Osteoporosis can develop for years, without a person feeling symptoms, and the first manifestation of the disease is often a fracture. What are the early warning signs, when should we examine our bone density and why should we not interrupt treatment arbitrarily? About risk factors, modern therapy and ways to prevent fractures… Assoc. Prof. Lachezar Lozanov, head of the Department of Endocrinology and head of the Clinic of Internal Medicine at Acibadem City Clinic UMBAL Tokuda, speaks in front of FACT.
- Assoc. Prof. Lozanov, osteoporosis is often called the “silent disease“, because it can develop without symptoms. How can a person understand that their bones are weakening before they break? What are the first signs and when should we seek an endocrinologist?
- Osteoporosis is insidious because it can progress for years without a person feeling anything unusual. Often the first manifestation is a fracture that occurred when falling from one's own height or even with a relatively small load. There are warning signs that we should not ignore - gradual reduction in height, stooping or new back pain, which can sometimes be associated with a vertebral fracture. However, the absence of such complaints does not rule out the disease. Consultation with an endocrinologist is especially important in people with previous fractures after minimal trauma, early menopause, low body weight, family history or prolonged treatment with corticosteroids. Some hormonal and chronic diseases are also important.
We should not wait for the bone to break to check if it is healthy. In the presence of risk factors, early assessment can prevent serious consequences.
- When should a person have their bone density tested and at what age?
- In women aged 65 and over and in men aged 70 and over, an assessment for osteoporosis, including a bone density test, is usually recommended. In younger people, the test may be necessary earlier if there are risk factors. These include premature menopause, fracture after minimal trauma, low body weight, prolonged use of corticosteroids and diseases such as hyperparathyroidism or hyperthyroidism. In certain patients with chronic diseases, it is also necessary to evaluate secondary causes of bone loss.
The decision should not be based solely on age. In people at high risk, the test may be needed much earlier.
Osteoporosis is not a disease that we should think about only after retirement. It is important to recognize patients in whom bone loss may begin earlier.
- What does the osteodensitometry test show and how are the results interpreted?
- Osteodensitometry, most often using the DXA method, measures bone mineral density. The lumbar spine and hip area are usually examined. The examination is quick, painless and involves low radiation exposure. In postmenopausal women and men aged 50 and over, the result is mainly assessed using the T-score indicator. A value above −1.0 is considered normal bone density, between −1.0 and −2.5 - for low bone density, and a value of −2.5 or lower meets the densitometric criterion for osteoporosis. However, it is important that the result is interpreted by a doctor in the context of the patient's overall condition. Age, previous fractures, concomitant diseases and other risk factors are important. Osteodensitometry helps us assess bone density, but our goal is to prevent fractures. Therefore, risk assessment is not limited to a single number from the study.
- Osteoporosis continues to be perceived as a disease primarily of women after menopause. Which other groups remain at risk?
- Osteoporosis is more common in women after menopause, but it is not just a female disease. Men also develop osteoporosis, and the consequences of fractures in them can be just as serious. People with low levels of sex hormones, chronic kidney and liver diseases, thyroid and parathyroid disorders, as well as patients who take corticosteroids for a long time fall into the risk groups. We should not forget younger people with eating disorders, very low body weight, disorders in the absorption of nutrients or certain chronic diseases. As endocrinologists, we pay special attention to hormonal disorders, because they can adversely affect bones long before visible consequences appear. It is important to change the perception that osteoporosis only affects older women. The risk should be assessed individually for each patient.
- How common is it in men and younger people and when should secondary causes of bone loss be looked for?
- Osteoporosis in men is a significant and often underestimated problem. The risk increases with age, especially in the presence of hormonal disorders, chronic diseases or prolonged use of certain medications. In young people, the detection of significantly reduced bone density or fracture after minimal trauma requires a particularly careful assessment. We need to understand whether it is a primary disorder of bone health, or if there is another cause.
Among the possible causes are hyperparathyroidism, hyperthyroidism, Cushing's syndrome, hypogonadism, chronic kidney disease, celiac disease and other conditions that disrupt the absorption of nutrients. Some medications, malnutrition and vitamin D deficiency are also important.
According to the specific case, we prescribe laboratory tests and additional diagnostic procedures. The goal is not only to determine the reduced bone density, but also to find the possible cause, because its treatment can significantly improve the prognosis.
- If a person has already suffered a fracture after a minor fall or seemingly minor trauma, should they be tested for osteoporosis?
- Yes, such a fracture should be a reason for assessing bone health, especially in people over 50 years of age. A fracture from a fall from one's own height can be the first signal that the bones have lost some of their strength. This does not mean that every fracture automatically proves osteoporosis. It is necessary to take into account the location of the fracture, the circumstances, age and other medical data. But we should not limit ourselves only to the treatment of the fracture itself. We should assess the risk of a new fracture, assess the need for osteodensitometry and look for secondary causes. In high-risk patients, it may be necessary to start medication without waiting for the next fracture to occur.
