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Contents
Definition and Epidemiology .................................................................................................................. 2
Aetiology ............................................................................................................................................. 4
Pathophysiology ................................................................................................................................... 5
Clinical signs and symptoms .................................................................................................................. 6
Differential diagnosis and investigations ................................................................................................. 7
Osteomalacia .................................................................................................................................... 7
Paget’s Disease (Osteitis Deformans) .................................................................................................. 8
Malignant Tumours ............................................................................................................................ 8
Orthodox medical treatment .................................................................................................................. 9
Avoiding and recovering from fractures ............................................................................................... 9
Drug treatments ................................................................................................................................ 9
Lifestyle changes ............................................................................................................................. 10
Natural medicine ................................................................................................................................ 10
Prognosis ........................................................................................................................................... 10
Resource list ...................................................................................................................................... 11
References ......................................................................................................................................... 12
Bibliography ....................................................................................................................................... 12
Appendix A Tables from the World Health Organisation technical report, 1994 ......................................... 13
Appendix B Case study........................................................................................................................ 15
Appendix C Table of orthodox treatments ............................................................................................. 17
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
page 1 of 17
Definition and Epidemiology
The
World
Health
Organisation
(WHO)
defines
osteoporosis as ‘a disease characterised by low bone
mass and microarchitectural deterioration of bone tissue,
leading to enhanced bone fragility and consequent
increase in fracture risk.’ The WHO report published in
1994, says that a bone mineral density of more than 2.5
standard deviations less than young adult reference
mean is the defined value for osteoporosis. The young
adult reference takes into consideration the ethnicity of
the patient.
Figure 1 shows the bone tissue for a normal adult female
compared with bone tissue of a 70 year old woman.
These images show that the trabecular bone structure of
the older woman has become thinner and more
connections between the structures are missing.
Figure 1 – scanning
show the structure of
old woman (top) and
(bottom). Copyright
(BMJ), 2006
electron micrographs to
L3 vertebra in a 31 year
in a 70 year old woman
British Medical Journal
Osteopenia is a low bone density value which is not low enough to be classified as osteoporosis, although an
osteopenic individual has a high risk of developing osteoporosis. Based on the 1994 WHO definition, a value
of between 1 and 2.5 standard deviations from the young adult mean would be classed as osteopenia.
Established (or severe) osteoporosis is diagnosed osteoporosis with a fracture. This information is
summarised in Table 1.
Table 1 – summary of bone mass values
Definition
Normal
Low bone mass (osteopenia)
Osteoporosis
Established (severe) osteoporosis
Value
0-1 standard deviation below young adult mean
1-2.5 standard deviations below young adult mean
More than 2.5 standard deviations below young adult mean
Osteoporosis + 1 or more fragility fractures
Based on information from WHO (1994) report – see reference list
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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There is a strong female bias for the condition with the highest incidence in white post-menopausal women,
although it is possible for anyone to be affected by the condition, including children (O’Connor and Perkins,
2005). Figure 2 compares the incidence of osteoporotic fractures between men and women and shows that
women are twice as likely to sustain wrist or hip fractures after 60, and vertebral fractures after 70 years of
age.
Race has also been shown to be a factor for osteoporosis: negro races are less likely than Caucasians to
have the disease because of higher initial skeletal mass (WHO, 1994).
As part of the aging process bone density naturally
decreases which means that older people are more
likely to have the condition. An older person is more
likely to sustain a fragility fracture (a fracture caused
by a minor trauma) and at this point be diagnosed with
osteoporosis which partially explains the relationship
between age and incidence (WHO, 1994).
The condition is often asymptomatic until a fragility
fracture
occurs
which
is
why
the
condition
is
sometimes described as the ‘silent thief’ (WHO, 1994).
In the UK, osteoporosis is responsible for over 60,000
hip, 50,000 wrist and 120,000 vertebral fractures each
Figure 2 – Epidemiology of osteoporotic fractures in
men and women. Copyright Dennison, Cole and Cooper
(2005), taken from BMJ, 2006.
year (National Osteoporosis Society [NOS], 2006).
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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Aetiology
Osteoporosis can be primary or secondary which means it can result from another condition such as
Cushing’s syndrome (Gould, 2006).
Figure 3 shows that bone mass naturally reduces after peak bone mass has been reached at around 35
years of age. In the primary form of the disease, the rate at which it diminishes with age is affected by
