Osteoporosis – Causes, Signs and symptoms

Osteoporosis

Summary

Osteoporosis is a disorder in which the bones lose mass and density and become prone to fractures. It frequently affects women during and after menopause, and it is also common in elderly men.

Bones lose mass naturally as people age, but osteoporosis hastens this loss. The many contributors to osteoporosis include:

  • Lifestyle factors such as physical inactivity, low-calcium diet, smoking and alcohol abuse
  • Low levels of sex hormones
  • Corticosteroid or other immunosuppressive therapy
  • Diseases ranging from rheumatoid arthritis to diabetes to asthma to cancer

Osteoporosis has no symptoms in its early stages. It may cause back pain and loss of height or a stooped posture as it progresses, but often the first sign of osteoporosis is a fracture in the spine, hip or wrist. Falls or even coughing, sneezing or bending over can lead to fractures in osteoporotic bones that can cause sharp and sudden pain.

Osteoporosis usually can be revealed through tests that measure bone density, such as a type of x-ray called a DEXA scan.

Treatment options include nutrition, exercise therapy and medications such as bisphosphonates. Men may be prescribed testosterone therapy, but long-term hormone replacement therapy is becoming less common for women because of the risk of serious side effects. In some cases spinal surgery such as vertebroplasty or kyphoplasty is used to treat pain associated with vertebral compression fractures caused by osteoporosis.

People can take several steps to reduce their risk of osteoporosis. The most effective preventive measure is to build bone mass at a young age through exercise and a good diet so that a store of strong bone material is built up for later years. However, people of all ages can strengthen their bones through improved diet, regular exercise and not smoking.

About osteoporosis

Osteoporosis is a disorder that causes bones to become porous, weak and brittle. It usually affects older adults and occurs when low levels of calcium, phosphorus and other minerals cause bones to lose mass. The early stage of decreased bone density is called osteopenia.

In most cases, osteoporosis does not cause pain. However, it can lead to fractures – most often in the spine, hip or wrist – that cause sudden, searing pain. Falls or minor events such as coughing, bending over or sneezing can break osteoporotic bones.

There are two main types of osteoporosis, according to the National Institutes of Health:

  • Primary. Caused by aging (senile osteoporosis) or by unknown factors (idiopathic osteoporosis).
  • Secondary. Caused by another disease, a medical treatment or lifestyle factors.

Osteoporosis is most common in women during and after menopause because lower levels of the hormone estrogen weaken bones. However, the disease also affects men and – in rare cases – children. In addition to aging, other contributors to osteoporosis include endocrine and many other disorders, a diet low in calcium and vitamin D, lack of weight-bearing exercise and use of certain drugs, such as corticosteroids taken by mouth for extended periods.

An estimated 44 million Americans are at risk for osteoporosis, or 55 percent of the population over age 55, according to the National Osteoporosis Foundation (NOF). Ten million Americans, 80 percent of them women, have been diagnosed with the disease.

One in two women and one in four men over the age of 50 will suffer an osteoporotic  fracture during their lifetime, according to the NOF. Osteoporosis is responsible for more than 1.5 million fractures in the United States each year, including about:

  • 700,000 vertebral fractures
  • 300,000 hip fractures
  • 250,000 wrist fractures
  • 300,000 fractures at other sites

Risk factors and potential causes of osteoporosis

Osteoporosis occurs when bones lose mass and density, which is partly a result of a decrease in calcium, phosphorus and other minerals. When this occurs, bone strength decreases and the bone’s internal supporting structure declines. Instead of being dense with interconnecting pieces, bone becomes porous and weak.

Scientists are unsure why this process occurs, although they do know that it is related to bone remodeling. This is the life-long process of creating new bone (formation) and breaking down old bone (resorption). The resorption and formation of bone are essential in repairing small fractures and replacing bone.

Bone remodeling takes two to three months to complete the cycle. Younger people generate new bone faster than old bone is broken down, causing bone mass to increase. By age 20, people have generally accumulated most of their bone mass. Bone mass peaks during the mid-30s. After that, more bone is lost during remodeling than is gained. Not exercising and not getting enough calcium (through diet) and vitamin D (through diet and sunshine) can accelerate the process.

When women reach menopause (change that occurs when a woman’s body no longer releases eggs), bone loss is accelerated even further. Bone loss related to menopause usually lasts for about 10 years. This continues until about age 60, when bone loss slows but does not stop. In contrast, men initially do not lose as much bone mass as they age. However, by age 65, men lose bone at the same rate as women. The risk of developing osteoporosis depends on the amount of bone mass developed between 25 and 35 and how rapidly it is lost during aging.

