Season 5 | Episode 4
1:52 - Significance of Bone Density for Women's Health - Explore the protective role of estrogen in maintaining bone health and the impact of its decline during menopause. Dr. Bolster highlights the relevance of bone density for women and outlines the utilization of bone density tests in osteoporosis screening.
4:18 - Osteoporosis and Osteopenia: Risks Explored - Delve into the distinction between osteoporosis and osteopenia and understand the implications of each. Dr. Bolster discusses the risk factors, fracture implications, and recommended screening age, shedding light on women's bone health beyond age 65.
6:21 - Unveiling Osteoporosis and Fracture Risk - Uncover the intricate relationship between osteoporosis and fracture risks. Explore how low bone density doesn't always result in fractures in pre-menopausal women. Discover the influence of medical conditions, medications, and family history on fracture susceptibility.
07:43 - Beyond Age and Gender: Key Osteoporosis Risk Factors - Dive deeper into the risk factors associated with osteoporosis. Explore factors such as postmenopausal status, body stature, tobacco, alcohol, and underlying health conditions. Dr. Bolster sheds light on how these factors contribute to heightened osteoporosis risk.
9:57 - Calcium Supplements: Guardians Against Osteoporosis - Unveil the significance of calcium and vitamin D supplementation in managing osteoporosis. Understand the challenges of obtaining sufficient vitamin D through dietary sources alone and learn how these supplements contribute to bone health.
11:30 - Osteoporosis and Hip Fractures: Urgent Concerns - Grasp the severity of hip fractures resulting from osteoporosis. Discover the startling statistics that underscore their impact on mortality, emphasizing the need for proactive measures to prevent such fractures.
13:11 - Identifying Spine Fractures: Symptoms and Diagnosis - Navigate the subtleties of spine fractures and the importance of their early detection. Learn how patients may experience spine fractures without evident symptoms and explore the role of vertebral fracture assessments in diagnosis.
15:04 - Career Impact and Osteoporosis Risk - Uncover the influence of careers and mobility on osteoporosis risk. Understand how professions and immobility can contribute to bone health issues. Discover the role of weight-bearing exercises in promoting bone strength.
16:32 - Effective Management of Osteoporosis - Gain insights into managing osteoporosis with an emphasis on active living and weight-bearing exercises. Dr. Bolster highlights the importance of adequate calcium and vitamin D intake, providing a comprehensive approach to osteoporosis management.
Joe McIntyre (Host): Imagine a young woman in her 20s slipping on ice and falling on her hip. The chances of a serious injury are probably relatively low. Now picture an 80-year-old woman in the same scenario. Her risk of injury and a medical emergency is far greater.
The reason has to do with decreased bone density as we age, which can lead to osteoporosis. Osteoporosis is much more common in women than men, but everyone is susceptible as they age. Of course, as we get older, it's crucial to understand osteoporosis and discuss preventative measures with a doctor.
Welcome to the Merck Manuals Medical Myths Podcast where we set the record straight on today's most talked about medical topics and questions.
I'm your host, Joe McIntyre, and on this episode, we welcome Dr. Marcy Bolster. Dr. Bolster is a professor of medicine at Harvard Medical School. She is also the director of the Rheumatology Fellowship Training program in the Division of Rheumatology, Allergy and Immunology at Massachusetts General Hospital. Dr. Bolster, thanks for joining us.
Dr. Marcy Bolster: Thank you so much for having me today. I look forward to our conversations.
Host: So, let's start off with a bit of a general question. Can you tell us what exactly osteoporosis is and how it affects bone density and strength?
Dr. Bolster: Osteoporosis is actually a systemic condition where it can affect all the bones in the body. It is a condition that develops in people causing them to lose bone density. And by the loss of bone density, bones are weakened and are much more likely to fracture.
Host: Now we mentioned in the introduction of this episode that osteoporosis is more common in women than it is in men, particularly after women go through menopause. Why is that the case?
Dr. Bolster: We know that estrogen is protective of bone. It's helpful for bone. So, at the time of menopause, there's a loss of estrogen and thus the loss of the beneficial effects estrogen has on bone, and it's at this time that the loss of bone density is most rapid. We know for women, within the first five to seven years of menopause, the loss of bone density is most rapid and it continues throughout life. There's not a distinct time in the lifetime of a man that is marked by this change in hormonal levels and thus the effects on bone. But we do know that men as they age do experience loss of bone density, it's just not as great as for women.
Host: How do you figure out if your bone density is at a concerning level? Is that really how it's quantified? What is the process there for even discovering, "Hey, I'm at risk for osteoporosis or I have osteoporosis?”
