You can't see or feel your bones getting thinner, and you may only become aware of osteoporosis when you fracture a bone. Osteoporosis weakens the bones in your back (vertebrae). Some signs to look out for include severe back pain (particularly in older people), your spine becoming curved and any reduction in your height. However, only one in three people with a fracture of the bones in the back have any symptoms at all.
If you’re at risk of having osteoporosis, your GP will carry out an assessment. He or she will examine you, and ask you questions about your lifestyle and family medical history. You may have a DXA scan (dual X-ray absorptiometry scan). This measures the density of your bones. The scan is painless and takes 10 to 15 minutes.
Osteoporosis is diagnosed if your bone density is found to be lower than average. If your bone density is slightly lower than average, it's known as osteopenia.
Osteoporosis is sometimes diagnosed after a fracture has happened, possibly after a trip or a fall. If this happens, you will have a DXA scan. You may also have some blood tests to rule out underlying conditions.
If you’re diagnosed with osteoporosis, the results of your DXA scan alongside other information can be put into an online risk assessment tool. This can say what your chance is of having a fracture over the next 10 years.
If you have osteoporosis, your GP may prescribe the following medicines to increase your bone density. Ask your GP for information and advice about which treatments are available and suitable for you. And always read the patient information leaflet that comes with your medicine.
- Bisphosphonates – these work by slowing down bone loss. Examples include alendronate (eg Fosamax), risedronate (eg Actonel) and zoledronate (eg Aclasta).
- Medicines that affect the action of your parathyroid gland. Parathyroid hormone (eg Preotact) and teriparatide (eg Forsteo) help to increase calcium levels and the activity of bone-producing cells.
- Raloxifene (eg Evista). This is an artificial hormone that works by copying the effects of oestrogen on your bones.
- Hormone replacement therapy (HRT). This relieves symptoms of the menopause by restoring hormones to a pre-menopausal level. It’s not used to treat osteoporosis on its own. It’s only recommended for certain people. This might be if you’ve had premature menopause or have severe menopausal symptoms. Or if you’re at high risk of having a fracture and other non-oestrogen treatments aren’t suitable for you.
- Denosumab (Prolia). This is a biological treatment that works by blocking the formation of the cells that break down bone.
For men whose osteoporosis is caused by hypogonadism (a condition in which your testicles don’t function properly), your GP may prescribe testosterone replacement therapy.
Healthy bone consists of a strong mesh made of protein and minerals (particularly calcium) surrounded by a thick outer layer. This mesh is living tissue that is constantly being renewed by two types of cells which work in balance with each other. One type of cell (osteoblasts) builds up new bone and the other (osteoclasts) breaks down old bone. Your bones are at their most dense in your early to mid 20s. After the age of about 35, your bones gradually lose their density as a natural part of ageing. This happens slowly at first, but the rate increases in women after they have been through the menopause.
Although the genes you inherit from your parents play an important role in how healthy your bones are, other factors can affect your risk.
- Age – the risk of getting osteoporosis increases as you get older.
- Gender – women in their late 40s and early 50s start to go through the menopause. This means they lose the protective effects of the hormone oestrogen and have a higher risk of developing osteoporosis.
- Race – Caucasian or Asian races are at greater risk than African-Caribbean people.
- Premature menopause – if you have your ovaries removed in a total hysterectomy, this increases your risk because you have less oestrogen.
- Long-term immobility – bones and muscles become weak if your body isn't active and using them regularly.
- Weight – if you're underweight or you have lost weight in recent years, you have an increased risk of osteoporosis. Weight loss can cause bone loss.
- Poor diet – low levels of vitamin D or calcium mean your body can't repair bones and keep them strong.
- Smoking – there’s increasing evidence that smoking is linked to having osteoporosis, and a higher risk of fractures.
- Alcohol – excessive amounts of alcohol over a long period of time affect the way your body uses calcium, and also disturbs your balance of hormones. This increases your risk of osteoporosis.
Some medicines and health conditions can increase your risk of osteoporosis.
- Long-term use of corticosteroids – used to treat severe allergies or inflammation.
- Aromatase inhibitors – used in breast cancer treatment.
- An overactive thyroid gland – such as hyperthyroidism or hyperparathyroidism.
- Rheumatoid arthritis – this is when your immune cells attack your joints and cause inflammation.
- Low level of testosterone – caused by a condition in which your testicles don’t function properly (hypogonadism) or as a result of prostate cancer treatment.
- Digestive disorders – for example Crohn's disease or any other condition that decreases absorption from your digestive system.
