Living with
Postmenopausal Osteoporosis

Postmenopausal Osteoporosis

Our bones are made up of living, growing tissue that is constantly in a cycle of breaking down, and being renewed. Osteoporosis is a condition where the replacement of new bone doesn’t keep up with the loss of old bone, which causes the bones to weaken and become brittle. This puts the person at risk for fragility fractures that can jeopardise their mobility and independence, and even result in death. 

Common osteoporosis-related fractures occur in the hip, wrist or spine, however, mild actions such as coughing, sneezing or bending over can also cause a fracture. Bone loss is gradual, so osteoporosis often develops without any symptoms, and is usually first discovered when a fracture occurs. 

Osteoporosis predominantly affects post-menopausal1 women. The National Osteoporosis Foundation of South Africa (NOFSA) estimates that more than one-third of women over the age of 50 and nearly half of those over age 70 are affected by this disease. A woman’s risk of sustaining a hip fracture is equal to the combined risk of developing breast, uterine and ovarian cancer. 

Osteoporosis, though not reversible, can be treated. The key to managing this disease is the prevention of bone loss and rebuilding of bones with medication and lifestyle changes. The treatment of advanced osteoporosis is difficult however once there is disability, especially of the spine or hip. 

What is osteoporosis?

The word ‘osteoporosis’ means ‘porous bone’. This condition causes the bones to have less bone mass and strength, putting the person at a greater risk for sudden and unexpected bone fractures. There are two types of osteoporosis: 

1. Primary osteoporosis occurs naturally with the normal process of ageing. It includes: 

• Type I osteoporosis (postmenopausal osteoporosis) which generally affects women during menopause. 

• Type II osteoporosis (senile osteoporosis) which typically occurs after age 70, and affects both women and men. 

2. Secondary osteoporosis is caused by certain medications and medical conditions that damage the bone. 

What is postmenopausal osteoporosis?

Postmenopausal osteoporosis is osteoporosis that results from decreased estrogen and progesterone levels that drop after menopause. Estrogen and progesterone play a role in bone metabolism – estrogen protects against excessive bone loss by controlling the osteoclasts (breaks bone down), and progesterone influences osteoblasts to make new bone. 

What causes postmenopausal osteoporosis?

Healthy bone consists of a dense outer shell (cortical bone) that envelops the spongy inner (trabecular bone). With osteoporosis, the “holes” in the “sponge” grow larger and more numerous, which weakens the inside of the bone. 

The bones store calcium and other minerals, and when the body needs calcium, it breaks down and rebuilds bone. This process of bone remodeling supplies the body with needed calcium. After age 35, bone breakdown occurs faster than bone build-up, causing a gradual loss of bone mass. 

For women, there are two phases of bone loss: The first is menopause-related bone loss which occurs when estrogen production drops, leading to more bone resorption than formation. In the first 10 years after menopause, women undergo rapid bone loss. The second is age-related bone loss. 

What are the symptoms?

Osteoporosis is a silent disease that often goes undetected until it’s advanced. Watch for these warning signs: 

• Loss of height (getting shorter over time) 

• Change in posture (stooping or bending forward) 

• Shortness of breath (smaller lung capacity due to compressed disks) 

• Back pain (caused by a fractured or collapsed vertebra) 

• Pain in the lower back 

• Bone fractures 

What are the complications of postmenopausal osteoporosis?

Osteoporosis doesn’t cause pain or other symptoms on its own, but complications arise from bone fractures, particularly in the spine or hip. In advanced osteoporosis, the bones in the vertebrae become so fragile that they can collapse without trauma. These compression fractures cause severe pain in the back, loss of mobility and autonomy, respiratory and cardiovascular complications, and loss of self-esteem and independence. Hip fractures that result in disability increase the risk of death within the first year after the injury. 

What are the risk factors?

Besides menopause, the following puts a woman at risk for postmenopausal osteoporosis: 

• Age 

• Ethnicity – White, Asian and Coloured women are more likely to develop osteoporosis. 

• A family history of the condition 

• A low body mass index (BMI) 

• Having an eating disorder (e.g. anorexia, bulimia) 

• Excess alcohol consumption 

• Smoking 

• Lack of exercise 

• Underlying medical conditions, such as hormonal conditions or inflammatory disorders 

• High-dose steroids which a person has taken for longer than three months 

• Medications that can affect hormone levels, such as anti-estrogen tablets 

How is it diagnosed?

Low bone mass is strongly associated with the development of fractures, and therefore, bone mass density and fractures can be measured using the following techniques: 

• Dual-Energy X-ray Absorptiometry (DEXA/ DXA). These x-rays use low amounts of radiation to determine how solid the bones of the spine, hip or wrist are. It is non-invasive and precise. The results are expressed as a ‘T-score’, and indicate the gap (standard deviation, SD) of the tested person to the normal healthy population. 

• Computerised Tomography. This accurately measures spinal bone mass, but (to date) does not measure hip bone mass. The radiation dose is higher than DEXA and the measurement less reproducible. 

• X-rays. This is used to detect fractures and deformities. Up to 40% of bone loss needs to occur before it is detected on X-rays. 