many factors: genetic (vitamin D receptors, family history, ethnic origin, skeletal mass), nutrition (calcium
intake, alcohol consumption), lifestyle (weight-bearing exercise, smoking). Secondary causes include
diseases affecting hormone balance, drugs and conditions such as anorexia nervosa (WHO, 1994).
The sex hormones, oestrogen and testosterone,
play a significant part in the rate of bone formation
because they stimulate osteoblast activity. During
the
menopause,
oestrogen
levels
are
greatly
reduced which that bone mass is reduced. In
addition to hormonal changes, women are more
likely to have osteoporosis because they have lower
Figure 3 – Age related changes in bone mass throughout
life in women and men, copyright BMJ, 2006.
peak bone mass (Tortora and Derrickson, 2006).
Details of the factors associated with osteoporotic fractures and causes of osteoporosis in adults can be
found in Appendix A.
Risk and predisposing factors are varied so that cause of the disease process in an individual is often
complex and not definitive. For example, Liz Larsson was diagnosed as osteopenic in 2006 at the age of 44
although her lifestyle and family history did not indicate she was particularly at risk. The mostly likely reason
for her condition was that she had started the menopause approximately 18 months previously. However,
there were other things which could have contributed to her low bone density such as prolonged use of the
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
page 4 of 17
contraceptive injection depo-provera. There may also have been a genetic element as a younger sister has
subsequently been told that her bones are thinner than expected. See Appendix B for her case study.
Pathophysiology
Normal bone tissue is constantly being broken down and then rebuilt. During childhood and early adulthood,
more bone is built than is broken down. After peak bone mass has been reached, bone loss starts in the
fourth or fifth decade of life (Poole and Compston, 2006).
The normal process for remodelling bone is described in Figure 4. In an osteoporotic patient, osteoclasts are
more active and / or osteoblasts are less active with the result that more of the internal structure and
therefore strength of bone tissue is reduced (see Figure 1, page 2)
A
trabecular bone surfaces are
covered by resting osteoblasts
(cells which create bone
matrix)
B
osteoclasts
(cells
which
break down bone matrix)
migrate to a dormant bone
surface
C
osteoclasts
excavate
resorption cavity
a
D
mononuclear cells smooth
the cavity
E
F
G
H
osteoblasts are attracted to
the site where they synthesize
bone-like matrix
synthesis of the new matrix
continues
Newly formed bone calcifies
When the process is
complete,
lining
cells
overlie
the
trabecular
surface
Figure 4 – Steps in the remodelling sequence of trabecular bone, adapted from 1994 WHO report
Bones consisting of proportionally higher cancellous (trabecular) bone are particularly likely to be affected
because this type of bone is relatively more hollow than compact or cortical bone. It also regenerates
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
page 5 of 17
quickly which means that there is more opportunity for problems with remodelling to have an effect (Gould
2006) (Reister O’Connor and Perkins, 2005).
Figure 5 - A man aged 78 presented with an
acute onset of thoracic kyphosis over a period of
10 weeks. The differential diagnosis on magnetic
imaging included the possibility of a neoplasm,
but further investigations confirmed osteoporotic
collapse.
Copyright: Shergill, I and Wilson-Macdonald, J,
Nuffield Orthopaedic Centre NHS Trust, Oxford
OX3 7LD
The effect of these changes on the body is that the patient’s bones are more prone to fracture. This results
in pain for the patient either through fracture or pressure on nerves through vertebral collapse. Spinal
fractures may cause loss of height and spinal deformity such as kyphosis (increased thoracic flexion, see
Figure 5) or scoliosis (increased lateral curvature). Spontaneous or fragility fractures occur most commonly
in the hip, wrist or vertebrae (Gould, 2006).
Clinical signs and symptoms
Reister O’Connor and Perkins (2005) describe osteoporosis as ‘a silent disease’ which means individuals are
likely to be asymptomatic until a fragility fracture occurs. They suggest that any fracture which happens
from a very minor trauma should be investigated as a fragility fracture, as should ‘multiple fractures, even
with significant trauma’.
Given that the definition of established osteoporosis according to the WHO study group report in 1994
includes a clinically apparent fracture, this type of break can be considered a pathognomonic sign.
Presentation of a fragility fracture, particularly if the patient history includes risk factor or factors listed in
Appendix A should be treated as a red flag and further diagnostic tests carried out.
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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Vertebral compression fractures may present as ‘nagging’ back pain initially but as the disease progresses a
patient will show clinical signs such as loss of height and deformity of the spine (Reister O’Connor and
Perkins, 2005). Figure 5 shows an example of kyphosis caused by osteoporotic vertebral fractures.
Osteoporosis is likely to cause fractures in specific areas because of the higher proportion of cancellous bone
particularly if it is under pressure from supporting the body (vertebrae, hip) or from protecting against falls.
A wrist or Colles’ fracture is a typical sign of osteoporotic fracture which occurs in the distal radius, ulna or
smaller wrist bones. It is often a protective injury when an individual puts out a hand to break a fall and
should be treated as a red flag (Reister O’Connor and Perkins, 2005).
Differential diagnosis and investigations
Osteoporosis is often asymptomatic, particularly if vertebrae are affected where approximately two thirds of
patients do not present a clinically evident fracture. When a patient has spinal deformity or sustains a
fragility fracture further investigation is required to confirm a diagnosis of osteoporosis (Poole and
Compston, 2006).
The primary investigative tool often seen as a gold standard is a dual energy x-ray absorptiometry (DXA)
scan (Reister and Perkins, 2005). It measures bone density using two sources of x-rays. The scan can be
carried out at any site but most commonly the test is used to measure the lumbar spine (L2-L4 or L1-L4)
and hip. This technique is easy to use and has a high level of precision (WHO, 1994). See Appendix A (table
7) for other investigative tools.
There are other causes of fragile bones and deformity which would need to be ruled out:
Osteomalacia

