Osteoporosis is a skeletal disorder characterized by decreased bone density and quality leading to increased fragility and a high risk of fractures—particularly of the wrist, hip, and vertebrae. It is often referred to as a «silent disease» because it progresses without symptoms for decades until a fracture occurs, sometimes from minimal trauma or even spontaneously. In North America, approximately one in three women and one in five men over age 50 will experience an osteoporosis-related fracture in their lifetime. Hip fracture, the most serious complication, is associated with a 20% to 30% % one-year mortality and permanent loss of independence in 50% % of survivors.
The menopausal transition represents a critical period for women's bone health: the abrupt drop in estrogen drastically accelerates bone resorption, with bone loss potentially reaching 2 to 3 % of bone mass per year in the initial years after menopause. This window precisely corresponds to when prevention and screening are most effective—identifying women with accelerated bone loss at age 50 allows for intervention before bone density reaches the fragility threshold. Clinique Omicron integrates osteoporosis risk assessment into its health check-ups for women aged 50 and over, across several of its Quebec locations, enabling personalized preventive management.
Risk factors for osteoporosis: who to screen first?
Osteoporosis Canada recommends fracture risk assessment for all women aged 65 and older, and for women aged 50 to 64 with clinical risk factors. Major risk factors—those that warrant bone density screening before age 65—include: a fragility fracture after age 40 (a fracture occurring from minimal trauma that would not have fractured a normal bone), a history of hip fracture in a first-degree relative, systemic corticosteroid therapy for more than three months (prednisone ≥ 7.5 mg/day or equivalent), early menopause before age 45—whether spontaneous or surgical—and certain conditions associated with accelerated bone loss: rheumatoid arthritis, celiac disease, Crohn's disease, hyperthyroidism, or hyperparathyroidism.
Secondary risk factors that contribute to the overall risk assessment include: active smoking, alcohol consumption exceeding two drinks per day, a low body mass index below 20 kg/m², vitamin D deficiency, sedentary lifestyle, repeated falls, and prolonged use of osteopenia-inducing medications – proton pump inhibitors, antiepileptics, antiandrogens for prostate cancer, aromatase inhibitors for breast cancer. The FRAX tool – Fracture Risk Assessment Tool, available online – integrates clinical factors to calculate the 10-year probability of major fracture and hip fracture, guiding the decision to treat or not.
Bone densitometry (DEXA): how to interpret the results
Dual-energy X-ray absorptiometry (DXA or DEXA) bone densitometry is the gold standard for measuring bone mineral density and diagnosing osteoporosis. It measures bone density at the lumbar spine and the hip, the two most informative sites for the risk of vertebral and hip fractures, respectively. The result is expressed as a T-score – the standard deviation from the peak bone density of a reference young adult of the same sex. A T-score above -1.0 is normal, between -1.0 and -2.5 corresponds to osteopenia (low bone mass without reaching the osteoporotic threshold), and less than or equal to -2.5 defines osteoporosis according to WHO criteria. The presence of a fragility fracture associated with a T-score ≤ -2.5 defines severe or established osteoporosis.
The T-score must always be interpreted in a clinical context—a T-score of -2.0 in a healthy 50-year-old woman with no risk factors calls for a different approach than the same score in a 70-year-old woman with a history of recurrent falls. The FRAX tool integrates the T-score with clinical factors to calculate the absolute 10-year fracture risk, allowing for personalized treatment decisions. In Quebec, bone densitometry is covered by the RAMQ according to specific indications—previous fragility fracture, prolonged corticosteroid therapy, early menopause, certain osteopenic diseases—and renewed every 2 to 5 years based on the initial result and risk factors. Health assessments at Clinique Omicron include an evaluation of osteoporosis risk and referral for densitometry when clinically indicated.
