Internal Medicine is the branch of medicine that deals with the prevention, diagnosis and non surgical treatment of adults diseases. Internal medicine especially diagonose the diseases which effect the internal organ system but not male or female reproductive organs and neourological diseases.
What is OSTEOPOROSIS
What is this disease? Does it affect women only? Do patients know that they are affected with the disease? Is Calcium alone enough for treatment as thought by lots of women? What is the role of exercise? These are all an important questions.
Osteoporosis is a silent disease, a normal bone which is a living tissue that is constantly renewing itself, replacing old bone with a new bone, but with osteoporosis the body loose bone faster than it is replaced. As a result bones weaken, becoming thinner and likely to break. Unfortunately we do not feel this process and osteoporosis can develop without knowing until a fracture can happen.
It affects people over 50 years and gradually increases with age, the most area affected by this disease and cause fractures are hip, spine and wrist. Fractures caused by osteoporosis are more common in women than men with 2-3 fold higher. It affects white Caucasian race higher than other races and is responsible for over a million and a half fractures annually in USA. Of course, there are several risk factors which can predispose for this condition such as smoking, excess alcohol, lack of Calcium and Vitamin D, Thyroid diseases, family history, low weight, chronic steroid use and finally lack of Estrogen either after menopause or after surgical removal of the two ovaries for any reason.
The most important complication of Osteoporosis is different type of fractures and sometimes spontaneous fractures. If fracture happens in the spine it will cause a collapse vertebra and sometimes height loss or curved back or kyphosis. Collapsed vertebra can cause severe back pain but on the other hand pain can be present without obvious fracture on the spine x-ray and this is due to micro fractures and this can lead to the wrong diagnosis like osteoarthritis, so it is very important to think about Osteoporosis and diagnose it early to prevent its complications.
We can diagnose Osteoporosis by doing a test to measure bone density called DEXA scan, which is a radiological test.
The test result can either tell us that the bone is normal with a low risk for fractures or can differentiates between two conditions either the presence of Osteoporosis with a high risk for fractures or a condition called Osteopenia which is the very early stage for osteoporosis and here you have a medium risk for fractures.
DEXA test measure the bone density in two areas, which are the hip and lumbar spine.
As I mentioned, Osteoporosis affects women more than men because the bone density in men is higher than women and the bone loss process in men is much slower with a life time fracture risk in men is about one third that of women. Nonetheless, the incidence of hip fracture in men rises sharply with age, and approaches that in women by age 85 years. It is important to investigate secondary cases of osteoporosis in men which can be treated such as Hypogonadism (low male hormone level), excessive alcohol intake and long term use of steroids used is some type of arthritis. It is very important to do DEXA scan at the beginning of the steroid treatment and periodically thereafter and even if the bone density was normal, it is accepted practice to start the patients on osteoporosis medication to prevent the development of bone loss with the long term use of steroids.
For the treatment of osteoporosis, it is a wrong practice to use calcium alone to treat this condition as studies showed that calcium alone does not build bone. On the other hand, calcium is important to take in an adequate dose for example women until age 50 are required to take total of 1000 mg daily, this dose should be increased to 1500 mg daily in women over 50 especially if they are not taking hormone replacement. This dose of calcium can be taken partially with food such as milk and dairy products, for example, an 8 oz glass of milk contain 300 mg of calcium, the rest of the daily required dose can be taken as calcium pill. It is also important to combine calcium with vitamin D, which can help absorb calcium from the intestine, it is estimated that the daily requirement of vitamin D is 400 IU if that person exposed to adequate sun light otherwise the dose should be increased to 800 IU daily.
Now, let me speak about a controversial subject, which is Estrogen or hormone replacement therapy. There are conflicting data regarding the benefit of hormone replacement. It is possible now that estrogen alone without progesterone can increase the risk of breast cancer and uterine cancer but on the other hand estrogen can prevents the rapid postmenopausal bone toss and osteoporosis. It is very well recommended that women taking hormone replacement should be under strict medical supervision and doing periodic mammogram and pelvic exam.
It should be mentioned also that Estrogen could cause deep vein thrombosis, increased Triglyceride level and cholecystitis.
There are several medications approved for the prevention and the treatment of osteoporosis and they are not hormone replacement, some of these are easy to take like a weekly pill, but of course, there are some side effects like all other medications and we have to weigh the advantages and the disadvantages for each one.
Finally, I want to remind that osteoporosis is a silent disease, we have to diagnose it early before progressing to its complications like the fractures, so women should seek medical care and screening by doing the DEXA scan as early as 50 years and should the following recommendations to prevent this disease:
- Diet rich in calcium and vitamin D either by food or by tablets as outlined by your doctor.
- Adequate sun exposure without over exposure.
- Regular exercises.
- Avoid smoking and excess alcohol.
- Doing DEXA scan as recommended by your doctor to diagnose osteoporosis early or osteopenia and treat these conditions hopefully to prevent the fractures down the roads.