Characterised by demineralisation related to vitamin D deficiency.

Weaker bones result in compression fractures especially in the vertebral body and femoral neck
(Thibodeau and Patton, 2007).
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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
Signs including site of fracture, and symptoms are very similar to osteoporosis and the two disorders
can co-exist.

Diagnosed by x-rays – bone demineralisation will be seen in the spine, pelvis and lower extremities.
Fibrous lamellae and incomplete areas of demineralisation are apparent in the cortex (Merck, 2008)
Paget’s Disease (Osteitis Deformans)

Characterised by more osteoclasts and compensatory osteoblast activity.

Bones are remodelled in a disorganised way which can cause weakness in some areas of bone and
additional strength in other areas.

Commonly affects the skull, humerus, femur, vertebrae and pelvic bones. Weakness can cause
fragility fractures similar to osteoporosis (Thibodeau and Patton, 2007)

Diagnosis is confirmed through x-ray (Figure 6) which would show abnormal architecture (cortical
trabeculation or thickening) and serum levels of alkaline phosphate, calcium and phosphate (Merck,
2008).
Figure 6 – X-rays of bones affected by Paget’s Disease. Copyright BMJ, 1996
Malignant Tumours

Osteosarcoma (osteogenic sarcoma) is the most common
malignant bone tumour and most often in the metaphysic of
the tibia, femur (see Figure 7) and humerus.

Presents as bone pain and sometimes pathological fracture.
This would need to be ruled out because it can quickly
metastasise to the lungs, although peak incidence is
between 10 and 25 years (Gould, 2006).

