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Canadian singer KD Lang belts out a song about a "big-boned gal" who moves across the dance floor with vigor and joy. Her "big bones" are the essential frame that gives her the power to dance with confidence and enjoyment. You probably think less about your bones than about many other parts of your body unless you've had the painful experience of a fracture: nothing calls attention to the importance of our bones until we're temporarily unable to use some of them.

Ignoring the health of our bones can have serious consequences. Osteoporosis, sometimes called the "silent disease," often exhibits no symptoms, but it insidiously thins and weakens our bones until we suffer a fracture, the first and only sign that our bones were deteriorating. The fact that osteoporosis exhibits no symptoms confuses many women. According to the National Osteoporosis Foundation, women often believe that stiffness, pain, or joint swelling are symptoms of osteoporosis when in fact these symptoms signal arthritis, an entirely separate condition with different causes and treatments. A woman who does not understand the difference between osteoporosis and arthritis may have a false sense of security because the absence of symptoms may make her believe she is not at risk for osteoporosis. Osteoporosis doesn't kill us; it just causes so much misery that it significantly changes our lives.

Bones are living things, constantly absorbing and casting off substances in processes called resorption, when old bone is removed, and formation, when new bone is developed. If you were to look at a cross-section of a bone, say a bone in your wrist, you would see tiny holes, which means that the bone is porous. Osteoporosis affects our bones by making those tiny holes bigger, so that a cross-section of the same wrist bone with osteoporosis would look much like honeycomb. Osteoporosis causes bones to lose mass and density, lessening their strength and their ability to flex. They become brittle and weak and can easily fracture.
We've all heard horrible stories about bone fractures in older women, or perhaps such an incident has occurred in your own family: the woman who turns to put her toothbrush away and falls, breaking her hip in that simple movement. Or the woman who lifts the Thanksgiving turkey from the oven and fractures both wrists, spending the rest of the holiday in the emergency room. One of my patients, Faith, told a particularly heart-rending story about her mother: her osteoporosis was undiagnosed until an exuberant hug from her grandson cracked two of her ribs.

Hearing about Faith's mother reminded me of a dear friend I had when I was in my early twenties, an older woman who was like a second mother to me. At 51, she fell on a patch of ice and broke her wrist. A smoker, she didn't exercise or take calcium. This happened twenty-five years ago, before the word perimenopause existed. The rest of her story is one of those "if only" tales. If only someone had recognized that her fracture signaled possible osteoporosis. (The sad irony is that she was married to a physician, and not even he realized that her broken wrist was a red flag.) If only she had been educated about exercise, calcium, the risks of smoking, and HRT. She eventually developed emphysema, suffered spinal fractures, and endured debilitating pain. Finally, when she reached 70, her physician suggested that she consider HRT. If only she had known about her options sooner.

This woman's saga, with all of its "if only" scenarios, is, in one sense, a story of the time in which she lived. What happened to her was tragic and avoidable. If she had been a member of our generation, she might have had more information about her health and might have taken proactive steps to reverse the trend indicated by her broken wrist at 51. Yet even today women of perimenopausal age still may not have access to the information they need to ward off the possibility of developing osteoporosis later in life.

While osteoporosis affects both women and men, women suffer from the disease in greater numbers. It's likely that hormonal influences and exercise and eating patterns combine to contribute to the higher incidence of osteoporosis in women. As young girls, we probably participated in fewer sports or other physical activities than boys. We were the spectators, watching our brothers and male classmates build up their muscles and bones. In people of both sexes, most bone mass is built up in the first thirty years of life, and the bone mass of adults is related to how much weight-bearing activity (running, jumping, and so on) we did before we reached 30. This early bone mass development is a good reason to encourage the children in our lives, boys and girls, to get plenty of physical exercise and to make exercise part of our own "playing" with our daughters, sons, nieces, and nephews.

The more bone mass we have, the longer it takes to lose it. Women have smaller body frames than men, with 25 to 30 percent less bone mass, which may also be why women develop osteoporosis earlier in life and more often than men. In addition, the aftermath of "career dieting" can be reduced bone density, particularly if we haven't been careful about getting enough calcium.