• Single Photon Absorptiometry (SPA). It measures bone in the wrist and forearm, but does not always provide accurate information about bone density in other sites. 

How is it treated?

The aim of treatment is to stop further bone loss, strengthen the bones and prevent bone fractures. Treatment starts with women who have osteopenia, which is not as severe as osteoporosis. A patient’s treatment will depend on the results of their bone density scans. The medication falls into two broad groups: 

1. Anti-resorptives act primarily to maintain bone mass and slow bone breakdown. They include: 

• Selective estrogen receptor modulators (SERMS): They affect the bone in a similar way to estrogen, e.g. raloxifene, tibolone, calcitonin-salmon. 

• Bisphosphonates: These medications slow down bone loss by stopping the body from reabsorbing bone tissue. Types of bisphosphonates include risedronic acid, alendronic acid, zoledronic acid, and ibandronic acid. They come in various formulations and dosing schemes. 

• Hormone replacement therapy (HRT): HRT is used to replace those hormones which decline during menopause: estrogen and progesterone. It’s usually recommended for women who are less than 60 years old and/or less than 10 years postmenopausal. 

• Calcium and vitamin D supplements: Calcium is the main mineral in bone, and vitamin D helps with calcium absorption. 

2. Bone-formation stimulating drugs aim to increase bone mass, and include: 

• Parathyroid hormone: This hormone regulates calcium levels in bones. Parathyroid treatments include teriparatide and romosozumab-aqqg and they are administered as injectables. 

• Other medications: fluoride, anabolic steroids, strontium salts and statins. 

Living and managing

If you’ve been diagnosed with osteoporosis, it does not mean that you’ll definitely have a fracture; it increases the risk of having one. Therefore, when living with osteoporosis, take care of nourishing your bones and safeguarding against falls. 

1. Good nutrition is important for healthy living. Here are a few points when adjusting your diet: 

• Ensure that you’re getting sufficient amounts of the micronutrients, calcium, vitamin D and magnesium. Calcium is a major component of bone tissue and essential for bone strength and structure. Sources of calcium include milk, yogurt, cheese or calcium-fortified foods such as cereal. NOFSA recommends that all patients with osteoporosis should ensure a calcium intake of at least 1000-1500mg per day. 

• Magnesium can be found in bone tissue and is also important for bone health. Magnesium-rich foods include nuts, seeds, whole grains, and legumes. 

• Limit your alcohol intake. 

2. Stop smoking. 

3. Spend time in the sun. Vitamin D is essential for calcium absorption, and we get most of our vitamin D from sunlight. If your sun exposure is limited, you can get vitamin D from food, albeit in lesser amounts. Food sources of vitamin D include cod liver oil, trout and salmon, as well as fortified foods such as cereals and margarine. If this isn’t possible, consider supplementation. The recommended amount is at least 600 international units (IU) of vitamin D a day, and 800 IU a day for those over the age of 70. 

4. Regular exercise helps you to slow bone loss and improve balance, endurance and posture. Weight-bearing exercises, such as walking, jogging, running, and stair climbing, are beneficial for the bones in your legs, hips and lower spine. Gentle exercise such as tai chi or yoga can help improve strength and balance as you get older. If you’ve had a broken bone, consult your healthcare professional about the best exercises for your condition. 

5. Safeguard against falls. Here are some tips to help you prevent falls inside and outside the home: 

• Keep your floors free of clutter. 

• Glue or remove loose wires and cords. 

• Use anti-slip carpet underlays under carpets and put non-skid pads on loose rugs. 

• Ensure that the lighting in the house is bright enough to see clearly. 

• Do not use detergents that leave your floors slippery. 

• Clean up spills immediately. 

• Install grab bars in the bathroom and use non-skid mats on bathroom floors. 

• Install railings on stairways. 

• Avoid walking around in socks. 

• Avoid having to climb or reach for items. Keep oft-used items, such as groceries and personal toiletries, in easy-to reach places. 

• Be careful around pets. Tripping over pets is common cause of falls. 

• When outside, use a backpack or other type of bag that leaves your hands free. 

• Keep areas outside in good repair and free of clutter. 

• Wear rubber-soled shoes for better traction. 

• Do light physical activities, such as tai chi or yoga, to help improve your balance, coordination, and muscle strength. 

• Have your vision checked regularly, and keep your glasses/ contact lens prescription up to date. 

• Sleep with a pillow between your knees if your hips and lower back needs support. 

6. Recovering from a broken bone. Recovery depends on the type of fracture you have. Some fractures heal easily, while others may need more intervention. Broken bones usually take six to eight weeks to recover, regardless of whether you have osteoporosis or not. During the healing process, you may need the help of a physiotherapist or occupational therapist so you can make as full a recovery as possible. 

7. Pain management. Fractures can be very painful and coping with pain is important for the quality of life. Pain can be managed with painkillers, heat treatment (warm baths or hot packs), cold treatment (cold packs) simple relaxation techniques, massage or hypnosis. 

Further resources:
The National Osteoporosis Foundation of South Africa (NOFSA) – https://osteoporosis.org.za/