Several risk factors are associated with osteoporosis. These include:

  • Sex and age. Fractures attributed to osteoporosis are more common in women than in men. This increased risk in women is due to the fact that they:
    • Tend to start out with lower bone mass
    • Tend to live longer than men
    • Experience a sudden drop in estrogen during menopause (either natural or surgical) which accelerates bone loss

    However, by age 65, men lose bone at the same rate as women. By age 75, osteoporosis is equally likely in both sexes. Osteoporosis will cause a hip fracture in 6 percent of men after age 50 and a vertebral fracture in 5 percent of that population, according to the National Institutes of Health (NIH).

  • Race. People with fair skin, such as Caucasians and Asians, are most likely to experience osteoporosis. African-Americans and Hispanics have lower incidences, but risk remains fairly high.

  • Family history. Osteoporosis runs in families, and a person’s risk increases if parents or siblings have the disease.

  • Frame. People who are thin or have small body frames have less bone mass, which puts them at higher risk.

  • Lifestyle factors. In addition to diet, these include:
    • Tobacco use. Researchers know that tobacco use weakens bones, although the exact relationship between tobacco use and osteoporosis is not clearly understood.

    • Sedentary lifestyle. Bone health begins in childhood and is strongly influenced by exercise. Exercise throughout life can increase bone density. Weight-bearing exercise, such as walking, aerobics or lifting dumbbells, is particularly beneficial in building bone mass.

    • Chronic alcoholism. Excess consumption of alcohol reduces bone formation and interferes with the body’s ability to absorb calcium. Among men, alcoholism is one of the greatest risk factors for osteoporosis.

  • Hormones. Lifetime exposure to estrogen is a factor for women. Those who began menstruating at an earlier-than-normal age or who experience menopause later in life are at reduced risk for osteoporosis. However, women are at higher risk if they:
    • Have a history of absent menstrual periods (amenorrhea)

    • Experience menopause earlier than their 40s

    • Have their ovaries surgically removed before age 45 without receiving hormone replacement therapy (HRT)

For men, a low level of testosterone (male hypogonadism) is a risk factor for osteoporosis as well as insulin resistance, sexual dysfunction and other health problems. Testosterone levels decline as men age, and scientists have documented a rising incidence of male hypogonadism in recent decades. Below-normal levels of estrogen and estradiol in men may also promote osteoporosis.

  • Eating disorders. A history of anorexia nervosa or bulimia in women and men elevates the risk of lower bone density in the lumbar spine and hips.

  • Rheumatoid arthritis (RA) or juvenile rheumatoid arthritis. These chronic diseases of the joints can lead to pain, limited mobility and bone loss.

  • Cardiovascular conditions. Studies have linked osteoporosis to disorders including coronary artery disease, heart attack, heart failure and stroke.

  • Diabetes. Research indicates that type 1 diabetes and possibly type 2 diabetes, which is far more common, increase the risk of osteoporosis in men and women.

  • Polycystic ovarian syndrome. An endocrine disorder that involves irregular menstrual cycles. The irregular estrogen levels associated with this condition may increase the risk of lower bone density.

  • Other diseases. Additional disorders that raise the risk of osteoporosis include asthma, chronic obstructive pulmonary disease (COPD), gastrointestinal diseases including liver disease and inflammatory bowel disorders, kidney disease, hypercalciuria (excess calcium in the urine, a sign of kidney stones), neoplastic disease (e.g., cancer or benign tumors), ankylosing spondylitis, cystic fibrosis, homocysteinuria (high levels of an amino acid called homocysteine), a genetic bone disease called osteogenesis imperfecta and a rare cellular disorder called systemic mastocytosis, according to the NIH.

  • Medications. Long-term use of some corticosteroids or other immunosuppressants damages bones. These medications are used to treat RA and other forms of arthritis, asthma, psoriasis, lupus and other chronic conditions. 

Intramuscular birth control medication has also shown to cause decrease in bone density, especially if used in teenagers.

Too much thyroid hormone can also cause bone loss. This may occur as a result of an overactive thyroid (hyperthyroidism) or when a person takes thyroid medication to treat an underactive thyroid (hypothyroidism). Blood tests can ensure that thyroid levels remain optimal.

Some diuretics can cause the kidneys to excrete excessive levels of calcium, which can contribute to thinning of bones. Diuretics are drugs that prevent the buildup of fluids in the body, and they are often used to treat high blood pressure.

