Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women
- Harold N Rosen, MD
Harold N Rosen, MD
- Associate Professor in Medicine
- Harvard Medical School
- Marc K Drezner, MD
Marc K Drezner, MD
- Section Editor — Bone Disease
- Professor of Medicine
- University of Wisconsin Medical School
- Section Editors
- Clifford J Rosen, MD
Clifford J Rosen, MD
- Section Editor — Bone Disease
- Professor of Nutrition
- University of Maine
- Professor of Medicine
- Tufts University School of Medicine
- Kenneth E Schmader, MD
Kenneth E Schmader, MD
- Editor in Chief — Geriatric Medicine
- Section Editor — Geriatrics
- Chief, Division of Geriatrics
- Duke University
- Director, Geriatric Research Education and Clinical Center
- Durham VA Medical Centers
Osteoporosis is characterized by low bone mass, microarchitectural disruption, and skeletal fragility, resulting in decreased bone strength and an increased risk of fracture. Decreased bone strength is related to many factors other than bone mineral density (BMD), including rates of bone formation and resorption (turnover), bone geometry (size and shape of bone), and microarchitecture (picture 1). The World Health Organization (WHO) has defined diagnostic thresholds for low bone mass and osteoporosis based upon BMD measurements compared with a young-adult reference population (T-score).
The majority of postmenopausal women with osteoporosis have bone loss related to estrogen deficiency and/or age. The initial evaluation includes a history to assess for clinical risk factors for fracture and to evaluate for other conditions that contribute to bone loss, a physical examination, and basic laboratory tests. Those with abnormal initial findings may require additional testing to detect potentially reversible causes of osteoporosis. In addition, low BMD Z-scores (age-matched comparison) identify individuals requiring further evaluation for secondary causes of osteoporosis.
Early diagnosis and quantification of bone loss and fracture risk are important because of the availability of therapies that can slow or even reverse the progression of osteoporosis.
The clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women will be reviewed here. The evaluation of osteoporosis in premenopausal women and men and the treatment of osteoporosis are reviewed separately. (See "Evaluation and treatment of premenopausal osteoporosis" and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in men" and "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)
Osteoporosis has no clinical manifestations until there is a fracture. This is an important fact because many patients without symptoms incorrectly assume that they must not have osteoporosis. On the other hand, many patients with achy hips or feet assume that their complaints are due to osteoporosis. This is unlikely to be true in the absence of fracture. In comparison, pain is common in osteomalacia in the absence of fractures or other bone deformities. (See "Epidemiology and etiology of osteomalacia".)
- Svedbom A, Hernlund E, Ivergård M, et al. Osteoporosis in the European Union: a compendium of country-specific reports. Arch Osteoporos 2013; 8:137.
- Yamamoto T, Bullough PG. The role of subchondral insufficiency fracture in rapid destruction of the hip joint: a preliminary report. Arthritis Rheum 2000; 43:2423.
- Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int 2014; 25:2359.
- World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Geneva 1994. http://whqlibdoc.who.int/trs/WHO_TRS_843.pdf (Accessed on March 09, 2012).
- Cranney A, Jamal SA, Tsang JF, et al. Low bone mineral density and fracture burden in postmenopausal women. CMAJ 2007; 177:575.
- Binkley N, Bilezikian JP, Kendler DL, et al. Summary of the International Society For Clinical Densitometry 2005 Position Development Conference. J Bone Miner Res 2007; 22:643.
- Johnell O, Kanis JA, Oden A, et al. Predictive value of BMD for hip and other fractures. J Bone Miner Res 2005; 20:1185.
- The International Society for Densitometry. 2013 ISCD Official Positions – Adult. Middletown, CT: The International Society for Densitometry, 2013 http://www.iscd.org/official-positions/2013-iscd-official-positions-adult/ (Accessed on January 06, 2014).
- Kalkwarf HJ, Zemel BS, Gilsanz V, et al. The bone mineral density in childhood study: bone mineral content and density according to age, sex, and race. J Clin Endocrinol Metab 2007; 92:2087.
- Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 1991; 114:919.
- De Laet CE, Van Hout BA, Burger H, et al. Hip fracture prediction in elderly men and women: validation in the Rotterdam study. J Bone Miner Res 1998; 13:1587.
- Genant HK, Engelke K, Fuerst T, et al. Noninvasive assessment of bone mineral and structure: state of the art. J Bone Miner Res 1996; 11:707.
- Kelly TL, Slovik DM, Schoenfeld DA, Neer RM. Quantitative digital radiography versus dual photon absorptiometry of the lumbar spine. J Clin Endocrinol Metab 1988; 67:839.
