We tend to think of our bones as hard and unchanging, like the bones we find on our dinner plate. But actually, they are living tissues that undergo constant change and renewal, just like our other organs. Cells called osteoclasts break bone down, and cells called osteoblasts build it back up, just as if you were remodeling your house a room at a time. The osteoblasts build up living tissue and reinforce it with minerals like calcium, magnesium, boron, and manganese.

Normally, these two processes–resorption and formation of bone–are closely linked so that bone stays strong. Quite a few factors can upset the balance, though. If the osteoclasts race far ahead of the osteoblasts, bone density can drop and eventually the bones are not strong enough. A minor fall can result in a broken hip, which can be catastrophic for an older person.

Osteoporosis, a condition of weakened bone, is responsible for 1.5 million fractures each year, including 300,000 hip fractures.766 The National Institutes of Health (NIH) estimates that 10 million Americans currently have osteoporosis. Two million of them are men. While osteoporosis is thought of as a women’s issue, it is not limited to women.

There’s no shortage of controversy surrounding osteoporosis. Perhaps the first issue is just how many people should be concerned about it. According to the NIH, 34 million people have low bone density. Add that to the 10 million who have been diagnosed with osteoporosis, and you come up with 44 million Americans for whom “osteoporosis is a major public health threat.”767 That’s more than half of the population over 50 years of age.

Lumping those 34 million who have low bone density together with those who have already been diagnosed with osteoporosis certainly makes for a larger potential market for the drugs that have been developed to prevent or treat bone loss. Some public health researchers have criticized this tactic by calling it “-disease-mongering.”768 Instead of characterizing osteoporosis or low bone density as a risk factor for fracture, calling it a disease implies that it requires treatment.769 The critics claim that this tactic mobilizes fear (and helps sell drugs) rather than promoting understanding and positive action.

The availability of bone density screening is a two-edged sword in this respect. On the one hand, it is helpful for those who are truly at risk to find out before they break a hip or develop debilitating back pain from vertebral fractures. Unfortunately, many of those being screened are not those who need it most. An analysis of nearly 44,000 women on Medicare found that the oldest women, ages 81 to 85, were only half as likely to be screened as women ages 66 to 70. The older women, however, are far more likely to have reduced bone density, even osteoporosis, putting them at risk of a fracture.

Increasingly, middle-aged women are being screened for bone density. The scoring system is a bit complicated, since it is based on standard deviations below the bone density of a young person at peak bone mass. Most of us don’t have the grounding in statistics to make much sense of “standard deviations,” so if the doctor does not explain carefully what the numbers mean, women often end up confused and alarmed. Critics point out that defining osteoporosis as bone density that is 2.5 standard deviations (T score -2.5) below the mean for a young person practically guarantees that approximately 30 percent of postmenopausal women will be diagnosed with this condition, whether they are truly at risk for osteoporosis or not.

When it comes to preventing broken hips and painful spinal fractures, there is no single treatment that stands head and shoulders above the rest. Each has benefits and disadvantages. People at risk for osteoporosis will need to think about the issues that might affect their treatment and their ability to stick with the program.

Even when the primary goal is prevention by getting adequate calcium and vitamin D together with exercise (and we strongly encourage that for everyone who can do it), the studies show that nutritional supplements are effective only if people actually take them all the time. Surprise! So consider whether you will take a pill or an injection every day, or if you’re better off with once-a-week or even once-a-month therapy.

Consider combining Evista or Menostar with one of the bisphosphonate medicines, such as Actonel or Fosamax. Some research shows that combining these treatments can increase bone density more than either one alone.804 We don’t know whether the combination also reduces the risk of fractures synergistically. There are, of course, costs associated with taking more than one drug. But if the therapy you are using does not seem to be working adequately, this option might be worth discussing with your doctor. There isn’t any advantage in combining Forteo with other medicines.

There are a couple of other treatments to watch for, although they are not currently available in the United States. A new hormone replacement therapy called Angeliq has been introduced in Europe. It contains a lower dose of estrogen (1 milligram per day of estradiol) along with a different type of progestin called drospirenone.805 We can’t tell at this point whether it would be safer than the usual HRT or how effective it might be at preventing fractures. Another new drug is called Preos. Like Forteo, it is based on parathyroid hormone.806 Not enough information is available at this time to tell if it would offer any significant advantages.