- Some anticonvulsant medicines – used to treat epilepsy.
If you have osteoporosis, you’re more likely to fracture bones after quite minor accidents like falling or tripping, or even bending and lifting. Your bones fracture much more easily than you would expect. You’re more likely to fracture bones in your spine, wrists and hip. However, you can fracture any bone in your body. Fractures are painful and can lead to a loss of independence and long-term disability in older people.
Making some changes to your lifestyle could help to reduce your risk of developing osteoporosis. A healthy diet and regular exercise can increase bone mass, especially in younger people whose bones are still growing.
High-impact exercise, where you support your own weight, is best for strengthening bones and encouraging bones to grow. This type of exercise includes jogging, tennis, dancing and brisk walking. Try also to include some activities, such as Pilates or tai chi, which may help to improve your balance and muscle strength. If you aren't used to exercising, start slowly and build up your exercise routine gradually.
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Smoking can have a harmful effect on your bone strength and can also cause an early menopause in women. If you smoke, try to give up. Also be careful not to drink too much alcohol.
It’s important to eat a diet that’s rich in calcium to keep your bones healthy. Adults should aim to have 700mg of calcium every day, which you should be able to get through healthy eating. Good sources of calcium include milk, cheese and yogurt, dried figs or apricots, oily fish, and some green leafy vegetables, such as broccoli and cabbage. See our FAQs for more information about what to eat.
Making sure you get enough vitamin D is also important for bone health as your body needs this to absorb calcium properly. Vitamin D is produced naturally by your body when your skin is exposed to sunlight and can also be obtained from some foods, such as oily fish. You may get enough vitamin D during summer by spending frequent short spells in the sun without wearing sunscreen. The exact time you need is different for everyone, but is typically only a few minutes in the middle of the day. Be careful and don’t let your skin redden.
If you don’t get much sun exposure, for example if you’re housebound or cover your skin for cultural reasons, you may need a supplement.
Talk to your pharmacist before you start taking supplements of any kind. This is important, particularly if you’re taking any medicines or if you’re pregnant or breastfeeding.
Always read the patient information leaflet that comes with your supplements.
If you have osteoporosis, you need to be careful of vigorous, high-impact exercise, such as running. However, leading an active lifestyle will improve your balance, coordination and develop muscle strength. This can reduce your risk of falling and fracturing a bone. Doing regular exercise is also good for your heart and your blood pressure. Beneficial exercise includes swimming, gardening, walking, golf and tai chi.
Your GP may prescribe or recommend you take a vitamin D supplement, or a calcium and vitamin D supplement together. This will depend on whether you’re getting enough vitamin D and how much calcium you’re getting. Talk to your GP about how much you need to take because this depends on factors such as your age, living circumstances and current intake of these vitamins and minerals. See our FAQs for more information.
If you have a fracture, you may wish to take medicines for pain-relief. Over-the-counter painkillers such as paracetamol or ibuprofen may help with this. Always read the patient information leaflet that comes with your medicine. See our FAQs for more information.
Physiotherapy can help you strengthen bones, prevent bone thinning and reduce falls. Acupuncture and TENS (transcutaneous electrical nerve stimulation) may also help with long-term pain. Or you may wish to try alternative therapies such aromatherapy. There’s no proof that this can help your condition but it may make you feel more relaxed as it’s designed to create a sense of wellbeing.
You should still be able to work if you have osteoporosis. Living a normal life as much as possible is really important for your wellbeing. Not only is an active lifestyle good for preventing fractures, it will also do your mood good. If, however, the nature of your job poses a risk to you having a fall or fracturing a bone, speak to your employer. There may be adjustments to your work and environment that can reduce the risk of anything happening.
You may also need to adjust how you do things. For example, taking breaks every half an hour or so to get up and realign your posture. Take care not to twist and bend down at the same time.
How much calcium and vitamin D should I be getting to prevent a fracture if I have osteoporosis?
The amount you need depends on how much you’re already getting and some other circumstances such as how old you are and where you’re living.
If you’re at risk of getting a fracture, your GP will recommend you get at least 1,000 mg of calcium a day.
To give you some idea about how to get enough calcium in your diet, here is the amount in some everyday foods.
- A 200ml glass of semi-skimmed milk contains 240mg calcium.
- A 100g pot of fruit yogurt contains 122mg calcium.
- 100g Cheddar cheese contains 739mg calcium.
- Four slices of white bread contain 175mg calcium.
- Four slices of wholemeal bread contain 105mg calcium.
- 100g tinned sardines (in oil) contains 500mg calcium.