Finally, hormonal treatment for prostate cancer, some anticoagulants, anticonvulsants and antacids containing aluminum have been shown to contribute to bone loss.

  • Low calcium. In addition to lack of dietary calcium, medical procedures (such as stomach surgery) and medical conditions (such as Cushing’s disease, parathyroid disease and digestive disorders) that inhibit the absorption of calcium can also contribute to bone loss.

  • Radiation therapy. Radiation treatment for cancers in the pelvic area may raise the risk of osteoporotic fractures.

  • Stem cell therapy. A type of stem cell treatment called hematopoietic cell transplantation reduces bone mineral density in children and sometimes causes osteopenia (a type of bone weakness) or osteoporosis.

  • Exposure to lead. The NIH is pursuing evidence that exposure to lead during childhood might limit bone development and predispose a person to osteoporosis later in life.

  • Consumption of cola. Recent research from the Framingham Osteoporosis Study found drinking cola to be an independent risk factor for low hipbone mineral density in women. 

Signs and symptoms of osteoporosis

In its early stages, osteoporosis lacks symptoms. Some people may experience back pain or a loss of height or stooped posture over time. Sometimes loss of height is the first presenting symptom in the physician’s office.

As bone loss progresses, fractures may occur. They are most likely to occur in bones that support a person’s weight, such as the spine or hips, or are injured in a fall, such as the wrist.

Vertebral fractures are the most common fractures associated with osteoporosis. In many cases, these fractures will occur without symptoms and will not be detected unless an x-ray is performed. However, in other cases, fractures manifest as sudden back pain, particularly when bending and lifting. Such pain often recedes for several weeks before returning as a chronic, dull ache. This pain usually subsides gradually but may persist for months.

In some cases, fractures occur in vertebrae that deteriorate to the point where they begin to compress. These compression fractures can cause severe pain and require an extended period of recovery. An accumulation of such fractures may cause a person to lose several inches of height as posture becomes stooped. This abnormal curvature of the spine (thoracic kyphosis) creates a rounding of the back known as dowager’s hump. The abdomen may become compressed, causing it to protrude. 

Multiple vertebral fractures may lead to hip discomfort due to a decrease in the space between the bottom of the rib cage and the top of the pelvis. Other symptoms include difficult or labored breathing and digestive abnormalities, such as constipation and early feelings of fullness while eating.

Hip fractures often occur after a person falls. They almost always require hospitalization and surgery such as joint replacement (arthroplasty). They can result in disability or even death from postoperative complications such as pneumonia or blood clots. In fact, 24 percent of hip fracture patients aged 50 or older die in the first year after the fracture, according to the National Osteoporosis Foundation (NOF).

Although women are two to three times more likely to suffer hip fractures than men, they are less likely to die from the fracture than males, according to the NOF. White women age 65 or older have twice the incidence of fractures as African-American women. In 2004, the U.S. surgeon general issued a report predicting that because of the aging population, the number of hip fractures may double or triple by 2020.

Hip fractures are usually marked by severe pain in the hip or groin, an inability to put weight on the injured leg, and stiffness, bruising and swelling around the hip area.

Wrist fractures usually occur in the lower end of the radius, the bone on the thumb side of the forearm. This causes backward displacement of the wrist and hand and is often known as a Colles’ fracture. These fractures may occur when a person uses an outstretched hand to try to break a fall. Symptoms include wrist pain, swelling just above the wrist, deformity of the arm just above the wrist and inability to hold or lift an object of significant weight.

Patients who experience pain should discuss pain management strategies with their physician. Left untreated, this pain can become chronic and lead to even more severe pain.

Diagnosis methods for osteoporosis

Early detection of osteoporosis is important because early treatment can slow the progress of the disease. A physician should compile a medical history and conduct a physical examination. Topics that will be discussed include the patient’s:

  • Reproductive history and time of menopause, or, for men, symptoms of low testosterone levels
  • Past or present medical conditions
  • Medications taken
  • Lifelong intake of calcium
  • Lifelong exercise patterns
  • Habits including use of tobacco and alcohol

Various blood tests may be performed to rule out other conditions that may cause bone thinning (osteopenia). These conditions include:

  • Osteomalacia. Demineralization, softening and weakening of the bone.
  • Multiple myeloma. A cancerous tumor of the bone marrow.
  • Hyperthyroidism or hypothyroidism. Excessive or deficient activity of the thyroid gland, respectively.
  • Renal insufficiency. Occurs when the kidneys cannot function adequately to maintain a normal state of health.

