A condition of skeletal fragility characterized by
compromised bone strength predisposing to an
increased risk of fracture
NIH Consensus Development Conference Statement, on Osteoporosis Prevention, Diagnosis, and Therapy, 2000.
Source: Dempster DW, et al. J Bone Miner Res. 1986:1:15-21; Reprinted with permission from the American Society of Bone and Mineral Research
Annual incidence of common diseases
Frequency of Common
Medical Events in Women
annual incidence all
1. Riggs, B.L., and Melton, L.J. III, Bone 17(5)(Suppl.):505S-511S, 1995
2. Heart and Stroke Facts: 1996 Statistical Supplement, American Heart
3. Cancer Facts & Figures—1996, American Cancer Society
•Osteoporosis is a health threat for an estimated 44 million
•Of that 44 million :
•10 million individuals already have the disease
•80% of these are women
•34 million more are estimated to have low bone
mass and increased risk for osteoporosis.
•Osteoporosis affect people of
all ethnic backgrounds.
•While osteoporosis is often
thought of as an older person's
disease, it can strike at any age.
•The estimated national direct expenditures for osteoporotic hip
fractures was $18 billion dollars in 2002.
•Office visits have increased five-fold (from 1.3 to 6.3 million) in
the past 10 years.
•In 2001, about 315,000 Americans age 45 and over were
admitted to hospitals with hip fractures.
Osteoporosis is highly preventable.
However, if the toll of osteoporosis is
to be reduced, the commitment to
osteoporosis research must be
significantly increased. It is
reasonable to project that with
increased research, the future for
definitive treatment and prevention of
osteoporosis is very bright.
•An average of 24 percent of hip fracture
patients aged 50 and over die in the year
following their fracture.
•Only 15 percent of hip fracture patients can
walk across a room unaided 6 months later.
•Hip fractures AND vertebral fractures are
linked with an increased risk of death.
•One in five hip fracture patients ends up in a
nursing home, a situation that participants in
one study described as less desirable than
•Hip fracture risk is increasing
most rapidly among Hispanic
•Women with a hip fracture are at
a four-fold greater risk of a
•Osteoporotic fractures lower a
patient’s quality of life.
Annually, 1.5 million osteoporotic fractures
300,000 hip fractures
700,000 vertebral fractures
250,000 wrist fractures
300,000 fractures elsewhere
One in two women and one in
four men over age 50 will
have an osteoporosis-related
fracture in her/his remaining
Osteoporosis in Women
>50 yr old
Non-Hispanic white and Asian women:
•20% have osteoporosis; 52% have low bone mass.
Non-Hispanic black women:
•5% have osteoporosis; 35% have low bone mass
•10% have osteoporosis; 49% have low bone mass.
Osteoporosis is under-recognized and under-treated not
only in Caucasian women, but in African-American women
Shrinking is NOT an Inevitability of Aging
and IS NOT normal!!
•White women ≥65 year old have
twice the fracture incidence versus
•Women have a hip fracture rate two
to three times higher than men.
•A woman's risk of hip fracture is
equal to her combined risk of breast,
uterine and ovarian cancer.
Osteoporosis and Women
Bone loss during breastfeeding?
Bone density can be temporarily lost during breastfeeding.
Several studies have shown that recovering full bone density
occurs within six months after weaning.
•Menkes' syndrome •glycogen storage diseases
•pregnancy and lactation
•use of glucocorticoids
caused by the therapeutic
•Osteoporosis, the "silent
disease," has bone loss without
•Onset only occurs with sudden
strains, bumps, or fall causes a
fracture or a vertebra to collapse.
•Collapsed vertebrae may initially
be felt or seen in the form of
severe back pain, loss of height,
or spinal deformities such as
kyphosis or stooped posture.
Bone Mineral Density Values
World Health Organization
(WHO) Osteoporosis Guidelines
Mean Lumbar Spine BMD:
Decades 3 to 9 of a Woman’s Life
WHO, Guidelines for Preclinical Evaluation and Clinical
Trials in Osteoporosis, 1998.
Consider preventive intervention
Consider therapeutic intervention
Adapted from AACE Guidelines. Endocr Pract. 2001;7:293-312.
Who Should Be Tested?
•All women aged 65 and older.*
•Younger postmenopausal women
with multiple risk factors
•Postmenopausal women who present with fractures
•Estrogen deficient women at clinical risk for osteoporosis
•Individuals with vertebral abnormalities
•Individuals receiving, or planning to receive, long-term
glucocorticoid (steroid) therapy
•Individuals with primary hyperparathyroidism
•Individuals being monitored to assess the response or
efficacy of an approved osteoporosis drug therapy.
*Medicare covers BMD testing for the following individuals age 65 and older. Medicare
permits individuals to repeat BMD testing every two years.