- Yamada M, Ito M, Hayashi K, et al. Dual energy X-ray absorptiometry of the calcaneus: comparison with other techniques to assess bone density and value in predicting risk of spine fracture. AJR Am J Roentgenol 1994; 163:1435.
- Seeley DG, Browner WS, Nevitt MC, et al. Which fractures are associated with low appendicular bone mass in elderly women? The Study of Osteoporotic Fractures Research Group. Ann Intern Med 1991; 115:837.
- Hui SL, Slemenda CW, Johnston CC Jr. Baseline measurement of bone mass predicts fracture in white women. Ann Intern Med 1989; 111:355.
- Cummings SR, Black DM, Nevitt MC, et al. Bone density at various sites for prediction of hip fractures. The Study of Osteoporotic Fractures Research Group. Lancet 1993; 341:72.
- Cummings SR, Black DM, Nevitt MC, et al. Appendicular bone density and age predict hip fracture in women. The Study of Osteoporotic Fractures Research Group. JAMA 1990; 263:665.
- Melton LJ 3rd, Atkinson EJ, O'Fallon WM, et al. Long-term fracture prediction by bone mineral assessed at different skeletal sites. J Bone Miner Res 1993; 8:1227.
- Eastell R, Wahner HW, O'Fallon WM, et al. Unequal decrease in bone density of lumbar spine and ultradistal radius in Colles' and vertebral fracture syndromes. J Clin Invest 1989; 83:168.
- Cummings SR, Black D. Bone mass measurements and risk of fracture in Caucasian women: a review of findings from prospective studies. Am J Med 1995; 98:24S.
- Cummings SR, Bates D, Black DM. Clinical use of bone densitometry: scientific review. JAMA 2002; 288:1889.
- Black DM, Cummings SR, Genant HK, et al. Axial and appendicular bone density predict fractures in older women. J Bone Miner Res 1992; 7:633.
- Kanis JA, Glüer CC. An update on the diagnosis and assessment of osteoporosis with densitometry. Committee of Scientific Advisors, International Osteoporosis Foundation. Osteoporos Int 2000; 11:192.
- Lobão R, Carvalho AB, Cuppari L, et al. High prevalence of low bone mineral density in pre-dialysis chronic kidney disease patients: bone histomorphometric analysis. Clin Nephrol 2004; 62:432.
- Miller PD. Treatment of osteoporosis in chronic kidney disease and end-stage renal disease. Curr Osteoporos Rep 2005; 3:5.
- Moe S, Drüeke T, Cunningham J, et al. Definition, evaluation, and classification of renal osteodystrophy: a position statement from Kidney Disease: Improving Global Outcomes (KDIGO). Kidney Int 2006; 69:1945.
- Hofbauer LC, Hamann C, Ebeling PR. Approach to the patient with secondary osteoporosis. Eur J Endocrinol 2010; 162:1009.
- Diab DL, Watts NB. Secondary osteoporosis: differential diagnosis and workup. Clin Obstet Gynecol 2013; 56:686.
- Hudec SM, Camacho PM. Secondary causes of osteoporosis. Endocr Pract 2013; 19:120.
- Miller PD. Unrecognized and unappreciated secondary causes of osteoporosis. Endocrinol Metab Clin North Am 2012; 41:613.
- National Osteoporosis Foundation, 2013 Clinician's guide to prevention and treatment of osteoporosis http://nof.org/files/nof/public/content/file/2237/upload/878.pdf (Accessed on March 19, 2014).
- Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA 2001; 285:320.
- Black DM, Arden NK, Palermo L, et al. Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 1999; 14:821.
- Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone 2004; 35:375.
- Tannenbaum C, Clark J, Schwartzman K, et al. Yield of laboratory testing to identify secondary contributors to osteoporosis in otherwise healthy women. J Clin Endocrinol Metab 2002; 87:4431.
- Lewiecki EM, Watts NB, McClung MR, et al. Official positions of the international society for clinical densitometry. J Clin Endocrinol Metab 2004; 89:3651.
- Ryan LE, Ing SW. Idiopathic hypercalciuria and bone health. Curr Osteoporos Rep 2012; 10:286.
- CLINICAL MANIFESTATIONS
- Vertebral fracture
- Other fractures
- Bone mineral density
- - T-score
- - Z-score
- - Applicability of WHO criteria
- - Method of BMD measurement
- - Site of measurement
- DIFFERENTIAL DIAGNOSIS
- EVALUATION OF LOW BONE MASS
- Initial evaluation
- Low Z-scores
- Additional evaluation
- Bone turnover markers
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS