Osteopenia

  • Medical Author:
    Catherine Burt Driver, MD

    Catherine Burt Driver, MD, is board certified in internal medicine and rheumatology by the American Board of Internal Medicine. Dr. Driver is a member of the American College of Rheumatology. She currently is in active practice in the field of rheumatology in Mission Viejo, Calif., where she is a partner in Mission Internal Medical Group.

  • Medical Editor: William C. Shiel Jr., MD, FACP, FACR
    William C. Shiel Jr., MD, FACP, FACR

    William C. Shiel Jr., MD, FACP, FACR

    Dr. Shiel received a Bachelor of Science degree with honors from the University of Notre Dame. There he was involved in research in radiation biology and received the Huisking Scholarship. After graduating from St. Louis University School of Medicine, he completed his Internal Medicine residency and Rheumatology fellowship at the University of California, Irvine. He is board-certified in Internal Medicine and Rheumatology.

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Osteopenia facts

  • Osteopenia is decreased bone density but not to the extent of osteoporosis. This decreased bone density leads to bone fragility and an increased chance of breaking a bone (fracture).
  • Women over the age of 65 and any postmenopausal woman with risk factors for bone loss should be tested for osteopenia or osteoporosis. The DXA scan is a widely available and accurate method for diagnosing osteopenia or osteoporosis.
  • Not everyone with osteopenia requires treatment with prescription medications. Your doctor can determine if you should be treated based on your bone density and other risk factors.
  • An adequate intake of calcium and vitamin D, avoiding excessive alcohol, not smoking, and getting plenty of exercise can help prevent osteopenia.
  • While most people affected by osteopenia are women, men can also be affected by osteopenia and osteoporosis and should be evaluated for these bone conditions when they are considered to be at risk.

What is osteopenia?

Osteopenia is a bone condition characterized by a decreased density of bone, which leads to bone weakening and an increased risk of breaking a bone (fracture).

Osteomalacia, osteomyelitis, and osteoarthritis are different conditions that are frequently confused with osteopenia because they sound similar. Osteomalacia is a disorder of the mineralization of newly formed bone, which causes the bone to be weak and more prone to fracture. There are many causes of osteomalacia, including vitamin D deficiency and low blood phosphate levels. Osteomyelitis is bone infection. Osteoarthritis is joint inflammation featuring cartilage loss and is the most common type of arthritis. Osteoarthritis does not cause osteopenia, osteoporosis, or a decreased bone mineral density.

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Osteopenia vs. Osteoporosis

It is important to note that while osteopenia is considered a lesser degree of bone loss than osteoporosis, it nevertheless can be of concern when it is associated with other risk factors (such as smoking, cortisone steroid usage, rheumatoid arthritis, family history of osteoporosis, etc.) that can increase the chances for developing vertebral, hip, and other fractures. In this setting, osteopenia may require medication as part of the treatment program.

Osteopenia vs. osteoporosis

Osteopenia and osteoporosis are related conditions. The difference between osteopenia and osteoporosis is that in osteopenia the bone loss is not as severe as in osteoporosis. That means someone with osteopenia is more likely to fracture a bone than someone with a normal bone density but is less likely to fracture a bone than someone with osteoporosis.

Osteopenia vs. osteomalacia

Osteopenia is a bone condition characterized by decreased bone density, which leads to bone weakening and an increased risk of bone fracture. Osteomalacia is a bone disorder characterized by decreased mineralization of newly formed bone. Osteomalacia is caused by severe vitamin D deficiency (which can be nutritional or caused by a hereditary syndrome) and by conditions that cause very low blood phosphate levels (such as genetic syndromes and cancer related syndromes). People with osteomalacia and those with osteopenia may have no symptoms. Both osteomalacia and osteopenia increase the risk of breaking a bone. However, symptoms of osteomalacia include bone pain and muscle weakness, bone tenderness, difficulty walking, and muscle spasms. These symptoms are not caused by osteopenia.

What risk factors and causes of osteopenia?

Osteopenia has multiple causes. Common causes and risk factors include

  • genetics (familial predisposition to osteopenia or osteoporosis, a family history of early bone loss, and other genetic disorders);
  • hormonal causes, including decreased estrogen (such as in women after menopause) or testosterone;
  • smoking;
  • excess alcohol;
  • thin frame;
  • immobility;
  • certain medications (such as corticosteroids, including prednisone) and antiseizure medications;
  • malabsorption due to conditions (such as celiac sprue);
  • and chronic inflammation due to medical conditions (such as rheumatoid arthritis).

What are osteopenia symptoms and signs?

Osteopenia does not cause pain unless a bone is broken (fractured). Interestingly, fractures in patients with osteopenia do not always cause pain. Osteopenia or osteoporosis can be present for many years prior to diagnosis for these reasons. Many bone fractures due to osteopenia or osteoporosis, such as a hip fracture or vertebral fracture (fracture of a bone in the spine), are very painful. However, some fractures, especially vertebral fractures (fractures of the bony building blocks of the spine), can be painless and therefore osteopenia or osteoporosis may go undiagnosed for years. In addition to back pain, recurrent spinal (vertebral) fractures can cause stooped posture (dowager's hump) and loss of height.

Why is osteopenia important?

Osteopenia is important because it can cause bone fractures. People with osteopenia are not as likely to fracture a bone as those with osteoporosis; however, because there are many more people with osteopenia than osteoporosis, patients with osteopenia account for a large number of patients who fracture a bone. In other words, while osteoporosis indicates bone that is more prone to fracture and people with osteoporosis have a higher percentage risk of fracture than osteopenia, because of the much larger number of people with osteopenia there is a greater total number of fractures in these people.

Bone fractures due to osteopenia and osteoporosis are important because they can be very painful, although some spinal (vertebral) fractures are painless.

In addition to the pain, hip fractures are a serious problem because they require surgical repair. Also, many patients require long-term nursing-home care after a hip fracture. Fractures, especially in the elderly, are associated with an increase in overall mortality (death rate). A significant percentage of people die in the year following hip fracture, due to complications including blood clots related to immobility, pneumonia, and many other reasons.

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When should someone see a doctor for osteopenia?

Anyone who has been diagnosed with osteopenia should implement lifestyle changes and discuss with their physician whether they should take calcium and vitamin D supplements and possibly receive prescription medication for their condition.

What types of specialists treat osteopenia?

Osteopenia can be diagnosed and treated by many different medical specialists, including primary-care providers (such as internists and family practitioners), rheumatologists, endocrinologists, and gynecologists. Other specialists may treat osteopenia, as well, especially if they are prescribing a medication that predisposes to osteopenia, such as the cortisone medication prednisone.

What tests do health care professionals use to diagnose osteopenia?

Osteopenia is diagnosed using measures of bone mineral density (BMD). The test recommended by the National Osteoporosis Foundation to measure BMD is the dual energy X-ray absorptiometry scan or DXA scan (formerly known as DEXA scan). A DXA scan measures BMD in the hip (femoral neck), spine, and sometimes the wrist. These locations are chosen because these are frequent sites of bone fracture. The DXA is a very accurate predictor of future fracture risk.

The DXA scan gives two results: a "T score" and a "Z score." The Z score compares the patient's BMD to the average of a person of the same age and sex. The T score compares the BMD to a healthy 30-year-old of the same sex. These scores are measured in standard deviations above or below normal. For example, if a T score is -1.0, this indicates a BMD that is 1.0 standard deviations below a healthy 30-year-old of the same sex. In other words, the lower the bone mineral density, the lower the T score or Z score and the higher the risk of fracture. The risk for fracture doubles with every standard deviation below normal. So, someone with a T score of -2.0 has an approximately twofold increased risk of fracture as compared to someone with a T score of -1.0.

T scores are used to diagnose osteopenia and osteoporosis; those between -1.0 and -2.5 indicate osteopenia, and T scores lower than -2.5 indicate osteoporosis. But it is important to realize that T scores are not the only indication of osteoporosis; if someone has a bone fracture without trauma, then they have osteoporosis by definition, regardless of T score. These patients should be treated as though they have osteoporosis, even if their T score is normal or in the osteopenic range.

