (B.M.D).

What about the x-ray?

            If there are signs of osteoporosis made by x-rays like thinning of the cortices, ballooning of the intervertebral discs or fracture of the spine that mean there is already decrease of bone mass at least 30%.

            DEXA beside has low radiation, it is highly accurate and has good precision. Precision is ability to detect small changes in bone density over time (fi :1%,2%,3% in a period of the time). DEXA is good for follow up after treatment.

SCREENING for OSTEOPOROSIS

            Bone densitometry is the most accurate way of diagnosing osteoporosis. Those individual who have the strong risk factor or signs suggesting osteoporosis can use bone densitometry to do a screening or for assessing the effect  of treatment.

Signs suggesting osteoporosis :

Thinning of bone on x-ray. Fracture caused by minor injury. Loss of height. Rounding of the back.

GENERAL TREATMENT of OSTEOPOROSIS

            No treatment to reverse effect  of osteoporosis. But can be done to minimize or retard bone loss and relieve painful symptoms. Treatment involves: relieving pain, improving mobility, helping the patient cope with the psychological and social effects of the disease, preventing further bone loss so that fracture risk is reduced. (Self help measures are very important!!!!).

Preventing Bone Loss

            Estrogen deficiency plays a part in decreasing bone density and increasing a number of fractures. Estrogen replacement is important in preserving bone density and preventing fracture.

What are the disadvantage or side effects in giving estrogen?

Short term side effects only for first few months, not serious, will disappear in time.

  1. Vaginal bleeding : 30% — irregular bleeding to spotty for first few months
  2. Breast tenderness, bloating, fluid retention, nausea, vomiting, headache, indigestion, mood swings.

Long term risk:

Endometrial cancer, Breast cancer, Venous thrombosis.

When to start HRT?

            It is never too late to start HRT, if you have osteoporosis. 10 years after menopause better to change with non-hormonal drugs (because of high incidence of side effects).

How long to take HRT?

5-10 years after menopause.

Who should avoid HRT?

Pregnancy and lactation. Cancer  of the breast or uterus. Undiagnosed vaginal bleeding. Malignant melanoma.

Use HRT with caution

Endometriosis. Fibroids. Phlebitis. History venous thrombosis. Severe liver disease. Osteosclerosis. Migraine.

New treatment

SERMs : Selective Estrogen Receptor Modulators

  • Raloxiphene

Non-Hormonal Treatment of Osteoporosis :

  1. Tibolon
  2. Bisphosphonates
  3. Calcitonin
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