The term describes the thinning of bones that results from a reduction in bone density. The decrease in bone density occurs silently over many years and may escape detection and remain undiagnosed for a long time.
Osteoporosis can cause low back pain, loss of height, or curvature of the spine, resulting in a rounded back, commonly known as a “hump.”
Osteoporosis is responsible for fractures occurring after minimal trauma (pathological fractures). Often, fracture healing is difficult due to the poor quality of the bone. It is a disease associated with a significantly increased risk of fracture. Fractures lead to hospital admission, immobilization, and reduced quality of life. It is a costly disease in terms of healthcare resources. To avoid these complications, early detection and treatment of individuals at high risk of osteoporosis is essential. Bone mineral density (BMD) measurement is a method used to assess actual bone mass. Through BMD measurement, the risk of osteoporotic fracture can also be estimated. Approximately 30% of postmenopausal Caucasian women have osteoporosis, and nearly 60% have low bone mass. Variations exist among different ethnic groups.
Apart from predicting fracture risk, bone density measurement is also used to monitor treatment effectiveness. Risk factors for osteoporosis include a previous history of fractures, low body mass index, smoking, excessive alcohol consumption, poor diet and low dietary calcium intake, low estrogen levels, chemotherapy, amenorrhea in young women who train intensively, rheumatoid arthritis, chronic liver disease, long-term treatment with heparin or steroids, and a family history of osteoporosis or fractures.
Women under 65 years of age who present any of the above risk factors, as well as women over 65, should undergo bone density testing. The most reliable method of bone density measurement is dual X-ray absorptiometry (DXA). Once the diagnosis is made, many different treatments can be applied.
Why menopause speeds up bone loss
Estrogen protects the skeleton because it slows down the cells that break down bone. When estrogen levels fall at menopause, the balance is tipped. Bone loss is fastest in the first five to seven years and can reach a significant percentage of bone mass. Women with early menopause, before 45, are more exposed.
How to read a bone density scan
The DXA result is given as a T-score, which is a comparison with the bone density of a healthy young adult:
- T-score of -1 and above: normal bone density.
- T-score between -1 and -2.5: osteopenia, meaning low bone mass.
- T-score of -2.5 or lower: osteoporosis.
The number alone is not enough. Your doctor takes into account your age, fracture history and other risk factors to estimate the likelihood of a fracture in the next decade.
Prevention: what you can do yourself
- Calcium: dairy products, small fish eaten with the bones, almonds, green leafy vegetables. A supplement only when your diet is not enough.
- Vitamin D: have your levels measured and replenish them if needed.
- Weight-bearing exercise: walking, climbing stairs, resistance exercises. Swimming benefits the heart, but not the bones in particular.
- Quit smoking and drink alcohol in moderation.
- Fall prevention: proper shoes, good lighting at home, vision checks.
Treatment of osteoporosis
Medication is decided on an individual basis. Bisphosphonates are usually the first choice. Alternatives include denosumab, selective estrogen receptor modulators and, in severe cases, bone-building (osteoanabolic) medications. In women near menopause with severe symptoms, hormone therapy also protects the bones. Monitoring is done with repeat scans, usually every one to two years.
Calculating fracture risk with FRAX
Two women with the same T-score do not necessarily have the same risk. That is why FRAX is used, a World Health Organization tool that calculates the probability of a fracture in the next ten years. It combines age, weight and height, fracture history, smoking, alcohol, cortisone use, rheumatoid arthritis, a parent with a hip fracture and, optionally, hip bone density.
The result helps with a critical decision: which woman with osteopenia needs medication and which simply needs to pay attention to diet and exercise. A 70-year-old woman with osteopenia and a previous wrist fracture may be at greater risk than a 55-year-old woman whose scan shows osteoporosis.
Osteoporosis caused by another condition
In some women, even after menopause, bone loss is accelerated by another condition or medication. Before treatment starts, the following are usually ordered:
- calcium, phosphorus, alkaline phosphatase and creatinine,
- 25-hydroxyvitamin D and parathyroid hormone,
- TSH for the thyroid,
- a complete blood count and, where appropriate, testing for celiac disease or other conditions.
Medications that harm the bones: corticosteroids taken for months, aromatase inhibitors after breast cancer, certain antiepileptic drugs, excessive thyroxine doses, GnRH analogs and long-term use of proton pump inhibitors. Do not stop them on your own. Tell your doctor so that protective measures can be taken.
Vertebral fractures that go unnoticed
Most vertebral fractures do not cause severe pain. The vertebra is gradually compressed, and the woman simply loses height or starts to stoop. Such a fracture, however, multiplies the risk of the next one.
- Loss of more than 3 to 4 centimeters in height compared with your youth.
- Sudden back pain after lifting something heavy, coughing or bending over.
- A protruding belly or difficulty breathing due to the curvature of the spine.
If any of these apply, ask for an X-ray or a dedicated vertebral assessment along with your DXA scan.
Calcium and vitamin D in practice
After 50, most guidelines recommend about 1,000 to 1,200 mg of calcium a day, preferably from your diet. For example:
- a glass of milk or a cup of yogurt provides about 250 to 300 mg,
- a 30-gram piece of hard cheese provides about 200 to 300 mg,
- sardines with the bones, tahini, almonds and leafy greens round out the day.
If your diet covers your needs, you do not need a calcium supplement. High-dose supplements offer no additional benefit and increase the risk of kidney stones. For vitamin D, the usual recommendations for women over 50 are around 800 to 1,000 units per day, adjusted according to blood levels. Adequate protein in your daily diet is just as important for bones and muscles.
