Throughout life, the skeleton is continually renewing itself through a process known as remodelling or bone turnover. In healthy bone, the rate of bone breakdown is linked to the rate of bone formation so that bone strength is maintained. As we get older, the rate at which bone is broken down increases and exceeds the rate at which bone is formed. This results in loss of bone and may lead to osteoporosis and an increased risk of fracture.
Several factors increase the risk of developing osteoporosis and/or fractures. These are age and ethnicity, medical risk factors and lifestyle factors. But being female and postmenopausal is a big risk factorfor osteoporosis which is several times more common in women than in men (for more information see resources).
Age and ethnicity
Postmenopausal white and Asian women are most at risk of developing osteoporosis. Oestrogen protects bones and after the menopause levels decrease significantly.
Other medical risk factors
Medical factors that significantly increase the risk of people developing osteoporosis are' premature menopause (before the age of 45), steroid therapy, previous fragility fractures, low body weight and amenorrhoea (absence of menstrual period before the menopause). Thyroid disease, rheumatoid arthritis, low levels of testosterone in men and conditions that affect the absorption of food such as Crohn’s or coeliac disease are also risks factors for osteoporosis.
Other medical conditions include: endocrine disease, kidney disease, liver disease and obstructive lung disease. Myeloma is a cancer that is frequently associated with a rapid destruction of bone, leading to osteoporosis.
Several frequently used medications have also been associated with increased fracture risk' anti epileptic drugs, breast cancer treatments such as aromatase inhibitors, SSRI’s - selective serotonin receptor uptake inhibitors (a group of antidepressant medicine), thiazide diuretics (a common treatment for high blood pressure) and possibly proton pump inhibitors (commonly used to treat acid reflux and ulcers of the stomach and duodenum).
Lifestyle factors include diet (calcium and vitamin D deficiency), drinking alcohol (more than 3 units per day); smoking and immobility (physical inactivity).
At the time of their diagnosis most people didn’t know what could have caused their osteoporosis. Many understood that it could be hereditary but most were unaware of the many other factors that might trigger bone loss leading to osteoporosis. Here they talk about what they think and what their doctors told them about the risk factors associated with their osteoporosis.
Many of the men and women we talked to were sure that they had inherited osteoporosis from their mothers and maternal grandmothers, who had been diagnosed with the condition. But not all were certain. Several elderly people said that they were not sure whether their mothers had osteoporosis because it was at a time when people knew little about osteoporosis or they simply weren’t diagnosed with it. Some said that in the past people commonly attributed the loss of height and the development of a ‘Dowagers hump’ – a rounding of the spine – to ‘old age’ rather than to osteoporosis.
Joan is a widow with three adult children. She lived abroad and worked as a radio presenter and as a teacher. She does voluntary work and drives to the continent.
It started off. I saw my mother in a reflection. My mother died many years ago. I suddenly saw the reflection of myself in, in a shop window and it was me and I was quite bent. And I already knew that I had, we call it in English, a Dowager’s hump. I can’t, I’ve forgotten the name now in French. Yes Dowager’s hump I suppose. And I'd realised that I was getting bent. And then at some point I don’t know for what, I was measured and I was [laugh] much shorter than I thought I was.
So your mum had osteoporosis, your mother?
One didn’t know about it then. She did break her arm and she did have a plate put in, screws because I looked. I was the eldest of the four of us. And I was 13 at the time and I looked after the household while she was in hospital. And certainly she became very bent and that’s one of the things that does it for me. I do, if I see, catch a reflection I do try and straighten up but the very top doesn’t straighten.
I look back and I realise although she wasn’t thin in fact she was larger than me she certainly, her bones didn’t feel, repair well and certainly she was, became very bent.
