Osteoporosis is a chronic, progressive, and silent disease of the skeletal system that leads to reduced bone mineral density and altered bone microarchitecture, resulting in bone fragility and an increased risk for fracture. Although classically associated with postmenopausal women, this condition can also affect women younger than 50 years and men.

Speaking with Univadis Spain, part of the Medscape Professional Network, and coinciding with World Osteoporosis Day on October 20, the Spanish Society of Internal Medicine (SEMI) emphasized the importance of evaluating potential causes and risk factors for osteoporosis in premenopausal women and men. “The problem is that because osteoporosis is a silent disease typically associated with women over 50, other at-risk groups often do not consider the possibility of osteoporosis. Therefore, anyone who meets certain criteria — such as smoking, prolonged cortisone use, excessive alcohol consumption, hypogonadism, thyroid or parathyroid disorders, breast cancer, or a family history of osteoporosis — should consult a physician to request a bone density scan, the gold standard for diagnosis ” said Maria Magdalena Femenías Sureda, MD, Department of Internal Medicine, Hospital Universitari Son Espases, Palma de Mallorca, Spain.

She noted that the silent nature of the disease and its association with women older than 50 years mean that other risk groups often do not suspect they have osteoporosis. “That is why it is important that people who meet certain characteristics such as tobacco use, prolonged corticosteroid therapy, excessive alcohol intake, hypogonadism, thyroid or parathyroid disorders, breast cancer, or a family history of osteoporosis attend clinic to request a densitometry, the reference tool for diagnosis,” she said.

Screening Test

Bone densitometry is a noninvasive test that measures bone mineral density, primarily at the spine and hip, to evaluate the risk for osteoporosis and fractures. The technique uses low-dose x-rays at two energies to estimate the proportion of mineralized bone vs soft tissue.

Bone densitometry is recommended for individuals with risk factors such as advanced age; postmenopausal status; family history of hip fracture; prior fragility fracture; metabolic bone disease such as rheumatoid arthritis; endocrine, hepatic, or renal disorders; or prolonged exposure to medications such as corticosteroids.

It is also useful for monitoring the response to treatment with antiresorptive agents, which inhibit bone resorption and are commonly used in postmenopausal osteoporosis, or with bone-forming therapies, which stimulate bone formation and are indicated for severe osteoporosis or for individuals with multiple fragility fractures.

Primary Care Barriers

Primary care is the main entry point for patients with osteoporosis. Several barriers complicate the screening of young men and women for osteoporosis.

“Many primary care clinicians, despite rising awareness, do not identify younger women or men who belong to the risk groups for osteoporosis. A high patient volume in primary care settings complicates screening workflows, even if patients want to be screened using bone density scans. In many autonomous communities, tests are prescribed only by specialists. This lengthens the process by several months, or even a year: a consultation with the primary care physician who must refer the patient to a specialist, waiting for an appointment with the specialist, requesting the bone density scan, waiting to have the test done, and then waiting again for the test to be evaluated and, if necessary, for treatment to begin,” said Femenías.

Although osteoporosis is usually associated with postmenopausal status, premenopausal women may develop osteoporosis when factors affect bone metabolism. These include endocrine disorders, such as primary hyperparathyroidism, hyperthyroidism, hypercortisolism, and hypogonadism; chronic inflammatory or rheumatological diseases, such as rheumatoid arthritis or systemic lupus erythematosus; intestinal malabsorption; and prolonged use of bone-depleting drugs, such as glucocorticoids, chemotherapy, aromatase inhibitors, or selective estrogen receptor modulators.

In premenopausal women, bone density is usually maintained by the protective effect of estrogen; however, these conditions can significantly reduce bone density and increase the risk for fracture. Therefore, it is essential to exclude secondary causes of osteoporosis.

“There are cases in which osteoporosis can be reversible and even cured, for example, when the cause is prolonged drug exposure and that drug is discontinued, provided osteoporosis is treated appropriately,” the SEMI spokesperson noted.

Despite these concerns, the World Health Organization does not recommend routine bone density screening in premenopausal women, except in cases of fragility fractures or suspected secondary causes of osteoporosis.

Treatment should focus on correcting the underlying causes, optimizing lifestyle (adequate calcium and vitamin D intake, regular exercise, and avoidance of toxic exposure), and using antiresorptive or anabolic agents only on an individual basis, with particular caution in women of childbearing potential.

Osteoporosis and fragility fractures are less common in men than in women; however, their consequences are often more serious. After hip fractures, men have higher morbidity and disability, increased need for care, and higher mortality. In men, osteoporosis is associated with older age and secondary risk factors, such as hypogonadism (low testosterone), alcohol and tobacco use, corticosteroid therapy, and chronic diseases, including hepatic, renal, rheumatological, and respiratory disorders, such as chronic obstructive pulmonary disease.

Raising Awareness

Osteoporosis is a serious chronic condition that requires awareness at various levels. “First, people belonging to at-risk groups are aware that they are members of a risk group and consequently seek medical consultation. Second, among medical professionals, there are still primary care physicians who do not give osteoporosis the importance it deserves and are unaware that osteoporosis must always be treated in every case. Finally, among healthcare administrators and government officials, osteoporosis should be included in the list of chronic diseases, which currently has protocols and a system for treating chronic patients in which osteoporosis is not fully included, despite being a very prevalent chronic disease,” Femenías said.

“To this end, at SEMI, we have issued press releases to help the media reach the public, held clinical sessions, and visited primary care centers to inform and remind clinicians how to identify high-risk patients. The results are encouraging: The number of people attending specialist consultations has doubled, whether they come on their own initiative or are referred by other professionals,” the SEMI spokesperson said.

Femenías reported having no relevant conflicts of interest.

This story was translated from Univadis Spain.