Diagnosed through bone biopsy (Merck, 2008).
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
Figure 7 - Osteosarcoma of the distal femur
in a young patient treated with pre-operative
chemotherapy and a limb-sparing surgical
procedure.
Copyright
www.Radium.no,
Cancer Research Norway
page 8 of 17
Orthodox medical treatment
Once the diagnosis of osteoporosis has been confirmed, the disease is managed according to the specific
requirements of the individual patient. The following strategies from Reister O’Connor and Perkins, 2005 and
National Osteoporosis Society leaflets might be used in a management programme:
Avoiding and recovering from fractures
An individual with osteoporosis is very likely to sustain a fracture from a fall and may even fall due to a
spontaneous fracture (stress fracture). Precautions such as installing grab bars and hand rails in the home,
sufficient lighting, taking extra care in snow/icy conditions as well as in the home can reduce the number of
falls.
Femoral fractures may require surgery and hip replacement. Vertebral compression fractures can be left
untreated if the fracture is stable. If the vertebra is unstable percutaneous vertebroplasty (injecting acrylic
cement into the vertebra) or kyphoplasty (injecting a small balloon) may be used for pain relief. Colles’
fractures (wrist) are treated by realigning the bones and then splinting to immobilise while the bone heals.
Drug treatments
There are many drug treatment options but the biosphosphonates are the most common group. They are
given in tablet form and work by inhibiting osteoclast activity which allows osteoblasts to work more
effectively. There are several licensed in the UK including Alendronate, Cyclical Etidronate, Ibandronate and
Risedronate.
Hormone replacement and hormone mimicking drugs are also available. These work by either stimulating
osteoblasts (parathyroid hormone treatment) or inhibiting osteoclasts (oestrogen and testosterone
replacement therapies, raloxifene). Stronium ranelate works by both stimulating osteoblasts and inhibiting
osteoclasts.
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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Dietary supplementation of calcium and vitamin D is often recommended in conjunction with other
medication and for elderly people.
Medication such as nonsteroidal anti-inflammatory drugs are prescribed or suggested for acute or chronic
pain associated with osteoporotic fracture. More information about drug treatments can be found in
Appendix C.
Lifestyle changes
Smoking, excessive alcohol intake, unbalanced diet and a sedentary lifestyle can all contribute to bone mass
loss. Management of osteoporosis is likely to include keeping active but this will depend on the severity of
the condition.
Natural medicine
There are not many natural treatments recommended for this condition. Natural treatments for pain
management such as acupuncture or massage (although this is not recommended for severely osteoporotic
patients) could be considered to mediate nerve pain from any spinal damage or other fractures (Reister
O’Connor and Perkins, 2005).
Diet, lifestyle changes and vitamin supplementation are often prescribed as part of orthodox management
for the condition (see ‘Orthodox Medical Treatment’ above).
Prognosis
The first stages of the disease are asymptomatic so the condition is often untreated until the patient has a
fragility fracture. Once diagnosed, ‘drug treatments have been shown to reduce the risk of fractures by up to
50%’ (NOS, 2006).
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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According to the NOS (2006) the likely outcomes of osteoporosis in the UK are:

significantly reduced quality of life with 60% of patients limited in class I (e.g. feeding, dressing) and
80% limited in class II activities (e.g. shopping, gardening) 12 months after a hip fracture

18% mortality in the first three months following hip fracture

55% of patients require assistance at home in the first 12 months following a hip fracture