In many cases there were one or more risk factors other than heredity. For example Jane’s osteoporosis was diagnosed through pregnancy and her mother also has the condition.. But she thinks that her coeliac disease, undiagnosed for many years, was the main factor in her osteoporosis. She said that it was an unfortunate coincidence the fact that she was pregnant at the time. Coeliac disease can lead to malabsorption of nutrients, including calcium, and it had affected a few of the women we talked to.
Michelle is a medical doctor; married. Her mother and maternal grandmother both had osteoporosis. She has always been physically active practicing several sports and jogging three times a week.
Well first of all until the last couple of years I didn’t think of myself as living with osteoporosis. In, I don’t know what year, perhaps 1981 I was diagnosed with very severe endometriosis, and this is what I’m really not willing to share except with you for your research. And I had I’ve had dozens and dozens of surgeries and operations and drugs over a period of fifteen years for multiple tumours. Tumours that invaded the bowel, tumours that invaded the bladder and I was put on a very high powered anti-oestrogen drugs.
So in about 1995 the senior professor of obstetrics and gynaecology reassessed my whole case because by then I was judged to be disease free and then what do you what are how do you manage the remaining [coughs] risk factors and what other risk factors have to be assessed? So I was sent to him for that. And there was also some reconstructive surgery question mark of that and he was going to send me to London to see somebody for that. So he reassessed my whole health and among the various risk factors looking at, you know, is your breast cancer risk better or worse? And what do you have to do about your nutrition? And what about sexuality? Which I wasn’t asking about but he seemed to have quite a bit to say about [laughs].
He said, ‘You are at risk for osteoporosis.’
And then the nutritional compromise with coeliac I did take that seriously. That that was a compound another reason to have poor nutrition so avoiding milk products because I had a little bit of trouble with them and coeliac disease being warned you might not absorb everything very well because if you’re in a period where your bowel’s not working, you know, it doesn’t matter how much milk you drink, you still don’t get enough of anything you’re eating properly. And so that kind of got my attention. So that I did modify my life but I didn’t again didn’t think of it as disease,
Several women thought an early menopause after hysterectomy had triggered their osteoporosis. Hysterectomy alone is not a big risk factor if ovaries are conserved. The average age of menopause is brought forward but much more relevant is whether ovaries are removed. It is important for women after hysterectomy to have ovarian function measured especially if they have menopausal symptoms. Lack of oestrogen has an effect on bone density and if oestrogen deficiency is found it should be replaced by hormone replacement therapy (HRT). A couple of women were put on HRT after surgery but one did not receive the hormone treatment until years later. Other women, who had an early menopauses not due to a hysterectomy, were not concerned at all about having an early menopause. At the time they were more than glad to see an end to their periods. It was only after diagnosis that they learnt that it is a big risk factor for osteoporosis.
Widow, works full-time as an office administrator. Lives with her two adult children and has an active social life. She has noticed some improvement since started on Strontium ranelate.
I had a hysterectomy in 1984…’85 approximately. And I was fine after that. I had no problems, nothing. But in 1992 I had started having severe headaches. And headaches were so bad that I could not cope at all. Even the painkillers wouldn’t, wouldn’t make any effect.
And then I had a sort of… I had a heart problem type thing… that I was I was going to have a heart attack. So I went to the doctor’s. And I told her that I sometimes I feel so hard at night I cannot breathe and I feel that I’ve got a heart attack. So we started looking into it whether I had any problems. And I think my GP under, understood me immediately what is the problem. And she said, “No you do not have a heart attack.” Because she took my blood pressure and everything and there was nothing wrong it. And suddenly she said I because of my hysterectomy I must be suffering from some sort of lack of hormones. And she started, she wanted me to put me on a hormone treatment, which we started on hormone treatment in the beginning.
And since 1992 onwards I had a very good life. I did not have any headaches. I did not… I had more energy. I was working full-time. And no problem at all.
And then at that time doctors said that I should, I may suffer from osteoporosis. She explained to my GP. And my own, my GP always said that I had problems with the bones. And I should be careful. And that’s it. Nothing else happened. And I was on HRT so I thought it was helping.