The best way to detect osteoporosis is by using one or more of several devices that measure bone density. These include:

  • DEXA scan (dual energy x-ray absorptiometry). The most popular method of gauging bone density in patients suspected of osteoporosis. It measures the density of bones in the spine, hips and wrists, the bones most likely to be fractured as a result of osteoporosis. During the test, an x-ray detector scans bone regions, and the varying amounts of x-rays that pass through the bone are measured. The information is then displayed as a color-coded, computerized image that reveals the patient’s bone density. Repeat DEXA tests can help reveal changes in the bones over time. DEXA exposes patients to minimal amounts of radiation.
  • Single-photon absorptiometry. Used to measure bone density of the forearms and heels.
  • Dual-photon absorptiometry. Used to measure bone density of the hips and spine.
  • CAT scan (computed axial tomography). A noninvasive or minimally invasive test that uses a rotating x-ray device to create detailed cross-sectional images (or slices) of body parts. It measures bone density in the spine and may be used as an alternative to DEXA in some cases.
  • Ultrasound. Imaging technique that uses high-frequency sound waves to visualize internal body structures. It can be used to measure the density of the heel.

The National Osteoporosis Foundation recommends bone density tests for women who are not taking hormone replacement therapy (HRT) and fall into any of the following categories:

  • Use medications, such as corticosteroids, that cause osteoporosis
  • Have type 1 diabetes, liver disease, kidney disease or family history of osteoporosis
  • Experience early menopause
  • Are postmenopausal, over age 50 with at least one risk factor for osteoporosis
  • Are postmenopausal, over age 65 and have never had a bone density test

Men with risk factors for osteoporosis are advised to ask their physician about screening for this disease, which is often overlooked in males. There is a popular misconception, even among some doctors, that osteoporosis is a “female disease,” but it also affects millions of men, who are less likely than women to recover from osteoporotic fractures and may be more likely to suffer additional fractures. Many informed physicians are now recommending routine bone density screening tests for men 70 and older, or starting at a younger age if there are additional risk factors.

Bone density measurements are expressed as T–scores, which reflect the patient’s bone density compared to that of a healthy adult of the same sex. A patient’s bone density will also be compared to a Z-score, which is the number of standard deviations above or below what is expected for someone of the same age, sex, weight and ethnic or racial origin.

Dental x-rays over time may also help diagnose osteoporosis by revealing bone loss in the jaw, according to recent research.

Treatment options for osteoporosis

If osteoporosis is due to another disease or to a medical treatment, treatment may begin with resolving or minimizing the cause, wherever possible. For example, patients taking corticosteroids or other immunosuppressives for conditions such as arthritis, asthma or temporal arteritis can work with their physician to find the lowest effective dose. In some cases the physician may be able to find another treatment or discontinue the drug, but patients should not stop taking the medication on their own.

Physicians often recommend that patients take supplements of calcium and vitamin D and engage in regular weight-bearing exercise such as walking. Patients with advanced osteoporosis may be cautioned to avoid certain high-impact activities.

The Food and Drug Administration (FDA) has approved has approved several medications for osteoporosis:

  • Bisphosphonates. These inhibit bone breakdown (resorption), preserve bone mass and increase bone density in the spine and hips and help prevent fractures. Their uses include preventive therapy for people requiring long-term use of corticosteroids, and they may be prescribed to people with cancer or other conditions that can weaken bones.

Some bisphosphonates are available in daily or weekly tablets, and one is available in a monthly tablet or an injection that is given every three months by a healthcare professional. Some research has found that bisphosphonates may be able to be discontinued after several years, but patients are urged to consult their physician and not to do this on their own.

Side effects associated with bisphosphonates include nausea, abdominal pain and irritation of the esophagus. There have been rare cases of jawbone deterioration (osteonecrosis). Esophagitis can be prevented by taking the pill with a full glass of water (8 ounces) and by not lying down for about half an hour after taking the pill on an empty stomach. Bisphosphonates are contraindicated in patients who already have esophageal strictures (narrowing) and in patients who are unable to stand or sit in an upright position for 30 minutes.