40% of patients with vertebral fractures will have constant pain

loss of height, kyphosis and severe back pain lead to a lack of mobility which can worsen the
osteoporosis
Reister O’Connor and Perkins (2005) include constipation, weight loss and possible lung compression leading
to lung disease as outcomes of spinal deformity following vertebral compression.
Resource list
National Osteoporosis Society (NOS)
Camerton, Bath, BA2 0PJ
tel: 01761 471771, helpline: 0845 450 0230
website: www.nos.org.uk, email: [email protected]
NOS Regional Support Groups:
Cardiff and District – www.osteoporosis-cardiff.btik.com
Bridgend and District – www.nos-bridgend.org.uk
Useful websites:
British Orthopaedic Association – www.boa.ac.uk
British Geriatric Society (Falls and Bone Health Special Interest Group) – www.bgs.org.uk
British Medical Journal – www.bmj.com
National Institute for Clinical Excellence (NICE) – www.nice.org.uk
NHS Direct - www.nhsdirect.nhs.uk
Word count: 2,495
This figure does not include contents page, section headings, appendices, reference list or bibliography.
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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References
Page numbers in brackets refer to pages of this assignment.
Gould, B E (2006)
Pathophysiology for the Health Professions, Third Edition, Saunders Elsevier, Pages: 657-659 (4, 6 & 9)
National Osteoporosis Society (January 2006) Osteoporosis Facts and Figures Version 1.1, Pages: 2-4 (6,
11)
Merck Online, accessed 13 March, 2008:
Osteosarcoma: http://www.merck.com/mmpe/sec04/ch044/ch044c.html
Paget’s disease: http://www.merck.com/mmpe/sec04/ch037/ch037a.html
Vitamin D deficiency (osteomalacia): http://www.merck.com/mmpe/sec01/ch004/ch004k.html
Osteomalacia and osteoporosis: http://www.merck.com/mmpe/sec04/ch036/ch036a.html
Poole, K E S and Compston, J E (2006)
Osteoporosis and its management, British Medical Journal Volume 333; Pages: 1251 (5),1252 (7)
Reister O’Connor, C and Perkins, S (2005)
Osteoporosis for Dummies, First Edition, Wiley Publishing, Pages: 63-67 (3), 23, 107, 109 (6), 109-110,
114-115, 136-137 (7), 107-117, 145-160, 161-175, 180-186, 194-196 (9-10)
Thibodeau, G A and Patton, K T (2007)
Anatomy and Physiology, Sixth Edition, Mosby Elsevier, Page: 248 (8)
Tortora, G J and Derrickson, B (2006)
Principles of Anatomy and Physiology, Eleventh Edition, John Wiley & Sons, Inc., Pages: 189-190 (4)
WHO Study Group (1994)
Assessment of Fracture Risk and its Application to Screening for Postmenopausal Osteoporosis, World Health
Organisation Technical Series (843), Pages: 3, 5-6 (2), 7-8, 62 (3), 15, 59-61 (4), 19 (5), 5-6, 29-30 (7)
Bibliography
Compston, J (1999)
British Medical Association - Family Doctor Guide to Osteoporosis, First Edition, Dorling Kindersley
Epstein, O et al (2004)
Pocket Guide to Clinical Examination, Third Edition, Mosby Elsevier
Mosby (2006)
Mosby’s Dictionary of Medicine, Nursing and Health Professions, Seventh Edition, Mosby Elsevier
Ralston, S H (1997)
Science, medicine, and the future: osteoporosis, British Medical Journal Volume 315; pages 469-472
Waugh, A and Grant, A (2006)
Ross and Wilson – Anatomy and Physiology in Health and Illness, Tenth Edition, Churchill Livingston Elsevier
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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Appendix A
Tables from the World Health Organisation technical report, 1994
Table 5 – Causes of generalized secondary osteoporosis in adults
Endocrine disease / metabolic causes
Nutritional causes
Drugs
Inherited disorders of collagen metabolism
Other
Hypogonadism
Hyperadrenocorticism
Thryotoxicosis
Anorexia nervosa
Hyperprolactinaemia
Systemic mastocytosis
Porphyria
Adult hyposphatasia
Diabetes mellitus
Thalassaemia
Pregnancy
Malabsorption syndromes / malnutrition
Chronic liver disease
Scurvy
Vitamin D deficiency
? Calcium deficiency
Alcoholism
Gastric surgery
Chronic heparin administration
Vitamin D toxicity
Anticonvulsants
Osteogenesis imperfecta
Homocystinuria due to cystathionine deficiency
Ehlers-Danlos syndrome
Marfan syndrome
Rheumatoid arthritis
Myeloma and some cancers
Immobilization / space flight
Table 7 - Advantages and disadvantages of various techniques to assess fracture risk
Technique
Quantitative computed
tomography
Dual-energy X-ray absorptiometry
Single-photon absorptiometry and
Single-energy X-ray
absorptiometry
Advantages
Gives true density values
Discriminates completely
trabecular from cortical bone
High resolution
Low precision error (radius)
No isotopes
High precision
Low radiation dose
Multiple sites of assessment
including spine and hip
Low radiation
High accuracy
High reproducibility
Low cost
Portability
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
Disadvantages
Comparatively high radiation dose
High cost
High accuracy error (single
energy)
Precision errors (spine)
Uncertain accuracy errors in vivo
Relatively high cost
Influenced by osteoarthritis and
aortic calcification at lumbar sites
Restricted to appendicular sites
Isotope half-life short for SPA