Dr. Bolster: Osteoporosis can be screened for with the use of a bone density test, which is an x-ray test called bone densitometry or a DEXA scan which stands for dual x-ray absorptiometry. The use of a DEXA scan can help identify the loss of bone density. It's a painless test. It's an x-ray test and it takes maybe 15 to 20 minutes. The DEXA scan provides information that includes a T-score, and the T-score is a measure of the number of standard deviations away from normal for bone density. We would ideally keep our peak bone density, and peak bone density occurs around the age of 30, but unfortunately, we don't keep peak bone density. The T-score measures the number of standard deviations away from peak. We know that with a T-score of -2.5 or lower, meaning -2 and half standard deviations from peak or 2 and half standard deviations lower than peak bone mass, there's an increased risk of fracture. So that is the point where we define osteoporosis, knowing that it is associated with an increased fracture risk. But there are also people who have a T score between -1 standard deviation and -2.5, and they have osteopenia, and we also know that some people with osteopenia will have a fracture. In fact, 50% of fractures occur in people with osteopenia. So, it behooves us to figure out which patients are at risk for an osteoporosis-related fracture even before getting to the point of osteoporosis.
Host: What are the recommended age ranges for someone who should consider getting a bone density screening? Is it a few years after you turned 30 or is it much later in life, especially for women who are going through the process of menopause?
Dr. Bolster: The recommended age for screening for women is actually 65 years old, and we know that the average age for menopause is around age 51 or 52, so there's a long period of time between menopause and when the actual recommendations start for screening. Assessing women's risk factors for osteoporosis can clue us into the need to screen at a younger age. We do know that there's a benefit in screening men who are 70 years of age or older, but we also know that some men will have risk factors for osteoporosis and they should be screened much earlier. The goal is to find osteoporosis before it presents with a fracture.
Host: Is there anyone who should consider screening in your 40s or earlier? Or is there anyone you know that you've come across in your career that you thought this is the kind of person who should be getting a screening much earlier than normal?
Dr. Bolster: Typically, no. If we find low bone density in premenopausal women, they really are not at increased risk for fracture, and we're trying to figure out who is at high risk for fracture. Now, having said that, there are certain health conditions and there are certain medications that people take that might increase their risk for fracture. And those people, it would be beneficial to screen them earlier, but in an otherwise healthy premenopausal woman or man younger than 50, there isn't a reason to perform screening.
Host: Are there any genetic factors that would contribute to the development of osteoporosis?
Dr. Bolster: Osteoporosis is thought to have an important family history component. We know that if there is a family history of osteoporosis, the risk is higher, and particularly if one of your parents has had a fracture and particularly a hip fragility fracture. So, we know that there's an increased risk for osteoporosis in any individual who has a family history, but particularly in those whose either of their parents have had a hip fracture.
Host: I think you mentioned earlier, but are there any other common risk factors associated with osteoporosis apart from gender and apart from age?
Dr. Bolster: There are a lot of risk factors associated with the risk of developing osteoporosis, and we mentioned postmenopausal status. Small body stature is also a risk factor, so women who weigh less than 127 pounds, for instance, are at a higher risk for developing osteoporosis. Other risk factors that are potentially controllable or modifiable would be tobacco use and excessive alcohol use. We know that smoking is a risk factor for osteoporosis. We also know that for alcohol use, drinking three or more drinks per day is associated with increased bone loss. There are also inflammatory conditions like rheumatoid arthritis that increase the risk for osteoporosis. And there are certain medications that people might be taking such as prednisone for inflammatory conditions or aromatase inhibitors are medications that women take as part of their treatment for breast cancer. Some medications for seizure disorders can be associated with an increased risk for osteoporosis. Progesterone can be associated with increased bone loss, and that's a medicine used in contraception. There are some underlying health conditions associated with increased risk for osteoporosis.
Host: Do only individuals with a family history of osteoporosis need to be concerned?
Dr. Bolster: Family history is one of the risk factors for osteoporosis, so I think any of the things that we just talked about, such as small body stature, postmenopausal state, tobacco use, other underlying conditions or other medication use, those were also substantial or those are also significant risks, so that can prompt the need for screening as well.
Host: Doctor Bolster, does taking calcium supplements guarantee protection against osteoporosis? I'm guessing the answer to that is no, but maybe you can explain why.
Dr. Bolster: I think calcium supplementation is an important part of the management of osteoporosis, and this is the same as vitamin D supplementation. But let's take a step back from that question. Actually, I would reframe the way I think about it. An individual should have an adequate intake of calcium and that could be through the use of supplements or through dietary sources. And the healthiest way to get calcium is through dietary sources. So, I do think it's important for people with osteopenia or osteoporosis to get adequate calcium, either through their diet or by adding supplementation. And the goal for calcium intake is 1200 to 1500 milligrams a day. We don't want people to take too much calcium because then they run the risk of kidney stones. Having a healthy amount of calcium in your diet, if that's possible that would be ideal. And then to add to it, to get to the 1200 milligram goal would also be beneficial. Likewise, the recommendation is 800 international units (IU) per day of vitamin D intake. And it's harder to get vitamin D through multiple dietary sources, so often patients need to take a vitamin D supplement.