- 100g tinned salmon contains 91mg calcium.
- 100g baked beans contains 53mg calcium.
You might be at risk of not having enough vitamin D if you’re over 65 and you don’t get very much sun exposure. This might be if you’re not able to get outside very much or you wear clothes that cover your skin.
If you’re not able to leave the house or live in a nursing home, you’ll be prescribed 20 micrograms (mcg) of vitamin D to be taken in combination with at least 1g of calcium a day. If you’re not able to get out in the sun often but have a good intake of calcium, then your doctor will prescribe 10 mcg of vitamin D. If you’re not getting enough calcium, your GP will advise you take 10mcg of vitamin D with at least 1,000mg of calcium daily.
It can be confusing to know how much of each vitamin and mineral you need, but your GP will be able to explain how much you need and why.
I can't eat dairy food so how can I make sure I get enough calcium to help prevent osteoporosis?
There are plenty of non-dairy foods that contain calcium so you should still be able to get enough from your diet.
Even if you don't eat milk or dairy food, there are other options. Good sources of calcium include oily fish such as canned sardines and pilchards, soya beans and tofu, bread, pulses, certain green vegetables including broccoli and watercress, dried fruit (especially figs), nuts and seeds (particularly almonds and sesame seeds). If you use soya, rice or oat milk, choose one with added calcium.
If you're concerned that you may not be getting enough calcium in your diet, talk to your GP or a dietitian.
My doctor has told me to eat a low-fat diet. How can I get enough calcium to prevent osteoporosis if I have to limit cheese and milk?
It's best to eat some dairy foods each day as they are good sources of calcium. There are many low-fat dairy products available and often these contain more calcium than full-fat versions.
You can try either switching to lower fat options or using a little less of high-fat foods such as hard cheese. Try changing from:
- whole milk to semi-skimmed or skimmed milk
- Cheddar or Edam cheese to cottage cheese
- cream to yoghurt or low-fat crème fraîche
How can I deal with the pain from a broken bone in my back caused by osteoporosis?
Talk to your GP about pain relief for osteoporotic fractures. It's important to explore all the options until you find something that helps you.
About half of all women over 50 will break (fracture) a bone due to osteoporosis in their lifetime. Men can also fracture bones as a result of osteoporosis, but it’s about six times more likely if you’re a woman. The most common fracture caused by osteoporosis is called an osteoporotic vertebral compression fracture. This is when pressure on weakened bones in your spine (vertebrae) causes them to crack and fracture.
You may or may not feel any immediate pain when the fracture occurs. However, if you do have pain, it can be very severe. You may also have chronic pain even after your bone has healed. Chronic means that it lasts a long time, sometimes for the rest of your life. The term chronic refers to how long you have it, not to how serious it is. Ongoing pain after a fracture can affect your quality of life.
Your GP is likely to suggest trying either over-the-counter or stronger, prescription painkillers. You may also be recommended a short period of bed rest. However, if these don't help control your pain, there are other options to consider. Some examples are listed below.
- You may find that physiotherapy, hydrotherapy (exercise in water), acupuncture or using a TENS (transcutaneous electrical nerve stimulation) machine may help to relieve your pain.
- Surgical treatments that include injecting cement into the fracture are available. These methods are called vertebroplasty and kyphoplasty.
It's important that your GP helps you to find an approach that works for you. It’s possible that you may need to be referred to a specialist pain clinic.
Why isn't spinach a good source of calcium?
Although spinach has a high calcium content compared with other foods, the calcium is bound to a substance called oxalate, which means that your body can't absorb it.
The calcium content of spinach is quite high compared with other foods. For example, 100g of boiled spinach contains around 160mg of calcium compared with 75mg in the same amount of spring greens. However, spinach isn't recommended as a calcium-rich source of food because the calcium is bound to a substance called oxalate. This stops your body from absorbing it. So, although spinach is a good source of other vitamins and minerals it isn't a good source of calcium.
If you're trying to increase the amount of calcium in your diet, there are plenty of other calcium-rich foods that you can eat, such as:
- milk and dairy products
- canned fish with bones, such as sardines
- fortified breakfast cereal
- soya bean products, such as tofu
- other green leafy vegetables
- dried fruit
I read in the newspaper that calcium supplements can increase the risk of having a heart attack. Should I stop taking them?
There is some evidence that calcium supplements increase the risk of heart attacks in women who have gone through the menopause. However, as other studies have reported different findings, more research is needed in this area before conclusions can be drawn. If your GP has recommended that you take calcium supplements because you're at risk of osteoporosis, talk to him or her before stopping.