page 13 of 17
Table 22 – Factors that have been associated with reduced risk of osteoporotic fracture
Negro race
Muscular strength
Osteoarthrosis
Lactation
Multiparity
High calcium intake
Moderate exercise
Obesity
Fluoridation of drinking water
Some drugs – oestrogen, thiazide diuretics & calcium supplements
Table 23 – Factors that have been associated with increased risk of osteoporotic
fracture in women
Age
Primary amenorrhoea (e.g. in Turner syndrome)
Secondary amenorrhoea (e.g. in athletes, anorexia
nervosa, prolactinoma)
Anovulatory menstrual cycles
Premature menopause
Idiopathic
Surgical oophorectomy
Hysterectomy (with ovarian conservation)
Nulliparity
Prolonged immobilization and inactivity
Race
Caucasian or Asian
Smoking
Alcohol abuse
Lack of physical exercise
Nutritional factors (low calcium intake, high caffeine,
protein, fibre or sodium intake)
Some drugs
Corticosteroids
Anticonvulsants
Prolonged heparin infusions
Thyroxine
Certain diseases
For complete list see Table 5 [in this
appendix]
Low body mass index
Positive family history
Prior fragility fracture
Short stature and small bones
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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Appendix B Case study
Subject name:
Elizabeth (Liz) Larsson
Age:
46
Ethnicity:
British, White
Diagnosed condition:
Osteopenia
Background
Liz had worked in public relations for a local authority and as a consequence was aware that osteoporosis
was a very serious condition which many people were not aware they were at risk from or even had until it
was too late.
Later in her career she attended a health fair at the university where she worked. One of the exhibitors was
selling wrist scans to check for osteoporosis and, although Liz was only 44 at this point, she decided to have
the scan.
She was given the result immediately and it showed that her bone density was that of someone 10 years
older than her. She was referred to her general practitioner (GP) at this point.
She would not have been considered a high risk (see below) and it is only by chance that she has been
diagnosed and treated for low bone density. If she had not been tested it is likely that she would have
continued to lose density and would have been at high risk of developing osteoporosis without knowing it.
Diagnosis and treatment
When she saw her GP, she was prescribed Calcichew which is a calcium supplement taken in lozenge form
once a day. She stayed on Calcichew for a year and was then sent for a dual energy x-ray absorptiometry
scan (DXA). The diagnosis of osteopenia, or low bone mineral density, was confirmed.
Her GP prescribed her ibandronate (Bonviva) which is taken in tablet form once a month. She question
whether she needed to take the drug and was advised that if she did not her bone status would be
compromised when she was 60 and she would be much more likely to sustain a fracture. She agreed to
medication and has not experience any adverse affects.
She was also given the following advice:
 don’t go into the menopause underweight
 avoid alcohol although small amounts of red wine may be beneficial
 keep dietary intake of calcium high
 continue with weight bearing, medium impact exercise
She will continue to be monitored and have DXA scans every two years.
Although she has not been given a definitive cause for her condition, it is likely that it was caused by early
onset menopause.
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
page 15 of 17
Patient history
Liz started her periods relatively late at 16 and began the menopause 18 months before her wrist scan and
so benefited from the protective effects of oestrogen for less time than average. However, her menstrual
cycle prior entering the menopause had been very regular so she was not at high risk because of this.
Liz was receiving the depo-provera contraceptive injection for seven years. Her doctor monitored her
oestrogen levels during this time. For the first five years she was at the high end of normal levels and it then
started to fall. Her GP advised her to stop the injection which she did. NICE guidance recognises that this
injection can cause bone mineral loss but states that this should return to normal after the injection is
stopped (see additional information).
Her mother had not been diagnosed or shown signs of osteoporosis and her maternal grandmother died at
60 from cerebrovascular accident. Her paternal grandmother died at 97 years of age and had not lost
significant height nor did she have spinal deformity or clinically apparent fractures.
Liz has three sisters none of whom have been diagnosed with osteopenia or osteoporosis. However, one of
her sisters who is two years younger, recently had a very minor accident and had persistent pain in her
ankle. When she went for an x-ray she was told that her bones looked ‘thinner than expected’.
Diet and exercise
Liz has always been very active. Between the ages of 10 and 14 she was a gymnast and enjoyed running
and swimming throughout her adolescence. She completed RAF officer training at the age of 28 and had ‘no