Host: You've mentioned hip fractures a number of times. Does osteoporosis only affect an individual's hips?
Dr. Bolster: Osteoporosis can actually affect any bone in the body, and we talk about hip fractures as an important part of the considerations for treating osteoporosis, because we know that hip fractures are associated with very high morbidity and mortality. What that means is that following a hip fracture, patients typically don't return to their prior level of activity and state of health. And we also know that even survival after hip fracture is altered. It's been estimated that one in five people will die within a year of sustaining a hip fracture. And it's not that the hip fracture itself causes the patient's demise, but the hip fracture is associated with increased frailty and so people develop increased frailty and the more they're at higher risk for falls. They also are more likely to get things like ammonia or a blood clot, like a blood clot in the leg that can go to the lungs. And these are the things that contribute to the decreased survival following a hip fracture.
So, in addition to hip fractures, we actually need to also mention spine fractures. Spine fractures are actually the number one type of fracture in patients with osteoporosis. They're the most common, and spine fractures can be very painful. That's if they are clinically apparent. We do know that about 2/3 of spine fractures are asymptomatic. So that means that patients can have spine fractures and not have any symptoms. They may have no pain and they may not even know they've had a spine fracture. But what they might notice is that there could be a loss of height or an increase in what we call the kyphosis, or the development of curvature of the upper part of the spine or what has been termed “dowager's hump,” and so those can be signs that patients have had vertebral fractures. For the asymptomatic vertebral fractures, those fractures are typically detected on imaging that patients have for other reasons, such as a chest X-ray or a CT scan of the chest or the abdomen.
Host: Doctor Bolster, you mentioned people may not know they have a spine fracture other than maybe seeing as mentioned, spine curvature or some other issues if they come to you and you recognize these individuals who probably have it, do you recommend tests? How do you decide or how do you figure out if you had a spine fracture or other ways to do that other than just coming in to see you and getting a test from there?
Dr. Bolster: If a patient has noticed a loss of height of an inch and 1/2 or more, we might consider getting radiographs of the thoracic and lumbar spine to evaluate for spine fractures that would be apparent on those tests. The DEXA scan really just shows us the change in bone density. In order to look for a vertebral fracture, there is a second part of a DEXA scan, or a different piece of software called a vertebral fracture assessment, or the FAA, which can look for vertebral fractures. But not all DEXA scans have that software availability, so we don't necessarily rely on that.
Host: Does a person's career impact their likelihood to develop osteoporosis? Or people who are at computers more of the time, hunching over potentially, does that lead to higher instances of osteoporosis?
Dr. Bolster: I would think of it more as if they have less mobility or more immobility, and I'm not sure that career decisions really impact that as long as people are active otherwise. But we think about people who have profound immobility having more bone loss. For instance, people who are not able to stand up and walk, people who have to get around in a wheelchair. We do know that weight-bearing exercise is good for the bones. Just to clarify, weight-bearing exercise just means being on your feet and bearing weight on your feet, so you don't actually have to be lifting weights for it to be thought of as weight-bearing exercise. Having said that, lifting weights has a lot of benefits for the bones because it can really help with muscle strengthening, with core strengthening and with ways to improve your balance, your stability and reduce your risk of falls.
Host: For individuals who have osteoporosis, is that essentially the same process? You should still remain as active as possible or other ways to reduce the risk of fractures?
Dr. Bolster: I think in people who have osteoporosis, it's really important to remain active. Weight-bearing exercise is an important component of the treatment. For osteoporosis, calcium and vitamin D adequacy and dietary and supplement intake are important. Consideration of the need for medications is also important. And thinking about how to manage osteoporosis by being active and having weight-bearing exercises as part of your routine is very important. The adequacy of calcium and vitamin D intake is important and the use of medications when indicated is also the mainstay of how we treat osteoporosis. But we should also remember that reducing fall risks is an important component of managing bone health. When people are less likely to fall, they're less likely to fracture, and so fall risk is an important modifiable risk factor.
Host: Doctor Bolster, thank you so much for joining us on this podcast to discuss osteoporosis and just some of the myths and misconceptions surrounding it as we close out. I'll let you leave our listeners with the final word.
Dr. Marcy Bolster: Thank you so much. My final words would be medical knowledge is power. Pass it on.