  • Hormonal drugs. These include:
    • Selective estrogen receptor modulators (SERMs). These medications block estrogen receptors in breast cells. These medications block estrogen receptors in breast cells. Used to fight breast cancer, they also strengthen bones in women after menopause. Side effects may include hot flashes, upset stomach or risk of blood clots.
    • Calcitonin (Fortical, Miacalcin). Produced by the thyroid gland, this hormone reduces bone resorption and may slow bone loss in postmenopausal women. Calcitonin may also prevent spinal fractures but does not appear to lessen the risk of hip fracture. Administered via nasal spray, it irritates nasal passages and causes nausea in some patients. It is very expensive and is not usually recommended as the first line of treatment.
    • Teriparatide (Forteo). This injectable synthetic version of parathyroid hormone helps to regulate calcium and phosphate metabolism in bones. It may be prescribed to women or men at high risk for fractures. Side effects may include nausea, dizziness and leg cramps.
    • Testosterone therapy. This may benefit men who have or are at high risk for osteoporosis because of low levels of testosterone.

Hormone replacement therapy (HRT) had long been the primary treatment for osteoporosis in women. By taking estrogen or combined estrogen and progesterone replacements, women have been able to slow down or halt the loss of bone mass associated with menopause. However, recent studies link long-term HRT to serious risks including breast cancer and blood clots. As a result, many experts no longer recommend HRT as a primary means of controlling osteoporosis.

Patients with osteoporosis may benefit from physical therapy to enhance balance, strength and mobility. Electrical therapy such as transcutaneous electrical nerve stimulation (TENS) can relieve severe pain and muscle spasms caused by an osteoporotic spinal fracture. Pain management techniques such as acupuncture or acupressure may also reduce back pain. Occupational therapy and instruction in posture and ergonomics can help maximize independence in daily activities.

Operations to repair osteoporotic fractures include arthroplasty such as joint replacement and spinal surgeries such as vertebroplasty and kyphoplasty.

Patients are advised to consult their physician before trying any alternative or complementary therapies. The FDA has warned dozens of companies promoting unproven “alternate” hormone therapies for osteoporosis and other conditions.

Scientists are conducting a great deal of research on osteoporosis. Researchers are developing additional medications, and investigating whether antidepressants that block a brain chemical called serotonin can prevent or treat the disease by increasing bone mass.

Prevention methods for osteoporosis

The risk of osteoporosis for both sexes depends on the amount of bone mass attained between ages 25 and 35, and how rapidly the bone is lost later. Higher levels of bone mass earlier in life help accumulate a store of bone that takes longer to deteriorate during aging. Some experts have suggested that young people can increase their bone mass by as much as 20 percent, which builds a store of skeletal mass crucial to preventing osteoporosis.

About 34 million Americans have low bone mass, according to the National Osteoporosis Foundation (NOF). This condition is known as osteopenia. People can take several steps to increase their bone mass. Valuable tools in fighting osteoporosis throughout a person’s lifetime include:

  • Regular exercise. Regular physical activity (about 30 minutes a day) can help build strong bones and slow bone loss, and the benefits can start at any age. Strength training exercises and weight-bearing activities can help build bone mass. Balance-improving exercise, such as tai chi, can help reduce the risk of falls. Older adults without a history of regular exercise can still increase bone density through exercise. Examples of weight–bearing activities include:
    • Walking, hiking, running or jogging
    • Aerobics, calisthenics or skipping
    • Stair climbing
    • Weight lifting
    • Skiing or skating
    • Tennis, racquetball, squash or handball
    • Field hockey, soccer or other field sports
    • Basketball
    • Dancing
  • Adequate amounts of dietary calcium. Calcium is particularly important while the skeleton is growing (in childhood and adolescence) and during pregnancy and breastfeeding. As people age, the body becomes less efficient at absorbing calcium. Chronic health problems and other medications can also interfere with absorption. Good sources of calcium include foods such as:
    • Milk, low-fat yogurt and cheese
    • Green vegetables such as spinach and broccoli
    • Canned salmon
    • Calcium-fortified orange juice
    • Tofu fortified with calcium
    • Soy beverages
    • Nuts such as almonds
  • Adequate amounts of vitamin D, which is essential for absorbing calcium. Milk is the primary source of vitamin D in the diet, and one cup contains 100 International Units (IU) of vitamin D. People ages 51 to 70 are urged to get 400 IU of vitamin D each day, while those over 70 should get 600 IU each day. Vitamin D is also found in eggs, fatty fish and cereal. The skin also produces vitamin D from sunlight, and small amounts of daily sun exposure can help meet vitamin D requirements. An additional benefit of fatty fish is omega-3 fatty acids, which recent research suggests may also promote bone mineral density.
  • Not smoking. Smoking increases bone loss, because it reduces the body’s ability to absorb calcium. It also decreases a woman’s production of estrogen.
  • Limiting alcohol. Having more than two drinks a day may decrease bone formation and reduce the body’s ability to absorb calcium.
  • Considering hormone therapy. Testosterone replacement therapy may reduce men’s risk of osteoporosis, decrease fatigue and improve mood. Yet it may increase the risk of prostate cancer. Short-term HRT can have several benefits for women undergoing menopause, but the serious health risks of longtime HRT have prompted many experts to warn women against taking HRT simply as a method of preventing osteoporosis.
  • Limiting cola and other sources of caffeine. Consuming excess caffeine (e.g., more than three cups of coffee a day) may raise the risk of osteoporosis, although there is some dispute about this, especially for people who have adequate levels of calcium in their diets.
  • Avoiding long-term use of corticosteroids, if possible. For patients who do take corticosteroids long term, the American College of Rheumatology recommends taking bisphosphonates.
  • Treating eating disorders. Conditions such as anorexia nervosa raise the risk of osteoporosis. 

