Osteoporosis is a major cause of disability, but many women don’t realise they’re at risk until it’s too late. Photo / 123RF
Half of women over 50 are expected to break a bone due to osteoporosis.
In the UK summer of 2022, Gaynor Fraser was standing at the back of church beside her husband when suddenly she keeled over. She thought it was the heat, dehydration and a drop in blood pressure. Instantly, she was in agony – Gaynor has a high pain threshold and gave birth to two children with little pain relief but now she was screaming.
“I remember looking at my legs, seeing that my left was shorter than my right and my foot was externally rotated,” she says.
As a retired nurse, she knew that her hip was broken. The ambulance arrived after 90 minutes, and once in hospital, the nerve blocks she was administered actually made the pain worse.
“By then, I was literally asking them to shoot me,” she says.
Until that day, Gaynor, then 60, was fit and active. After stepping back from nursing, she began working as a healthcare assistant. She cycled, went to the gym and walked so fast that her husband called her “the whippet”. She regularly jumped in the car or train to travel from her Northumberland home to Hampshire to visit her son who has autism and mental health problems.
All this changed in an instant. In fact, Gaynor didn’t see her son for the next eight months. The recovery process took two operations, regular physio (in the end, she went private for physio) and 20 months off work.
Gaynor was still walking with a stick almost two years after the accident and in the midst of all this, she learnt the real reason for the fracture. Gaynor had severe undiagnosed osteoporosis, with bone density so low that she was at high risk of breaking another bone. It was as if she’d been catapulted 20 years forward into frailty and old age.
“My anxiety was sky high,” she says. “I felt like a burden. I was terrified of going out.”
But Gaynor had every reason to be anxious. A third of people who fracture their hip die within a year, and 10% die within a month. Between 10 and 20% who fracture a hip when living at home will move to institutional care.
Broken bones aren’t just a temporary inconvenience. They are the fourth worst cause of disability and premature death in the UK and the second greatest filler of adult hospital beds. Untreated osteoporosis is usually the cause – yet YouGov research found that 52% of people have never considered they might have it.
Women are especially vulnerable – half of women over the age of 50 are expected to break a bone because of osteoporosis (compared to one-fifth of men). The complications caused by this condition kill as many women as breast cancer. There are effective preventative treatments but few women realise they might need them, nor is there a national screening system to identify those at risk. For this reason, experts believe middle-aged women are sitting on a bone health time bomb.
Dr Nicky Peel, a consultant in metabolic bone medicine and trustee for the Royal Osteoporosis Society, says men and women start out with similar bones and hit peak bone mass in their 30s. By then, men’s skeletal size and bone density tends to be greater, a disparity believed to be a result of the hormone surges that come with puberty. So men already have stronger bones when gradual age-related decline sets in – and for women, this decline is turbocharged by menopause. An early menopause is a particular risk factor.
“We tend to think of bones as a coat hanger but actually they are dynamic and active,” says Peel. “Bone turnover occurs all through life, with bone being broken down and filled with new bone. Oestrogen plays an important role in this so during menopause when oestrogen levels decline, there’s a period of three to five years where bone renewal really falls behind the rate of bone loss. It can add up to quite a big deficit.”
Age is another factor. Women tend to live longer and are more likely to experience the lower bone strength that comes with old age.
Data over the last 20 years shows a significant drop in our consumption of key nutrients in the UK. According to the Health and Food Supplements Information Service, calcium and folate intake have both fallen by 10%, while intake of vitamin D has declined by more than 20%. Calcium is important for building bone – but a range of nutrients is required to absorb and use it.
“Bones get stronger when we use them,” says Dr Peel. “The sedentary lifestyle, even working from home and not going outside and getting vitamin D all impact bone health. Research suggests that there’s been a rise in alcohol intake too.” This slows down bone cell turnover, vitamin absorption and the production of oestrogen and testosterone, all of which are crucial for strong bones.
Smoking also reduces the production of new bone, and research has indicated a rise in smoking amongst middle-class women.
“A range of health conditions can increase osteoporosis risk, including ones that affect food absorption like Crohn’s or coeliac,” says Dr Peel. “There are also many medications that can impact bone health, like steroids for asthma or arthritis.”
Genetics plays a part too. Having a parent who has suffered a hip fracture is a significant risk factor.
There are excellent treatments to slow the rate that bones break down, speed up the process of bone renewal and reduce the risk of further fractures by between 50 and 90%. However, in the UK, systems to identify the people who need them are patchy and postcode dependent. Health and Social Care Secretary Wes Streeting has promised to remedy this with a national roll out of “fracture liaison services”. He said that it would be one of his first acts in the post, but five months into power, nothing has emerged.
Most experts are calling for targeted assessment, where people most at risk are invited to have bone density measured by a dual energy X-ray absorptiometry (Dexa) scan which assigns a T-score, where above -1 is healthy and below -2.5 is considered to be osteoporosis.
In the meantime, it’s possible to understand your own risk through the Royal Osteoporosis Society’s risk checker. Anyone who believes they could be at high risk should speak to their GP about a Dexa scan, or at least, a risk-assessment such as the Frax tool which looks at a very wide range of factors to give the 10-year probability of an osteoporosis fracture.
Even Gaynor almost missed out on a diagnosis. Despite breaking a hip from a fall from standing height, she was not initially offered a Dexa scan, nor was there any discussion about bone health or why this fracture happened. (She later asked the orthopaedic surgeon who had operated on her why this was and he replied, “We don’t deal with bone health, we just fix you.”)
It was only because her recovery was so slow that Gaynor was eventually transferred to the elderly care ward, and it was here that a Dexa scan was arranged.
“I had the scan in October and was told, ‘If you don’t hear anything, it means everything is fine’. By December, I’d heard nothing but decided to check. Only when I chased it did my GP call in a panic to tell me I had osteoporosis.”
In January, Gaynor was referred to a rheumatologist. Finally, in May last year, nine months after the fall, she began taking the drug treatment romosozumab. Several other factors may have increased her risk. Gaynor’s mother had fractured a wrist in her late 60s so genetics may have played a role. Gaynor is also a vegan and is now taking vitamin D and calcium supplements. Her latest Dexa scan showed that her bone density is improving.
There are a range of steps we can take to protect bone health. “A balanced diet with calcium, a healthy amount of protein and fresh fruit and vegetables, as well vitamin D supplements to help utilise the calcium is important,” says Dr Peel. “Regular exercise, especially weight bearing and muscle strengthening exercise, builds strong bones.”
Keeping alcohol consumption down and not smoking are also key. Women who have early menopause should consider HRT which mimics oestrogen and reduces fracture risk.
For Gaynor, recovery is ongoing. “For a long time, I was relying on my husband to do everything – the cooking, the housework, the driving. He literally had to lift my leg into bed. My statutory sick pay ended after 28 weeks so there was a huge financial impact too.
“Ten months after the first operation, I still needed two crutches. Then I only needed a stick. Now I’m walking unassisted but with a slight limp.”
Gaynor returned to work in April this year. She is cycling again and at the gym two or three times a week.
“I’m still cautious,” she says. “If it’s icy, I’m very careful. At the back of my mind, I’m always thinking, ‘Could it happen again?’ I’m very aware of trip hazards and I don’t work in the emergency department because it’s so busy. I’m worried that someone will knock me over.
“But I’m getting out of the house, I’m visiting my son every month and I’ve got my identity back. All of that is wonderful. I hadn’t given bone health a thought, but my life changed in an instant. I don’t take it for granted now.”
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