Other tests used to measure bone density include the peripheral dual-energy X-ray absorptiometry (pDXA), quantitative computed tomography (QCT), peripheral QCT (pQCT), and quantitative ultrasound densitometry (QUS). Bone density test results can be obtained by any of these methods. Sometimes a routine X-ray reveals diffuse osteopenia (osteopenia in all bones visualized by the X-ray) or osteopenia of a particular location, such as spinal osteopenia. Periarticular osteopenia is an indication of past inflammation around a certain joint. This can be seen in conditions such as rheumatoid arthritis and does not necessarily indicate a decreased BMD throughout the bony skeleton. While routine X-rays may suggest decreased bone mineral density, the DXA scan is much more precise in diagnosing osteopenia and osteoporosis.

Who should be tested for osteopenia?

Not everyone needs to be tested for a decreased bone mineral density (osteopenia or osteoporosis). Your doctor can determine if you should be tested. The National Osteoporosis Foundation recommends the following groups of people be tested for osteopenia or osteoporosis:

  • Women 65 years and older and men 70 years and older
  • Postmenopausal women and men 50-69 years of age at increased risk for osteoporosis
  • Adults who have a bone fracture after age 50
  • Adults with a medical condition associated with bone loss (such as rheumatoid arthritis) or who take a medication that can cause bone loss (such as prednisone or other steroids)
  • Anyone being considered for prescription treatment for osteopenia or osteoporosis
  • Anyone being treated for osteoporosis to monitor treatment

What is the treatment for osteopenia?

People with osteopenia should make certain important lifestyle modifications and ensure that their dietary intake of calcium and vitamin D (vitamin D2, vitamin D3, cholecalciferol) are adequate. Management of an underlying condition causing malabsorption, such as celiac sprue, can improve bone density. Not everyone with osteopenia requires treatment with prescription bone-building medication. This is because while 34 million people have osteopenia, and therefore the condition accounts for a large number of bone fractures, the absolute risk for fracture in any individual is low. So, if bone-building medications were prescribed to everyone with osteopenia, that would result in a large number of people who may never even have had a bone fracture taking medication for many years, exposing them to unnecessary expense and potential side effects.

If you have osteopenia, your doctor can determine if you need treatment with prescription medication. The decision to treat is made on a case-by-case basis depending on each individual. Factors other than bone mineral density can increase the risk of fracture, and these risk factors can be used to determine if a certain individual requires treatment for osteopenia. These include a parent who fractured their hip, previous or current treatment with corticosteroids (such as prednisone), thin and small-framed individuals, rheumatoid arthritis, smoking, and drinking more than two alcoholic beverages daily. Your doctor may use this information to calculate your risk of a bone fracture in the next 10 years. This risk can then be used to determine if treatment is necessary.

The diagnosis of osteopenia can be an eye-opening wake-up call to make certain lifestyle changes. Lifestyle modifications are an important part of the prevention and treatment of osteopenia and osteoporosis. These lifestyle changes include weight-bearing exercise (for example, walking or lifting light weights), quitting smoking, not drinking excessively, and ensuring an adequate daily intake of calcium and vitamin D. If dietary intake is not adequate, then supplements may be prescribed. The Institute of Medicine released the following guidelines on calcium and vitamin D intake on Nov. 30, 2010:

Vitamin D

  • 800 IU (international units) daily for women over the age of 71
  • 600 IU daily for women in other age groups, men, and children
  • 400 IU daily for infants under 12 months of age

Calcium

  • 1,200 mg (milligrams) daily for adult women over the age of 50 and men 71 years and older: At least 1,200 mg is recommended, including diet and calcium supplements. Calcium should be taken in divided doses, no more than 600 mg at once, to ensure optimal intestinal absorption.
  • 1,000 mg daily for younger adult women (who are not breastfeeding or lactating) and adult men

The following prescription medications are treatment options for osteopenia and osteoporosis:

Alendronate (Fosamax), risedronate (Actonel), zoledronic acid (Reclast), and raloxifene (Evista) have an indication from the Federal Drug Administration (FDA) for the prevention of osteoporosis (such as for those with osteopenia), as well as for the treatment of osteoporosis. For raloxifene (Evista) and risedronate (Actonel), the doses used for osteopenia are the same as those used for osteoporosis. Zoledronic acid (Reclast) is an intravenous medication given yearly for the treatment of osteoporosis but every other year for the prevention of osteoporosis. Alendronate (Fosamax) is given as 10 mg daily or 70 mg weekly for osteoporosis, and the dose is halved for the prevention of osteoporosis (5 mg daily or 35 mg weekly).