Thyroxine replacement therapy is not bad for bone health unless an inappropriate dose is used, for example too high. This treatment can be monitored with thyroid function tests. A few of the women we talked to had been diagnosed before or soon after the diagnosis of osteoporosis with thyroid disease. Two were on medication but one decided to stop it after she developed breathing difficulties.
Carol is married, works part-time and has two sons. Initially she felt devastated by her diagnosis but now she feels lucky because she can take control of her osteoporosis.
Are you having treatment for that?
I am. I’m on 25 microgram, which is a very low dose a day of thyroxine. The reason… to begin with the, the doctor didn’t want prescribe it. She said it’s bad for your bones. But because I was so depressed with the double fracture, the osteoporosis, the under active thyroid and my hair was falling out, she said, “Well can’t have you getting so upset.” So she agreed to give me this 25 microgram of thyroxine. And I feel a lot better. I don’t feel so tired.
And I was very constipated. And another doctor in the surgery had been following up this constipation over a period. And I had all sorts of tests and whatever. And it turned out to be this under active thyroid. And since I’ve been the thyroxine, the small dosage, I haven’t been constipated. So yeah I mean obviously if you’re under active thyroid you feel very sluggish don’t you? Weary. So yeah I feel a lot better since then. So she agreed to put me on that.
Osteoporosis is commonly viewed as affecting women, primarily after the menopause, but it can also affect men. Deficiency of the sex hormone testosterone has been found in men with osteoporosis.
Keith works full-time as a statistician and he is also a concert pianist; single. He was aware of breast cancer in men but thought that osteoporosis affected women only.
I had mentioned that my mother had had osteoporosis, for you know quite a number of years, and so you know there wasn’t, and the endocrinologist just thought that it was a possibility that the low-ish testosterone could give me a risk of, you know, of Osteoporosis in later life, because if anybody had thought there would be a problem now, my GP certainly didn’t. He just thought the, he was being very cautious.
He said [the consultant], I mean, Osteoporosis is mainly hereditary, and he says “The fact that your mother’s got it, you know, is probably, could even be the main reason why you’ve got it you know. And the low testosterone could just be exacerbating it.” Just making it, making it worse that it would otherwise have been.
Yeah, I think the only two risk, risk factors I’ve got they were, there was hereditary, for me, which was the main one, he thought that was the most important. And then the low testosterone. My GP was very surprised, and she said, “Well you know this one’s low but it’s not that low, you know?” And she was expecting the bone scan to come negative; she was very surprised when it came back positive.
That’s when she said well we’ll do some other blood tests, and then we’ll check the liver and gut functions to check I’m absorbing calcium, and they were fine. So you can see that they, they were the only two, unless you know these low levels, high levels of the luteneizing hormone and the the FSH, unless they have some effect in their own right, because there is a little bit on the web about this possibility that you know they could also cause, you know, I think the luteneizing hormone could possibly you know deplete calcium because, because of this one experiment in, in mice.
But if you follow the links to that there are other people disputing that and saying you know well that doesn’t, that doesn’t prove anything.
Two people we talked to had been on the antidepressant drugs phenelzine or tryptophan for many years. They learnt that these were a likely factor for their osteoporosis.
Dennis is married and has two adult children. He has had depression for over twenty year. He said he is very lucky because he has the support of his family, GP and consultants.
I think it first occurred when I was on medication for not sleeping and I fell down the stairs twice. And hurt my back. And I just went to the doctors and said, “And my back hurts.” And it snowballed from there. So now I attend [name] Hospital every three months. But my doctor, said, that, she thinks I was on the wrong drug because it should have stopped this happening with my spine collapsing.
Which drug were you on before?