  • A lifetime of healthy living, with plenty of physical activity and adequate intake of calcium and vitamin D, is the best osteoporosis preventive. It’s (almost) never too late to start. But if you already have had fractures, check with your doctor before you begin a new exercise program! You don’t want to make things worse.
  • Bone density screening can be a useful tool for determining who may need treatment for osteoporosis. It is underutilized for those most at risk, women of more than 80 years of age.
  • Don’t bother with calcium supplements alone. Make sure they are paired with adequate vitamin D. Your skin can manufacture its own D with roughly 15 minutes of sun exposure three or four days a week. If you shun the sun, you should be getting a minimum of 700 IU of vitamin D3 a day; 1,000 IU daily might be even better, but don’t go overboard because vitamin D can be toxic at very high doses.
  • Evista can do double duty, reducing the risk of both osteoporosis fractures and breast cancer. If you are concerned about both issues, discuss this possibility with your doctor.
  • The bisphosphonates are fairly similar in side effects and efficacy, though alendronate (Fosamax) may have an edge. Consider one of these medicines unless you have had problems with your esophagus (such as bleeding or trouble swallowing) or expect to need dental surgery.
  • Forteo builds bone, but its long-term benefits and risks are unknown. As a daily injection, it is less convenient and more expensive than most other treatments.
  • Miacalcin might be a good choice for a person who already has osteoporosis and vertebral fractures. It may ease back pain as well as increase spinal bone density.
  • Menostar offers an alternative for women. This ultra-low-dose estrogen patch can increase bone mineral density and may not cause the harm associated with conventional HRT.

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  1. Nanette
    Carlisle SC

    There was no mention of Prolia. What are your thoughts on this medicine?

  2. Kay E.

    I was diagnosed with osteoporosis at age 38, after a hysterectomy. I have had three fractures — both wrists (separately) and my spine. All three involved trauma. I have refused the bisphosphonates for years. Been on Evist for about 8 years, not really improving, but getting worse just a tad. Doctor wants to use Prolia. Anyone know anythinng about this drug?
    I have lost a significant amount of bone in my jaw, so I always worry about the osteonecrosis.

  3. jh

    My bone density is -3.2, spinal osteoporosis and his osteopenia. It appears to me there is nothing safe to take for this. Do you or docs have any answer? I was to take Reclast but after looking at side effects don’t think I will take any of the offerings. I need good suggestions.

  4. JO

    Verity R- Now that a year has gone by, have you had any improvement?

  5. kah

    I know they prescribe strontium ranelate in Europe and have done so for a number of years, but it isn’t an FDA approved drug here. I am newly diagnosed with osteopenia of the hip and osteoporosis of the spine. I too am trying a combination of strontium, magnesium, fosteum (prescription food geninstein in combination with zinc and cholocalciferol)in addition to calcium and D supplements. I did not want to take Fosamax or any of the related until I had tried something with fewer dire side effects. Good luck!

  6. Verity R.

    I’m 58 and newly diagnosed with Osteoporosis after I broke a rib when it really shouldn’t have broken and a Dexa scan confirmed my suspicions… I’ve done a lot of research on therapies and I’m going to try a natural approach by using a combination of strontium, calcium, magnesium, Vitamin D and Vitamin K2 (MK7) for a year to see if it improves my T-score; if it does, then I’ll stick with it, if not, I’ll reluctantly try one of the main-stream meds. At the moment, though, the evidence I’ve found for Strontium and Vit K2 is compelling.

  7. suzanne

    I have a very bad back, per my doctor, but now my shoulders/neck and going down my arms hurt very bad, can’t left my arms without squealing from pain and also hard to turn the steering wheel when I drive, What to do?? need some advise, input, anything that can help, I have been told I have mild arthritis, well if this is mild, sure hope it does not get worse. Thank you

  8. Lise

    I am very concerned about Fosamax which I have been on for 5-6 years. I have several friends, one just yesterday, who had a femur break. Both were on Fosamax for 5-7 years. There must be something that isn’t a drug to help us build up our bones even at age 65. HELP I am afraid to just walk around after yesterday’s news of my friend.

  9. LL

    I will be 65 this year and have taken the forteo for two years and it increased my bone density 17% in two years. I have been off my Boniva since I have a bad hiatus hernia in esophagus and now waiting to take the Reclast. I hurt in my back over to my hip and when this happens I wear a wrap around back brace that comes down on my hips, This helps me do some house work.

  10. ezk

    I am 84. Have been diagnosed with osteoporosis for over 40 years. My bone density is going down. I have taken calcium for as many years, along with other supplements… without obvious success. I have had bi-lateral knee replacement, both hips replaced and recently a shoulder replacement with the surgeon’s comment, “the bone looked like the surface of the moon”.
    I have heard that an infusion of alendronate can possibly reduce the rate ofloss of bone density. Do you know of such a procedure and its possible value?
    Is there a reason for taking calcium/magnesium combinations in supplements?
    I do take Vitamin D twice daily.
    Thank you for your program. I love it!. Estelle

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