more than a blister’.
She has maintained good levels of dietary calcium through daily intakes of cheese and yogurt which she now
supplements with fortified soya milk.
She has never smoked and has always been a very moderate drinker. She has increased her alcohol intake
over the last couple of years but even so she has rarely gone over 14 units a week.
Additional information
Liz has joined the National Osteoporosis Society and learnt more about her condition from the magazine and
website. She feels very luck to have been diagnosed early. She feels that there will be many people in her
situation and would like to see a screening programme put in place to help prevent the onset of
osteoporosis.
Depo-provera and osteoporosis:
National Osteoporosis Society website – Conference paper from 2005
http://nos.org.uk/dr_media/nos/Contraceptive_jab_in_bone_thinning_debate_14-Mar-08.pdf
NHS National Institute for Clinical excellence – Clinical Guideline 30: Long-acting reversible contraception
(quick guide) October 2005
http://www.nice.org.uk/nicemedia/pdf/cg030quickrefguide.pdf NICE guidance
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
page 16 of 17
Appendix C
Table of orthodox treatments
Name
Alendronate
(Fosamax,
alendronic acid)
Treatment Type
Drug,
bisphosphonate
Description
Inhibits osteoclasts. Daily
or weekly tablet.
Indicated for
Post menopausal women.
Men who are corticosteroid
users.
Calcitriol
(Rocaltrol)
Drug, active
vitamin D
Calcium &
vitamin D
Supplement
Post menopausal women.
Men only under specialist
care.
As a drug – older people in
residential nursing homes.
Cyclical
Etidronate
(Didronel PMO)
Drug,
bisphosphonate
Helps absorption of
calcium. Capsule twice
daily.
Supplements given as a
drug or as well as other
medication.
Inhibits osteoclasts. Taken
in tablet form in 90 day
cycle with Cacit
(proprietary calcium
supplement)
Hormone
Replacement
Therapy
Drug, HRT
Ibandronate
(Bonviva)
Drug,
bisphosphonate
Pamidronate
Drug,
bisphosphonate
Percutaneous
Vertebroplasty /
Kyphoplasty
Surgical
procedure
Raloxifene
(Evista)
Drug, SERM*
Risedroante
(Actonel)
Drug,
bisphosphonate
Inhibits osteoclasts. Weekly
or daily tablet.
Stronium
Ranelate
(Protelos)
Drug
Suppresses osteoclasts and
stimulates osteoblasts.
Powder mixed with water,
daily.
Increases oestrogen which
protects bone tissue.
Evidence that risk of colon
cancer is reduced. Tablets,
patches, implants, gels,
vaginal ring and nasal
spray.
Inhibits osteoclasts.
Monthly oral tablet or
injection every three
months.
Inhibits osteoclasts and
some evidence that it
reduced bone pain.
Intravenous drip once
every month to six months.
Injection of surgical cement
(PV) or small balloon (KV)
into the vertebrae for pain
relief .
Mimics oestrogen on some
organs. Daily tablet. Shown
to reduce spinal fractures
but not hip.
Not indicated for
People with moderate to
severe renal impairment. Not
tested with pregnant/breast
feeding women. Anyone with
gastrointestinal tract problems.
People with hypercalcaemia or
pregnant/breast feeding
women.
Not as treatment under 75.
Post menopausal women
with established
osteoporosis or osteopenia.
Corticosteroid users. Male
osteoporosis and premenopausal women under
specialist care.
Menopausal women up to
the age of 50 and at lowest
dose. Not often prescribed
for treatment of
osteoporosis.
People with moderate to
severe renal impairment.
People with very high
blood/urine calcium.
Post menopausal women.
Male osteoporosis and premenopausal women under
specialist care.
Drug for Paget’s disease
and only used in specific
circumstances for
osteoporosis.
People with renal impairment.
Not tested on pregnant /
breast feeding women.
Recent spinal fractures
with moderate to severe
pain.
If bones are too porous and
fragile (cement leaks out).
Post menopausal women
for treatment of
osteoporosis and
prevention in some cases.
People with history of clots,
immobile, taking breast cancer
drug treatments. Has not been
tested for men and premenopausal women.
People with renal impairment.
Not tested for pregnant /
breast feeding women.
Post menopausal women
for treatment of
osteoporosis or at risk due
to corticosteroid use.
Post menopausal women.
Men, pre-menopausal women.
Not licensed for osteoporosis.
Men – drug effects not yet
tested.
* selective estrogen receptor modulator
Collated from National Osteoporosis Society Information Sheets:
Alendronate (Fosamax or Alendronic acid) (June 2006)
Calcitriol (Rocaltrol) (December 2005)
Cyclical Etidronate (Didronel PMO) (June 2006)
Hormone Replacement Theraby and Osteoporosis (January 2007)
Ibandronate (Bonviva) (June 2006)
Pamidronate (December 2005)
Percuatneous Vertebroplasty (PV), Percutaneous Kyphoplasty (KP) and Osteoporosis (February 2007)
Raloxifene (Evista) (October 2005)
Risedronate (Actonel) (June 2006)
Stronium Ranelate (Protelos) (August 2005)
Supplements of Calcium and Vitamin D with Osteoporosis Treatments (January 2005)
Emily Greenslade (Bristol), Medicine Semester I Assignment – Osteoporosis
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