Calcium supplements are sometimes advised for women who have gone through the menopause to keep their bones healthy. A recent study, however, found that heart attacks were more common in women taking calcium supplements than in women taking a placebo (dummy pills). Scientists don't yet know why calcium supplements could cause this effect, but high calcium levels could lead to a build-up of calcium in the blood vessels. However, more research is needed to understand the link between calcium supplements and heart attacks.
If your GP has recommended that you take calcium supplements, it may be because he or she thinks that you're at risk of osteoporosis. In the UK, the recommended calcium intake is 700mg a day for adults and at least 1,000mg if you have been diagnosed with osteoporosis and are on prescribed medicines.
If you get enough calcium from your diet, you may not need calcium supplements. If you’re prescribed a calcium supplement, it will be to take in combination with a vitamin D supplement. Calcium that you get in your diet doesn’t appear to lead to an increased risk of heart attack.
Always talk to your GP before stopping any medicine or supplement that has been recommended or prescribed for you. It's important to remember that any risks associated with taking calcium supplements must be balanced against the risk of osteoporosis and fractures that may happen if you don't take them.
- Kumar P, Clark M. Clinical medicine. 8th ed. Edinburgh: Saunders; 2012
- Osteoporosis. Medscape. www.emedicine.medscape.com, published 4 October 2013
- Overview of osteoporotic compression fractures. Medscape. www.emedicine.medscape.com, published 14 May 2013
- Osteoporosis. BMJ Best Practice. www.bestpractice.bmj.com, published 26 February 2014
- Osteoporotic spinal compression fractures. BMJ Best Practice. www.bestpractice.bmj.com, published 26 February 2014
- Osteoporosis. PatientPlus. www.patient.co.uk/patientplus.asp, published 2 October 2012
- Osteoporosis. The Merck Manuals. www.merckmanuals.com, published December 2012
- Osteoporosis. NICE Clinical Knowledge Summaries. cks.nice.org.uk, published September 2013
- What is osteoporosis? International Osteoporosis Foundation. www.iofbonehealth.org, accessed 17 June 2014
- Osteoporosis: assessing the risk of fragility fracture. National Institute for Health and Care Excellence (NICE), August 2012. www.nice.org.uk
- Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women. National Institute for Health and Care Excellence (NICE), 2008 (amended 2011). www.nice.org.uk
- Alendronate, etidronate, risedronate, raloxifene, strontium ranelate and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women. National Institute for Health and Care Excellence (NICE), 2008 (amended 2011). www.nice.org.uk
- Denosumab for the prevention of osteoporotic fractures in postmenopausal women. National Institute for Health and Care Excellence (NICE), 2010. www.nice.org.uk
- Smoking and Bone health. NIH Osteoporosis and Related Bone Diseases – National Resource Center. www.niams.nih.gov, published January 2012
- Antiepileptics: adverse effects on bone. Medicines and Healthcare products Regulatory Agency. www.mhra.gov.uk, published April 2009
- Aromatase inhibitors. American Cancer Society. www.cancer.org, published 17 July 2013
- All about osteoporosis: A guide to bone health, fragile bones and fractures. National Osteoporosis Society. www.nos.org.uk, published April 2014.
- Management of osteoporosis: A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN), 2003 (updated 2004). www.sign.ac.uk
- Osteoporosis. Joint Formulary Committee. British National Formulary (online). BMJ Group and Pharmaceutical Press. www.medicinescomplete.com, accessed 4 July 2014
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- Healthy bones – facts about food. National Osteoporosis Society. www.nos.org.uk, published June 2011
- Theobald H. Briefing paper: Dietary calcium and health. British Nutrition Foundation. Nutrition Bulletin 2005; 30 (3): 237–277. doi:10.1111/j.1467-3010.2005.00514.x
- Bolland MJ, Grey A, Avenell A, et al. Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women’s Health Initiative limited access dataset and meta-analysis. BMJ 2011; 342:d2040. doi:10.1136/bmj.d2040
- Lewis, J, Calver J, Zhu K et al. Calcium supplementation and the risks of atherosclerotic vascular disease in older women: Results of a 5-year RCT and a 4.5-year follow-up. J Bone Miner Res 2011; 26: 35–41. doi:10.1002/jbmr.176
- Safe upper levels for vitamins and minerals. Expert group on vitamins and minerals. Food Standards Agency, May 2003.
- What is osteoporosis? Chartered Society of Physiotherapy. www.csp.org.uk, published June 2014
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