One fracture can be a warning sign of another. Therefore, after a fracture with minimal trauma, we should also think about preventing future fractures.
- Why can a fracture of a vertebra, wrist, or hip be the first manifestation of the disease and what should follow?
- Bone loss usually occurs without pain. Therefore, in many patients, the first manifestation of osteoporosis is precisely the fracture. Wrist fractures often occur when falling on an outstretched hand. Vertebral fractures sometimes develop during normal daily movements and may go unrecognized. They can cause back pain, loss of height, and gradual stooping. Hip fractures are particularly serious, as they can lead to prolonged immobilization, complications, and loss of independence. After the fracture is treated, a plan for the prevention of further fractures should be developed. This includes an assessment of bone density and overall risk, testing for secondary causes, appropriate therapy, and measures to prevent falls.
Coordination between orthopedists, endocrinologists, and general practitioners is important here. The patient should receive not only treatment for the fracture, but also long-term care for their bone health.
- Many patients are afraid of prolonged treatment and stop taking prescribed medications. What are the consequences and how important is compliance with therapy?
- Osteoporosis is a chronic disease and treatment should be planned in the long term. The goal is not just to increase bone density, but to reduce the likelihood of fractures and their consequences.
Discontinuing therapy without consulting a doctor may lead to loss of the achieved effect and leave the patient exposed to high risk. Particular attention is required with denosumab treatment. Delaying or stopping it without appropriate follow-up treatment may cause rapid bone loss and an increased risk of vertebral fractures.
With some bisphosphonates, it is possible to discuss a therapeutic pause after a certain period, but this depends on the individual risk and should not be undertaken arbitrarily. We understand patients' concerns about the duration of treatment and possible side effects. Therefore, it is important for the doctor to explain the expected benefits, risks and possible alternatives. The most important advice is not to interrupt treatment on our own. If there are concerns or side effects, we should discuss with the treating doctor how to continue safely.
- Can osteoporosis be prevented at a young age? What is the role of nutrition, calcium, vitamin D, strength training and exercise, and when is it necessary to take nutritional supplements?
- Prevention begins in childhood and adolescence, when a large part of the bone reserve is built, which will serve us throughout life. Therefore, healthy nutrition and physical activity are important long before the age at which the risk of osteoporosis increases.
Calcium is a basic building block of bones, and vitamin D supports its absorption and normal mineralization.
It is important that nutrition provides sufficient calcium and protein. Suitable sources of calcium are dairy products, some fortified foods and certain plant products. Nutritional supplements are not necessary for everyone. They have a place when dietary intake is insufficient or there are specific medical indications. Vitamin D should also be taken according to individual needs, avoiding unnecessarily high doses. No less important are exercises with the load of one's own weight, strength training and movements to improve balance. They support bones and muscles and reduce the risk of falls. Of course, the load must be adjusted to age, health status and the presence of already established osteoporosis. Quitting smoking, avoiding excessive alcohol consumption and maintaining a healthy body weight are also important. Healthy bones are built over the years. Prevention is much more effective when it starts early, rather than when a fracture has already occurred.
- How can we reduce the risk of falls and fractures in older people?
- To prevent fractures, we need to work in two directions - to maintain bone strength and to reduce the likelihood of falls. It is important to assess vision, balance, gait and medications that can cause dizziness or a drop in blood pressure. If necessary, additional tests are performed and treatment is adjusted. Slippery carpets and obstacles should be removed from the home, and there should be good lighting and stable supports in the bathroom and on the stairs. Appropriate shoes and the use of a cane or walker when necessary can also help.
Strength exercises and balance training, tailored to the person's abilities, improve stability and confidence when moving.
However, we should not forget about the treatment of osteoporosis itself. Even when we cannot completely prevent a fall, we can reduce the likelihood that it will end in a serious fracture.
- What would you say to people who have already been diagnosed with osteoporosis and believe that a fracture is inevitable as they age? What results can be achieved with modern treatment and how is it monitored whether the therapy actually reduces the risk of future fractures?
- I would tell these people that a diagnosis of osteoporosis does not mean that a fracture is inevitable. Today we have effective drugs that can significantly reduce the risk of future fractures. Modern treatment includes medications that suppress excessive bone breakdown, as well as therapies that stimulate the formation of new bone tissue. In patients at very high risk, anabolic therapy may be preferred, followed by antiresorptive treatment. The choice depends on the severity of the disease, previous fractures, concomitant conditions and individual contraindications. The effect is monitored by assessing new fractures and risk factors, adherence to treatment and at appropriate intervals - repeated osteodensitometry. In certain cases, we also examine markers of bone turnover, which can provide additional information about the response to therapy. It is important to know that successful treatment is not measured solely by the change in the densitometry result. The goal is to reduce the risk of fractures, maintain mobility and prevent loss of independence. Osteoporosis is a disease that we can treat. We cannot promise zero risk of fractures, but we can significantly reduce it with timely diagnosis, appropriate therapy, and regular follow-up.