Well my depression drugs. I'm on Phenelzine and Lanzipan. And I've been on Phenelzine for over twenty years. And the Lanzipan about five years. And they suit me. Phenelzine is a very old drug and they don’t like prescribing it because there are restrictions with it. I can’t eat cheese, yeast extract, anything fermented. Yoghurts. I have to avoid them. Gravy is another thing. I just can’t have them. But they suit me, I have been in hospital and tried to come off them. And tried other drugs, but they just made me worse. And I think it's those drugs that have caused the osteoporosis. They can’t think of any other reason why.
The consultant explained to you that the factor in your case was the medication for depression?
They know. They said it could be. They haven’t definitely said it is. But they said I've been on it so long it could well be a factor in getting the osteoporosis.
Any other ideas why you might have got it?
Several men and women had used oral steroid therapy (prednisolone) to treat various conditions such as rheumatic disease, inflammation of the bowel and some lung diseases. But several elderly people said that in the past they had been on ‘terrifically’ high doses of steroid for more than 3 months. Only one of them knew that steroids could cause bone loss and osteoporosis.
Neville is married, has two sons and he is a retired Head porter. He is grateful for all the support his wife, sons and grandchildren give him.
What do you think caused this osteoporosis?
Well, they reckon it was caused through taking prednisolone, a very high dosage of prednisolone over a two or three year period when I had the ulcerative colitis. When I first, was first diagnosed with ulcerative colitis I had intravenous, the prednisolone, very high dosage. And I took prednisolone for three solid years before it was reduced. And this is why they sent me for the back, the bone scan, and that’s when, they reckon that’s what caused it.
Did your mother have osteoporosis?
No, no, no. There’s never, nobody in my family or my wife’s family ever had osteoporosis.
But I mean, before, I mean before I had the, my operation, I used to take a lot more tablets. But when, when I had the operation they took all the pr-, the inside away, so I don’t, I’ve lost, quite a few tablets I don’t take now. I mean I don’t take prednisolone any more. Only, I can take prednisolone, occasionally if I really have a bad spell I can take a course of prednisolone and it takes the pain away for a while. And that seems about the only thing that does help at the moment. But I don’t take it very often these days.
Age at interview:
Age at diagnosis:
Married with two daughters, before retirement Joan worked as a local government employee. Her husband is her main carer. Joan's advice to others' ask questions about your condition and medications. Nationality/ethnic background' British
I think it was round about 1994, something like that, that I originally went to the doctor. I had been so tired over the Christmas. When we came home, because we always go to our daughter’s for Christmas, when we came home, I went to the doctor. He took my blood, my blood pressure or something, and then said, “Oh you must go to the haematology department. And let them see. You have got some form of anaemia.” Which they whittled down eventually to haemolytic anemia. And they said they could put that right, by giving me some tablets.
Well the first lot didn’t have any effect whatsoever. I don’t even know what they were. And then they eventually put me on steroids. Well they started off with quite a low dose, I was taking something like two or three in the morning and two or three in the evening, till they were upping and upping and upping them. Every time I’d go back for a check up, it wouldn’t be any different or it would be worse or something. And then they would increase the steroids, so in the end I was taking 24 per day of 5 mgs tablets. They were, I was taking 12 in the morning and 12 in the evening.
And that went on for about nine months. And although every body said I was taking a high dose, nobody told me anything other than it was all right to take them. And of course I went on taking them till in the end they decided, well they weren’t having any effect on the blood treatment I was supposed to be having, and the only thing was to remove the spleen. So they removed the spleen and put my blood right and of course I stopped taking the osteoporo…, the steroids.
Well after some little while, I don’t recall how it really happened, but I was going to the haematology department regular, on a regular basis to check the blood and some how or other they found out that, at least I star… my back started curving and somebody noticed it, and then they investigated and found that yes I had osteoporosis.
I think they did a bone scan then and then they found out it was very widespread and you know, there was not really much they could do about it.
Age at interview:
Age at diagnosis:
David lives at home with his parents and siblings. He recently finished university and now works full-time as a Customer Relations Administrator. He loves is independence that he says are facilitated by his car and wheelchair.