Exercise: which types help and which need caution
The skeleton gets stronger when it bears load. The ideal program combines three elements:
- Resistance exercise, two to three times a week: resistance bands, small weights, machines, with a gradual increase in load.
- Weight-bearing exercise: brisk walking, stair climbing, dancing.
- Balance: tai chi or specific exercises, which reduce falls and therefore fractures.
If you already have osteoporosis or a vertebral fracture, avoid forceful bending and twisting of the spine under load, such as sit-ups or lifting weights with a rounded back. A physical therapist can show you a safe alternative.
Treatment duration and what you should know about the medications
Bisphosphonates
They stay in the bones for years after they are stopped. After about 5 years of oral or 3 years of intravenous treatment, the risk is reassessed. Women at lower risk may take a treatment break, while for those at high risk treatment continues. The tablets are taken on an empty stomach with a glass of water, and you should stay upright for at least half an hour.
Denosumab
It is given as an injection every six months. It should not be stopped or delayed, because stopping abruptly can lead to rapid bone loss and multiple vertebral fractures. When it is stopped, another medication usually follows.
Bone-building (osteoanabolic) medications
They build new bone and are intended for women at very high risk, for example those with multiple fractures. They are given for a limited period and are followed by a medication that maintains the gain.
Rare side effects
Osteonecrosis of the jaw and atypical femur fractures are rare complications of long-term osteoporosis treatment. The risk is much smaller than the benefit for women who truly need treatment. A dental checkup before starting and reporting any thigh or groin pain during treatment are simple preventive measures.
Bones are built in youth
Peak bone mass is reached around age 25 to 30 and is the “capital” for the rest of your life. What happens in adolescence matters: adequate nutrition, exercise and a normal menstrual cycle. Young women who have no periods for months, whether from low body weight or excessive training, lose bone at an age when they should be gaining it.
Pregnancy and breastfeeding cause a small, temporary decrease in bone density, which usually recovers within a few months after breastfeeding stops. In contrast, premature ovarian insufficiency before 40 requires hormone replacement at least until the natural age of menopause, to protect the bones and the heart. If you notice changes in your cycle after 40, read about the symptoms of perimenopause.
How to prepare for a DXA scan
The test is painless, takes a few minutes, and the radiation is much lower than a simple chest X-ray. For a reliable result:
- Do not take a calcium supplement in the 24 hours before the test.
- If you have recently had a barium study, a contrast exam or a nuclear medicine scan, let the center know. The test may need to be postponed for a few days.
- Wear clothes without metal buttons, zippers or a belt around the waist and hips.
- For future scans, choose the same center and the same machine. Comparisons between different machines are not accurate.
Your home as a risk factor: preventing falls
Most hip fractures happen after a fall at home. A few simple changes lower the risk:
- Remove slippery rugs and cables from hallways.
- Use a non-slip mat and a grab bar in the bathroom.
- Install a night light along the path from your bed to the toilet.
- Have your vision and glasses checked every year.
- Discuss with your doctor any medications that cause dizziness or drowsiness, such as certain sleeping pills and blood pressure medications.
- Wear closed shoes with a firm sole instead of backless slippers.
Osteoporosis myths and facts
- “It is only a problem for the elderly.” Bone loss starts at menopause, and even earlier in younger women with absent periods, cortisone use or early menopause.
- “I drink milk, so I am covered.” Calcium is necessary but not enough. Without vitamin D, exercise and adequate protein, bone is not built.
- “Since I am not in pain, I do not need treatment.” Osteoporosis only hurts when a fracture occurs. The goal of treatment is to keep you from getting there.
- “The medications are more dangerous than the disease.” For women at high risk, the fractures prevented far outnumber the rare serious side effects.
For a personalized assessment of your case, book an appointment with Dr. Panagiotis Polyzos at his office in Athens or Volos.
Frequently Asked Questions
Does osteoporosis have symptoms?
Usually not, which is why it is called a silent disease. Many women find out after fracturing a wrist, vertebra or hip following a minor fall. Loss of height and a curved back are late signs.
At what age should I have a bone density scan?
All women aged 65 and over. Earlier, starting at menopause, if there are risk factors such as early menopause, low body weight, smoking, long-term cortisone use or a family history of hip fracture.
What is the difference between osteopenia and osteoporosis?
Osteopenia is a milder decrease in bone density, with a T-score between -1 and -2.5. It is not a disease but a warning. Osteoporosis is present when the T-score is -2.5 or lower.
Can osteoporosis be reversed?
Appropriate treatment stops bone loss, increases bone density to some degree and, most importantly, significantly reduces the risk of fracture. Full recovery is not always possible, so prevention matters.
Does hormone therapy protect the bones?
Yes. Hormone replacement therapy reduces bone loss and fractures. However, it is given mainly for menopausal symptoms and after an individualized assessment of benefits and risks.
Do I need to take a calcium supplement?
Only if your diet does not cover your needs. Two to three servings of dairy a day are usually enough. If a supplement is needed, small doses taken with food are preferred, for better absorption and fewer side effects.
Can I do Pilates or yoga if I have osteoporosis?
Yes, with modifications. Balance, strengthening and posture exercises are beneficial. Avoid deep forward bending of the spine and forceful twisting, especially if you already have a vertebral fracture. Let your instructor know.
Should I see a dentist before starting treatment?
It is good practice, especially before bisphosphonates or denosumab. If you need extractions or implants, it is best to have them done before starting. Always tell your dentist that you are taking osteoporosis medication.
How often should the scan be repeated if it is normal?
If your bone density is normal and there are no new risk factors, the scan can be repeated after several years. With osteopenia the interval is shorter and depends on how close you are to the osteoporosis threshold.