Prevention and treatment: calcium, vitamin D, and medications
Preventing osteoporosis is based on measures that can be applied throughout life, but are particularly important from the age of fifty onwards. Adequate calcium intake - 1,200 mg per day for women over 50, preferably from food - is the foundation of bone health: dairy products, green leafy vegetables, firm tofu, legumes and fortified foods. Calcium supplementation is recommended only when dietary intake is insufficient, as recent meta-analyses suggest a possible association between excess calcium supplementation and slightly increased cardiovascular risk. Vitamin D is essential for the intestinal absorption of calcium - a daily intake of 800 to 2,000 IU is recommended for women over 50 in Quebec, given the lack of sun exposure most of the year. Weight-bearing physical activity - walking, hiking, weight training, dancing - stimulates bone formation and improves muscle strength and balance, reducing the risk of falls.
Pharmacological treatment is recommended for women with established osteoporosis (T-score ≤ -2.5) or a high FRAX 10-year fracture risk. Biphosphonates - alendronate, risedronate, zoledronic acid - remain the first-line therapeutic class: they inhibit bone resorption, increase bone density and reduce the risk of vertebral fractures by 40-70 % and hip fractures by 30-50 %. Denosumab - a twice-yearly subcutaneous injection - is an effective alternative, particularly useful in cases of contraindication or intolerance to biphosphonates. Strontium ranelate, teriparatide (recombinant parathyroid hormone) and romosozumab are options for severe or refractory osteoporosis, prescribed as specialties. Hormonal treatment of the menopause - estrogen alone or combined with a progestin - is effective in preventing post-menopausal bone loss, but its indication is guided by the individual benefit-risk ratio, taking into account other manifestations of the menopause.
Frequently Asked Questions About Osteoporosis
Does osteoporosis also affect men? When should they be screened?
Yes, osteoporosis also affects men, albeit less frequently and later than women due to the absence of a male equivalent to menopause - age-related bone loss is more gradual in men. Around one in five men over the age of 50 will suffer an osteoporosis-related fracture in his lifetime. Hip fractures in men are associated with even higher mortality than in women - up to 37 % at one year in some studies. Men are under-diagnosed and under-treated for osteoporosis compared to women. Osteoporosis Canada recommends fracture risk assessment for all men aged 65 and over, and for men aged 50 to 64 with risk factors - past fragility fracture, prolonged corticosteroid therapy, hypogonadism, anti-androgen treatment for prostate cancer, osteopenic diseases. Diagnosis and treatment options are similar to those for women.
Can bone density be improved naturally without medication?
To a certain extent, yes - but the possibilities depend on the stage of the disease. In the prevention phase - mild to moderate osteopenia without fracture - lifestyle modifications can stabilize or modestly improve bone density: regular physical activity with weight-bearing and muscular resistance exercises two to three times a week, adequate dietary calcium intake of around 1,200 mg per day, vitamin D supplementation maintaining serum levels at 75 nmol/L or more, stopping smoking, reducing alcohol consumption, and maintaining a healthy body weight. These measures are important and must be maintained for life, including in conjunction with pharmacological treatment. However, in women with established osteoporosis - T-score ≤ -2.5 - or after a fragility fracture, hygienic-dietary measures alone are insufficient to significantly reduce the risk of fracture - in which case drug treatment is recommended by clinical guidelines.
Are calcium supplements sold in pharmacies useful or dangerous?
The nuanced answer is that calcium supplements are useful when they compensate for inadequate dietary intake, but unnecessary and potentially problematic when added to already adequate dietary intakes. Priority should always be given to dietary sources of calcium - they provide calcium along with other beneficial nutrients, and without the potential risks of isolated supplementary doses. Recent meta-analyses have raised the question of a possible association between high-dose calcium supplementation - above 1,000 mg per day as a supplement - and slightly increased risk of cardiovascular events and kidney stones, although this association remains debated in the literature. The current recommendation is to assess actual dietary calcium intakes before prescribing a supplement: if intakes are close to 1,200 mg per day, a supplement of 200 to 500 mg is sufficient; if intakes are very low, higher supplementation is justified. Calcium carbonate is best absorbed with a meal, while calcium citrate can be taken independently of meals and is preferred in cases of achlorhydria or when taking proton pump inhibitors.
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