Hello my name is David, and I’ve had chronic rheumatoid arthritis for the last twenty three years, you know? And I’m 25 years old. And over that time I’ve had you know many operations, you know taken many medications, and for the last two and a half to three years, I’ve also been diagnosed with osteoporosis, you know, which is known as a thinning of the bones and you know and that means also I can have an increased risk of fractures and breaks of the bones.
And I’m thinking that this has been brought on you know because of my longstanding chronic rheumatoid arthritis. You know which I’ve had since I was two, you know and I’ve got all my bones, joints, muscles all damaged because of that. And also I think, also I’ve been on steroids since I was two you know? And I mean I’m only on a fairly low dose at the moment of 7mg, but I mean I’ve been up to like 40, 50mg a day, I mean and I’ve had them every day since I was two. So I think you know a combination of the steroids and of the arthritis, of the chronic rheumatoid arthritis have resulted in you know all the joint you know damage, and has resulted in the osteoporosis.
Many people think that lifestyle factors are primarily responsible for their osteoporosis in particular, calcium and vitamin deficiency in their diets. Several recalled that as children or young adults they had little milk or other dairy products in their diet. Two women suffered from ME and allergies and therefore avoided dairy products for many years. A few mentioned lack of exercise or smoking as ‘triggers’ for their osteoporosis. But not everyone realised that lifestyle could also contribute to bone loss and/or osteoporosis. Christine has been semi-paralysed for over 20 years and had learnt only recently that immobility is a risk factor. Likewise, Valerie said that no one ever mentioned to her before she developed osteoporosis that smoking is a serious risk but she still does not intend to give up (see also Osteoporosis, smoking and alcohol).
Married; two daughters. Iris has recently retired and says that it is in denial about her osteoporosis because this was supposed to be her 'me time'.
So what do I think caused it? I think because I was such a heavy smoker up until I was 40. I used to smoke 40 to 60 cigarettes a day. And also I think because I had a… and I stopped when I was 40 because I had to have a hysterectomy. So I needed to stop smoking for the operation. The hysterectomy was to try and cure the iron deficient anaemia problem. And, they left my ovaries there. At some stage I had… oestrogen.
Yes, but it was just oestrogen only. And, but it didn’t agree with me at all. The pill never agreed with me, and the oestrogen didn’t either and I had a suspected deep vein thrombosis. And so I wasn’t on it very long and my legs would swell up and everything else and then after nine months, the consultant said, “Oh we could probably put you on Premarin.” Is it? Is that one of them? And I said, “No I don’t think so.” So I was only on sort of HRT, not for very long. I wouldn’t have said more than a year. I wouldn’t have said.
From what I understand about osteoporosis that could have been the reason that I have got it. I had no family history at all. My Mum’s one of ten. Seven sisters. And nothing. And my grandmother lived till she was 94. She was straight backed like me. No Dowagers humps, nothing in the family at all. So I put it down, probably the smoking. I have always eaten dairy, always, I have always been similar weight to this really.
Two elderly women attributed their osteoporosis to ‘wear and tear’ of their bodies from heavy physical work caring for an ill spouse over the years, combined with the menopause.
Widow, two children, lives on her own in a small rural community. She enjoys the support of neighbours and friends. Noreen recommends Kyphoplasty, it has reduced her level of pain.
So it was a shock, I must say…
To be diagnosed?
To be diagnosed with that, because I thought that I was tough. Well I am tough, but then again with my husband having rheumatoid arthritis you see, I have always done a lot of lifting. So my wrists are not good, and my hands are not good, because he couldn’t do it. So if there was furniture to move, I did it. You know, I was always… and then I had a lot of years looking after him in the end. But that was lower back though, looking after him, and everything is the wrong height, the chair, the bed, the bath, so looking back I have worked my body quite a lot so that is the reason for the wear and tear I suppose.