Risk Factors for Hip Fracture
Factors for Fx
Factors for Falls/Fx
-Age (>80 yr)
-Low BMD (T< -2.5)
-Family history Fx
-Meds that increase
risk of falling
-Loss of soft tissue
-History of falls
Risk of Hip Fx =
Risk of Hip Fx =
Detection: Bone Mineral Density Tests
Type of Test
DXA (Dual Energy X-ray Absorptiometry)
spine, hip or total body
pDXA (Peripheral Dual Energy X-ray
wrist, heel or finger
SXA (single Energy X-ray Absorptiometry)
wrist or heel
QUS (Quantitative Ultrasound)
heel, shin bone and kneecap
QCT (Quantitative Computed
pQCT (Peripheral Quantitative Computed
RA (Radiographic Absorptiometry)
DPA (Dual Photon Absorptiometry)
spine, hip or total body
SPA (Single Photon Absorptiometry)
Therapeutic Agents Used in
• Inhibitors of bone
– Estrogens +/- progest
• Stimulators of bone
A. Normal Spine
Women's Health Initiative Trial
•Hip and vertebral fractures decreased by at
least one-third in both of the trials and total
fractures decreased by 24%-30%.
•The clear fracture benefits of postmenopausal
hormone therapy (HT) are offset by the adverse
– increased risk of stroke,
–cognitive impairment, and
–deep vein thrombosis
•HT provided no cardioprotective benefit, and
increased the risk of breast cancer. (AMA)
1. Estrogens (brand names, such as Climara®, Estrace®, Estraderm®,
Estratab®, Ogen®, Ortho-Est®, Premarin®, Vivelle® and others)
2. Estrogens and Progestins (brand names, such as Activella™, FemHrt®,
Premphase®, Prempro® and others)
3. Parathyroid Hormone – Teriparatide (PTH (1-34) (brand name Fortéo®)
•The use of an anabolic and antiresorptive agent
is less effective than an anabolic agent alone.
• Since the effects of antiresorptive therapy with
bisphosphonates are long-lasting, until more is
known, bisphosphonate use should be
discontinued before initiating PTH.
•Combination therapy with two antiresorptive
agents is generally reserved for those who:
•have experienced a fracture while on
therapy with a single drug
• start out with a very low BMD and a history
of multiple fractures
•have a very low BMD and lose more bone
mass on therapy with a single drug
Algorithm for women Older than 80
Discuss calcium, vitamin D,
•Older women do not convert vitamin D in
the skin & should be on an oral supplement
Discuss fall prevention
Consider hip pads
•Check sedative use, vision, muscle weakness,
balance, environmental problems (cords, rugs,
poor lighting). Hip padding for thin women.
Height loss >4cm?
•Raloxifene, calcitonin, or lowdose bisphosphonate. Do not
start hormones. BMD not
needed to decide treatment.
Hip DEXA or heel ultrasound
No further work-up
Counsel All Women on:
•Risk factors for osteoporosis
•Adequate calcium and vitamin D intake
•The need for weight bearing exercise
•Fall prevention strategies
•Avoidance of tobacco and moderate use of
Consider Bone Mineral Density Screening for:
•Women over 65 years of age
•Women 50 to 64 with one or more of the following
clinical risk factors
•Any fracture after age 40
•Family history of osteoporosis
•Weight <127 lbs.
•Post-menopausal women who present with a fracture
Consider Treatment of Post-menopausal Women with:
T-score of < 2.5 or less
T-score of - 2.0 or less in the presence of one or more risk factors listed
Any vertebral or hip fractures
School of Nursing
University of Washington Medical Center
Check out OsteoEd, an educational web site, for quick answers to osteoporosis questions.
*Guidelines from pamphlet for providers by the National Osteoporosis Foundation. http://
Five Steps Toward Prevention
98% of a woman’s skeletal mass is acquired by age 20
Optimal strategies for building strong bones occurs during childhood and
1. A balanced diet rich in calcium and
2. Weight-bearing and resistancetraining exercises
3. A healthy lifestyle with no smoking
or excessive alcohol intake
4. Talking to one’s healthcare
professional about bone health
5. Bone density testing and
medication when appropriate
A study of disease management
in a rural healthcare population
demonstrated that a preventive
program was able to reduce hip
fractures and save money.
•The best predictor of fracture is a previous fracture.
•Treatment can improve fracture risk considerably.
•Fractures can lead to decreased mobility and an
additional risk of deep venous thrombosis and/or
•Vertebral fractures can lead to severe chronic pain of
neurogenic origin, which can be hard to control.
patients have an increased
mortality rate due to the
complications of fracture,
most patients die with the
disease rather than of it.