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Bone Basics and the Estrogen Connection

Most of us know someone who has broken a hip, an older person who had to go into nursing care because they couldn't manage on their own as they were healing, and some didn't heal. What can we do to avoid that for ourselves and the ones we love?

This is from Obstetrics and Gynecology at the University of Utah, and we're talking about osteoporosis, how to diagnose it and how to treat it, at the "7 Domains of Women's ÐÇ¿Õ´«Ã½."

Our bones are there to hold us up, to provide a framework for our muscles and organs. They are a dynamic organ that's always remodeling, building up, and breaking down in tiny areas on the surface of the bones. When the breaking down process, the resorption process exceeds the building up part, you can have thin bones or a condition called osteoporosis.

One in five women over 50 years will have osteoporosis, and one in 20 men, and that risk goes up significantly as you get older, especially for women. Estrogen plays an important part in maintaining bone density, and women over 50 go through menopause and lose their estrogen. Some women take menopausal hormone therapy, and they tend to have better bone density. Men continue to make hormones, estrogens and testosterone, into their 80s, and they have a slower decline in bone density as they age.

What Are Fragility Fractures and Where Do They Strike?

So, how do you know if you have osteoporosis or thin bones, and what is a fragility fracture? Well, let's talk about fractures first. What's a fragility fracture, and what are the bones that tend to break?

A fragility fracture is a bone that's broken under a condition that doesn't usually cause a bone to break, a fall or a misstep. In the case of a crush fracture, the vertebrae of the back that can get too thin, especially in women, a hard sneeze or a cough may be enough to cause a crush fracture of the vertebral body in the thoracic spine, the mid part of the spine.

The bones that tend to have fragility fractures are the wrist, falling down, and putting your hands out to brace your fall is the most common way, the middle vertebrae, called the thoracic vertebrae that I just mentioned, and the hip, which is the biggie. A wrist fracture is an inconvenience, a big one, if you don't have anyone to help you open a can or chop some veggies or fasten your bra, or attend to your personal hygiene. A hip fracture is life-threatening.

How to Know If Your Bones Are at Risk

So, how do you know if you have thin bones before you break one? Well, there's something called bone densitometry. It's a great name because it describes exactly what it is.

Now, a regular X-ray, if you fracture your wrist on a fall and they take an X-ray of your wrist, the radiologist might note that the bones in your arm look thin. Now that's a pretty crude tool. It's not a great tool.

When to Get a DEXA Scan—and Who Really Needs One Early

So we have a better one called bone densitometry, or a DEXA, D-E-X-A, DEXA scan. This is a scan of your lumbar spine and hip with low-level X-rays. The lumbar spine isn't the one that breaks, but it's easy to measure, unless you have an old arthritic spine, in which case, they just use the hip density. The hip density is the most useful of the measurements. It can tell you if you have thin bones (osteopenia) or really thin bones (osteoporosis) and can give you an estimate of your risk of hip fracture in the next 10 years.

The report will calculate something called a T-score, which is a comparison of your bone density to that of a woman at age 35 years, when we are at our peak bone density. It will also give you a Z-score, which compares your bone density to a woman your age. But once we're 65 or 70 years old, we all have crummy bone density. So Z isn't so important, and T is the one that they use to calculate the risk of fracture.

If the risk of hip fracture in the next 10 years is greater than 3%, your clinician will recommend treatment. Of course, some women with pretty good bone density will still get a fracture, and some with low bone density will not.

So the National Task Force on Preventative Care recommends a DEXA scan at age 65, and it's paid for by Medicare. Some women are at increased risk and should have a bone density scan earlier. Increased risk because there's a strong family history of osteoporosis, or a medical condition that weakens bones, or a previous fragility fracture.

Calculate Your Risk Without the DEXA Scan

So there's a FRAX score calculator that you can look up online. Just put FRAX, F-R-A-X, calculator into your search engine, and you can see the site from the University of Sheffield in England. You can enter your age, your weight, your sex, your ethnicity, your personal and family history, and it will calculate the risk of a hip fracture in the next 10 years. This is based on these characteristics.

It also has a place for you to put your DEXA bone density. But if you haven't had one, you can calculate your risk based on these factors, your weight, your height, your ethnicity, your personal history of diseases, etc., etc., your drinking, and smoking. If your risk of hip fracture is greater than 3% in the next 10 years, you should talk to your clinician about getting a bone density test to better look directly at your bones.

Treatments That Strengthen Your Bones

So you had this test and you discovered that you have osteoporosis. What is your treatment? Well, you can increase weight-bearing exercise. Increasing your weight-bearing exercise, meaning walking or doing things with weights in your arms. So if you're walking with a little extra weight, that increases the stress on your bones. If you can jump up and down safely, jump up and down a little bit. Dancing is great.

