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Photoshop can’t “fix” bones (bone health part II)

With the right software program, a couple of minutes, and a little skill, we can transform the girl in the picture on the left to the girl on the right.

That’s right! Photoshop can fix or manipulate many things within just a matter of minutes, making the enhanced version appear even better than the original!

Unfortunately, even with the right equipment and ample skill, a fractured hip can’t be repaired as quickly or as easily. Broken bones are painful at any age and weak bones can be deadly for the older population. Statistics clearly show that hip fractures are associated with loss of independence, decreased quality of life, financial burden and frequently death. In fact, it is estimated that 14 to 58% of people will die within a year following a hip fracture.

If the prime time for calcium deposition has passed (if you are older than age 30), you can still decrease the risk of a fragility fracture by…

#1. Being aware of your bone health
#2. Evaluating your risk for fracture
#3. Discussing treatment options
#4. Evaluating what is the best treatment for you

This article discusses bone health, risk factors associated with osteoporosis and subsequent fracture, and treatment options.

Bone Mineral Density (BMD) is a test that uses

X-ray technology to measure the number of minerals (specifically calcium) in the bone that reflects the strength of the bone.  A normal BMD is defined as a T-score greater than -1.0.  Osteopenia or mild bone loss is reflected via a T-score between -1.0 to -2.5 and individuals diagnosed with osteoporosis have a T-score of -2.5 or lower.  The majority of fragility fractures occur in patients with bone mineral density in the osteopenic range.

Bone Mineral DensityT-score
Normal-1.0 and above
Osteopenia (low bone density)-1.0 to -2.5
OsteoporosisLess than -2.5

Measuring the BMD is typically evaluated through a medical test called a dual-energy x-ray absorptiometry, otherwise known as a DEXA scan.  It is a simple, painless test that takes about 5 to 10 minutes to perform.  Typically, a DEXA scan should be done at age 65 for healthy women who are not at particular risk for osteoporosis. Depending on risk factors, it may need to be done earlier or be repeated every two to five years after the initial evaluation.


There are several known risk factors that can increase the risk of fracture.  These are:

  • significant weight loss or lower body weight (women < 127 pounds)
  • smoking
  • family history of fractures
  • decreased physical activity
  • alcohol or caffeine use
  • low calcium and vitamin D intake (especially vegans, those with lactose intolerance, disease of the digestive system causing absorption issues or those who consume large amounts of protein or sodium causing excess secretion of calcium through the urine)
  • long-term corticosteroid use

The Fracture Risk Assessment Tool (FRAX) was developed in 2008 by lead researchers involved with bone health in a combined effort with the World Health Organization (WHO) to improve the predictability of assessing patients with low bone density and risk for fracture.  Although the FRAX calculator has not been proven in randomized controlled trials to be beneficial, it is a widely used tool in the treatment decision-making process throughout the world.

Advancing age is the most important risk factor in developing a low BMD. 

The FRAX is a helpful tool in assisting the decision making process regarding pharmaceutical treatment.

The American College of Obstetricians and Gynecologists (ACOG) and the American College of Physicians (ACP) recommend that women who have known osteoporosis should be treated with prescription medication.  If a woman falls into the low bone mass category (T-score between -1 and -2.5) the FRAX tool can assist the woman and provider in making a treatment decision.  Generally, if a woman is at increased risk of experiencing a hip fracture or other major fractures in the upcoming 10 years, treatment with medication is recommended.

Prescription medication is recommended when the FRAX calculator predicts a ten-year risk of:

a hip fracture of 3% or more
a major fracture of 20% or greater


All women should be getting adequate amounts of calcium, vitamin D and participating in a weight-bearing activity on a regular basis.  Ideally, this is done through a healthy diet.  However, over-the-counter supplements may be necessary for many individuals.

menopausal women – 1,200 mg/d ≈4 cups of milk or calcium equivalents

women with low bone density (osteopenia) – 1,500 mg/d

women at risk for fracture (osteoporosis) – 1,500 mg/d

All need vitamin D – 1,000 to 2,000 IU/d

All need regular weight-bearing and bone-strengthening exercise
(ie: walking, jumping rope, hiking, dancing, yard work, elliptical machine, elastic bands, free weights or weight machine)

All will benefit from exercises, such as Tai Chi or Yoga, that will improve coordination, flexibility and strengthen muscle, decreasing the chance of a fall.

Women who have a lower bone density should discuss the risks and benefits of starting a prescription medication, along with the above lifestyle modifications.  When medication is initiated, treatment often continues for three to five years and there is no benefit in continued DEXA testing during this period. Evidence shows that even if no increase in BMD occurs, women still have fewer fractures when treated with pharmacologic treatment.

The prescription medication works by slowing down the destructive process of the bone matrix, hence the cells that build bone are able to work more effectively.  It can be given via tablets that are taken weekly or monthly, through an injection every 3 months or an annual infusion directly into the bloodstream.

If oral tablets are used, it is important to take the medication on an empty stomach with a full glass of water and remain upright for 30 minutes afterward in order to allow for proper absorption and the least amount of side effects. Your dentist should be aware of the medication you are taking and regular dental check-ups are important to detect a rare side effect that decreases the blood flow to the jawbone.  Heartburn or difficulty swallowing should be reported to your provider and calcium and vitamin D need to be continued during the course of treatment.  Use caution with other medications (ie: ibuprofen or aspirin) that may cause more irritation to the stomach and esophagus.


Personal risks and coexisting conditions should be discussed when deciding how aggressive treatment needs to be.  When symptoms of menopause need to be treated, hormone therapy will also help maintain bone mass.  Clinicians believed that when a woman stopped hormone therapy the rate of bone loss would increase at the same rate after stopping hormones as it would with natural menopause.  However, further analysis and reanalysis of the Women’s Health Initiative (WHI) trial data shows that even 5 years later, women who stopped hormone therapy had no increase in the hip or total fractures.  This suggests a residual benefit in reducing bone fractures for even several years after cessation of hormone therapy.

Risk and treatment need to be individualized for each woman.  Talk to your provider if you have questions regarding your bone health. 

To succeed in life,
you need three things:

a wishbone,
a backbone
and a funny bone.

-Reba McEntire

Haley Pledger, PA
Women’s Care
Matthew Walton, DO
Austin Bills, DO
Family Medicine
Aaron Fausett, PA
Family Medicine
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