Side effects of alendronate (Fosamax) and other bisphosphonates (risedronate, zoledronic acid and ibandronate) prescribed for osteoporosis and osteopenia are a subject of intense medical research and media scrutiny recently. The risks under scrutiny include unusual hip fractures and a jawbone problem known as avascular necrosis of the jaw. These side effects are rare. Generally these medications are used only when the benefits of preventing bone fractures far outweigh the risks.

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Is there a recommended diet for people with osteopenia?

A diet containing sufficient calcium and vitamin D, as detailed above, is key for people with osteopenia. Low-fat dairy products such as low-fat milk, yogurt and cheese, vegetables such as broccoli and collard greens, and salmon and sardines are some good sources of dietary calcium.

In addition, studies have shown that higher fruit and vegetable consumption is associated with improved bone density.

Minimizing drinking alcohol and not smoking are essential for people with osteopenia. Drinking more than two alcoholic beverages daily is associated with decreased bone density. Smoking reduces bone density. Stopping smoking, of course, improves health in many different ways.

What follow-up is needed after treatment of osteopenia has been initiated?

Often osteopenia does not require treatment with prescription medications. In this situation, the bone density test may be repeated to monitor the bone mineral density (BMD), usually after two years, to detect progressive bone loss and determine if treatment is necessary. Two years may seem like a long time between tests, but BMD changes very slowly, and this length of time is usually necessary to detect significant changes in bone density.

A follow-up test for BMD is frequently repeated after treatment with prescription medication for osteopenia is begun. Again, because changes in BMD occur slowly, the repeat testing is usually done several years after treatment is begun. However, follow-up testing while on treatment is controversial because

  • decrease in the risk for fracture while on treatment for osteopenia and osteoporosis is not always mirrored by an increase in BMD on DXA or other testing
  • and if repeat testing shows continued bone loss, this does not mean the medication is not working because it is also likely the bone loss would have been much worse if left untreated.

Is it possible to prevent osteopenia?

The best way to prevent osteopenia is by living healthfully. In regard to osteopenia, prevention includes ensuring adequate calcium intake either through diet or supplements, ensuring adequate vitamin D intake, not drinking too much alcohol (no more than two drinks daily), not smoking, and getting plenty of exercise. Weight-bearing exercise, such as walking, lifting light weights, or doing push-ups, is the most effective exercise for preventing and treating bone loss. This is because this type of exercise signals to the bones to become stronger.

For most people, prescription medications are not necessary to prevent osteopenia. However, some people taking certain medications (such as prednisone or other steroids) for more than a few months may need to take prescription medication to prevent bone loss.

Is osteopenia reversible?

Infrequently, osteopenia can normalize on follow-up testing. This is more common in certain situations, such as when only mild osteopenia on the initial bone density test. When mild osteopenia is caused by significant vitamin D deficiency, and the vitamin D deficiency is treated, then the osteopenia may reverse. Another example is when osteopenia is caused by malabsorption from celiac sprue, and the celiac sprue is treated, then osteopenia often improves.

These specific examples apply to a minority of people with osteopenia. Usually, osteopenia does not reverse, but with the proper treatment, the bone density can stabilize and the risk for a bone fracture improves.

What is the prognosis of osteopenia?

Frequently, bone loss can be slowed or stabilized with lifestyle changes or medication if necessary. In some situations, bone loss may continue due to hormonal factors, medical conditions, or medications. Examples of these situations may be untreated celiac sprue, untreated or resistant rheumatoid arthritis, and treatment with steroid medication such as prednisone used for another medical condition.

REFERENCE:

Katz, Seymour. "Prevention, Detection, and Treatment of Osteopenia and Osteoporosis." Gastroenterol Hepatol (N Y) 9.3 Mar. 2013: 176-178.

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Reviewed on 1/31/2017
References
REFERENCE:

Katz, Seymour. "Prevention, Detection, and Treatment of Osteopenia and Osteoporosis." Gastroenterol Hepatol (N Y) 9.3 Mar. 2013: 176-178.

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