You should stop smoking. Limit drinking. And you should have nutrition with adequate calcium and vitamin D. You can see our podcast on "Vitamin D Supplements."

There are many medications to decrease the resorption of bone that is part of the hormonal normal bone health, but is increased with aging and not balanced by bone building that happens when we are younger. These drugs include a category called bisphosphonates that slow bone resorption. There are drugs called monoclonal antibodies that target proteins that are part of the bone resorption process. There are some drugs that mimic a hormone called parathyroid hormone, which actually builds bones. They all have their costs, risks, benefits, and effectiveness. And you'll need to talk to your clinician or an expert in bone disease, and that's not an orthopedic doctor, who you'll see if you break, but an endocrinologist who specializes in bone metabolism.

How to Fall Less and Live More

So what about the prevention of fractures? Well, don't fall down. I fell down hard. I fell down hard last week. I was carrying garden tools in two hands, watching out for my 3-year-old granddaughter, and walking across uneven ground and new stones in the process of making a new garden. I didn't look where I was going, and I fell down hard. Luckily, I didn't fall on my wrists because I was carrying stuff, and I only had a bad bruise. I'll be more careful, as I'm now officially an old woman at risk.

My 3-year-old granddaughter falls down, that's a fake fall down, all the time, and she says, "I fall down," which means she gently lowers herself to the ground and rolls around a little bit. And she says, "I fall down." Well, when you're 3 and you're skiing at 3 or you're dancing at 3 and you fall down, force equals mass times velocity. Your mass isn't very much, and your velocity is low because you're little. So kids don't break stuff usually when they fall down when they're little. But when you're older, force equals mass times velocity, it can break stuff.

Clear your home of things to trip on, stuff left out on the floor, a grandkid's toys, or a pet's toys. Don't climb up on ladders or tables, or counters to reach stuff. Get the proper little ladders with handholds. My pet peeve is the smoke alarm that goes off in the middle of the night always. And so you're sleepy, and it's dark, and you get up there on a ladder. Don't do that. If smoke alarms go off, it is usually the indication that you need to change your batteries. Of course, if it says "Fire, fire," that means you need to walk out of the house. But if it's just the batteries, they're high up in the ceiling and a guarantee for a fall risk for older people. Get someone else to do that if you can.

So, fall risks are drugs, rugs, and pets. There are medical conditions and drugs that can affect your balance. Get up slowly and make sure that you aren't dizzy before you walk. Talk to your clinician about drugs that are prescribed that are risky for you if you have low bone density. Sleeping pills are notorious. Alcohol not only decreases bone density but also increases the risk of falls because you've had too much and you're dizzy.

Throw rugs are a risk of a throw-down. Put them out of the way of regular walking paths. Pets like dogs and cats are one of the biggest risks. They may pull you over on a leash or show up behind you or in front of you when you aren't expecting. You may not be willing to get rid of your pet, but try to be aware of where they are when you step back.

Movement

Exercises. You need good hip and leg muscles to get out of a chair and walk with confidence, and pick up your feet. Some conditions, such as Parkinson's disease, are particularly associated with falls as balance decreases, and shuffling gait, not picking your feet when you walk, is an increased risk for falls. So people with Parkinson's disease or gait disorders are definitely at risk and have to be extra careful about the rugs, drugs, and pets.

Balance

Balance exercises. Tai chi in a randomized trial showed that people who practiced tai chi, which isn't terrible for your joints, it's easy on your joints. You do have to stand up, though. People who practiced tai chi had fewer falls than people who didn't. And this was randomized so that people were randomized to tai chi or just some regular weight-bearing and strengthening exercises. But tai chi has balance, and people who took tai chi had fewer falls in the subsequent year.

Bob & Brad Method

So, consider other options. I'm a fan of Bob and Brad, Bob and Brad the most famous physiotherapists on the internet. Go to YouTube. Just go to "Bob and Brad balance exercises," and they have some really simple ones that they recommend.

Diet

Make sure you have a balanced diet with enough calcium and vitamin D, and other minerals. A balanced diet with dairy and vegetables, and protein to keep our muscles strong will do it. But if you're not able to have that diet, or take any diary, consider a multivitamin with minerals. You can talk to your clinician if a referral to a dietitian would be helpful.

Want to Prevent Osteoporosis? Start Early

This is part of a two-part series on osteoporosis at The Scope from the University of Utah with the "7 Domains of Women's ÐÇ¿Õ´«Ã½." Share it with your friends and the people you love. And you can listen to all of our podcasts on women's health at the "7 Domains of Women's ÐÇ¿Õ´«Ã½" or wherever you get your podcasts.

Thanks for listening, and stay strong, and don't fall down.