In addition, certain steps can be taken to prevent the likelihood of bone fractures in those with osteoporosis or who may be at risk for the disease. These measures include:

  • Practicing good posture and ergonomics. Keeping the head held high, chin in, shoulders back, upper back flat and lower spine properly arched helps prevent stress on the spine. Tips for maintaining good posture include:
    • Placing a rolled towel in the small of the back while sitting or driving.
    • Not leaning over when reading or doing homework.
    • Using proper lifting techniques. This involves bending at the knees rather than the waist and lifting with the legs while keeping the upper back straight.
  • Preventing falls. Unexpected falls are the source of many fractures, especially those of the hip and wrist. People can take several steps to reduce the risk of falling. These include:
    • Wear low-heeled shoes with nonslip soles.
    • Eliminate potential sources of slipping in the home or workplace, such as poorly placed electrical cords and area rugs.
    • Install adequate lighting in all areas inside and around the home.
    • Avoid walking on ice, wet or polished floors, or other slippery surfaces.
    • Avoid walking in unfamiliar areas.
    • Beware of the effects of medicine. Certain drugs may cause drowsiness or otherwise impair a person’s coordination or mental alertness.
    • Treat health conditions that may increase the risk of falling. These include poor or impaired vision, impaired arm or leg strength and gait disturbances.
    • Control pain. Patients should not ignore chronic pain, as it can limit mobility and cause additional pain if left untreated.
  • Considering wearing hip pads. Fat or muscle that pads the hips helps to reduce hip fractures. Researchers are investigating whether external hip pads may provide a cushion that lessens the risk of fracture when a person falls. Initial results in studies involving nursing home residents have been encouraging.

In addition, research shows that men who take the cholesterol-controlling drugs known as statins may be less likely to suffer osteoporotic fractures. Studies have produced mixed results on whether statins affect women’s risk of such fractures.

Questions for your doctor about osteoporosis

Preparing questions in advance can help patients have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions about osteoporosis:

  1. What can I do to help prevent osteoporosis? How much exercise should I get, and what kind?
  2. Does my diet need improvement? How much calcium and vitamin D should I be getting? Do I need to take supplements?
  3. Should I limit cola, coffee or alcohol? Is this another reason for me to quit smoking?
  4. Are there preventive medications that can help me if I’m at high risk? If I’m on corticosteroid therapy, should I be taking bisphosphonates? 
  5. Are there any signs and symptoms of osteoporosis I should watch for?
  6. What diagnostic or monitoring tests might I undergo? What do these tests involve?
  7. Should I ask my dentist to look for signs of osteoporosis in my dental x-rays?
  8. What do my test results show? Do I have or am I at risk of developing osteoporosis?
  9. What are my treatment options, and which do you recommend? What are the best medications for me? Can physical therapy or occupational therapy help?
  10. Will I need to my osteoporosis medication for life, or can you discontinue it at a certain point?
  11. Is osteoporosis likely to cause me pain?
  12. What complications can I expect from osteoporosis?
  13. What will be done if I have or am at risk of fractures? If I need surgery, what type, and what will it involve?
  14. What is the expected course of my condition?
  15. Should I have regular screening tests, such as a DEXA scan? How often, and starting at what age? 
  16. Does osteoporosis affect only older women, or can my younger sister, husband or children get it too?
  17. What are the risk factors associated with osteoporosis, and which can I control? 
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