Some people could not explain their condition because they had none of the clinical or lifestyle factors and were relatively young. Many older people on the other hand attributed their osteoporosis more to aging than to anything else.
Married, two daughters; early retirement due to osteoporosis. Works as a volunteer for the National Osteoporosis Society. He thinks it is important to raise awareness about osteoporosis in men.
I’ve always been an active sports person. I used to play rugby and football. And I can remember breaking like my wrist playing football and my fingers but nothing that would say that, you know, that to say, to suggest that I had osteoporosis. And actually I, you know, I’d quite an active lifestyle but the only thing I can think of is, is that I became. In my job I was a sales director so I actually became sitting either behind the steering wheel of a car or actually behind a desk. So I’d very, very little exercise, probably ten years before it happened. And really I’m one of seven children and we’ve all been, you know, I was the biggest out of the seven children. I’m the sort of largest. I’ve always have been the fittest and probably the strongest. So when this happened it was twice as much of a shock really to be honest. So I had no sort of prior hint or prior inkling that this would ever happen to me because it came as quite a shock to find out I had osteoporosis.
Do you have any ideas about what caused this osteoporosis?
I was actually tested for testosterone levels in the beginning. I went through all the normal tests. I used to smoke but I wouldn’t consider myself a heavy smoker. I was never, certainly never been a heavy drinker, just a social drinker if anything. So I’m really at a loss and but apparently 50% of males who are osteoporotic, who have osteoporosis are actually what they call idiopathic. But I find, you know, there’s no real cause and I find that the most frustrating thing really. Is not knowing why it happened to me. You know I did, if I find there’s a reason, that you know somebody could say, ‘Well it was because you did this or because of that’. I think I would feel a little bit better. But not knowing why or how it happened is quite frustrating really as a patient.
A very rare condition named mastocytosis was the risk factor linked to Rose's osteoporosis.
Married with two adult daughters; retired secretary. Her involvement with a support group provided her with knowledge about osteoporosis and has helped her come to terms with the condition.
Mastocytosis is a sort of proliferation of the mast cells. I’ve got too many mast cells. Some of them are the wrong shape. And they don’t die off as they’re supposed to. And therefore they can congregate in different organs of the body. And by the, main organ is the skin. Which, which I’ve got. You can get mastocytosis which is only a skin problem. But that can often turn to systemic mastocytosis, where it affects other organs. And I’ve got the systemic form of it. So I do get problems with stomach cramps and occasional diarrhoea, that sort of thing. And another unpleasant effect of it is called flushing, where I come over really very very hot. It’s not the same as the hormonal heat. It’s a different sort of heat.
And who told you that mastocytosis was a major factor?
My consultant told me that. In fact he confirmed that to me a few weeks ago. I contacted him when this came and said, could he tell me whether it was the major factor or a contributory factor, my mastocytosis. And he told me it was the major factor and one that could be, well, it wouldn’t be looked for because it’s such a rare thing. And the other factor which is common to most people is the fact that I was post-menopausal. But the mastocytosis was the major factor.
But you see when I was diagnosed just, people just didn’t know about it and that was that. Doctors, don’t know about it now, consultants don’t know about it now. It’s, and it takes so many forms. You can’t have a, a mastocytosis consultant because it affect, can affect your, you know, your liver, your spleen, your, you know, with these anaphylactic attacks, you know, that sort of thing. And all other aspects of, of, it’s complicated. And some people have been found to have mastocytosis when they haven’t had the rash. So that’s, that was very difficult to, to diagnose.
And for how long have you had this rash?
Well, I had the rash for at least, at least five years before I was diagnosed when I was in hospital. Because blood tests revealed nothing and no one knew any better.
Anorexia nervosa, over exercising, secondary amenorrhoea and other gynaecological problems are some of the other factors that are putting men and pre-menopausal women at risk of developing osteoporosis.