Our hormones play a key role in keeping our bones healthy:

- Estrogen promotes the absorption of calcium.

-Estrogen acts on cells in the bones called osteoclasts, which dissolve old bone. The hormone inhibits these cells from dissolving bone at an excessive rate.

- Progesterone has a bone-building effect, acting on osteoblasts, or cells that form new bones.

- The hormone testosterone (usually mentioned in connection with perimenopause only for boosting libido) also builds bone by stimulating osteoblasts.

It is estimated that women lose 50 percent of the bone mass that we are going to lose in our entire lifetime during the first seven years of estrogen depletion. Clearly, estrogen decline is only one factor in this scenario ¡ª progesterone and testosterone also play roles in bone buildup and breakdown. But since we don't know exactly when we start to lose estrogen, we really can't pinpoint the beginning of this bone mass loss. We do know, however, that preventive measures to minimize bone loss can start today.

These statistics from The Osteoporosis Handbook made me sit up and take notice:

- In the United States, more than 1 million fractures result from osteoporosis every year.

- Half of the people who could walk unaided before a hip fracture cannot do so afterward.

- Every year 50,000 deaths result from hip fractures. Deaths occur because of blood clots, pneumonia, and other complications.

- Fifty-four percent of women who are 50 today are expected to have some type of fracture due to osteoporosis during their lifetime.

The bones most affected by osteoporosis are those in our wrists, spinal column (vertebrae), and hips. When the bones in the spine become weak, we can develop spinal fractures, which are extremely painful. You probably have seen women with dowagers humps¡ªthey are hunched over with a distinct curve at the top of their spines. The next time you are in a public place with a lot of people, take a look around¡ªchances are you'll see an older woman with this stooped appearance. She has probably sustained breaks in several of her vertebrae, one on top of another, which ultimately led not only to her shorter stature but also to her prominent hump at the top of her back.

As is the case with heart disease, family history plays a role in women's personal risk for osteoporosis. If your mother broke her wrist when she was in her fifties, had a vertebral (spinal) fracture in her sixties, or broke her hip as she aged, you are more likely to develop osteoporosis than the daughter of a woman who experienced none of these things.

Some medical experts say that if you have a family history of osteoporosis, hormone replacement therapy is a must for you. A calm, calculated assessment of your risks is in order, along with a thoughtful discussion between you and your health care provider.

There are several ways to determine whether you are losing bone too quickly. One way is to have a DEXA, a diagnostic procedure that measures the density of your bones.

- DEXA stands for "dual energy X-ray absorptiometry."

- DEXA is a low-dose X-ray, usually done on the wrist, hip, and a section of the spine.

- DEXA is done with a special X-ray machine, not the regular kind used to X-ray a broken bone.

- Not all health care facilities have DEXA machines.

- A DEXA costs between $150 and $200. Not all insurance companies cover this cost. You may be able to make a successful case by pointing out that the cost of the test is far below the cost of hospitalization for a fracture.

You may want to talk with your health care provider about having a DEXA. If your DEXA test results reveal that you are losing bone mass early and rapidly, you can take several concrete measures to stop bone deterioration. You might want to have a DEXA done now, and then follow it up with another DEXA in a year.

DEXA results are used by women and their health care providers to:

- assess baseline bone density, particularly if the woman has a family history of osteoporosis.

- evaluate whether medication is needed to arrest bone loss or to build back new bone.

- determine if a treatment for bone loss or restoration is effective.

Bone loss can also be detected through a laboratory test that measures bone fragments (deoxypyridinoline) that are released into the bloodstream and then excreted into urine. A special urine test indicates the rate of bone resorption (bone loss) and thereby assesses the condition of your bones.

When Mary and I reviewed her health profile and family history, she mentioned that a friend of hers, also in her forties, had had a DEXA. "Should I have one done too?" she asked.
I told her that measuring bone density or bone loss isn't necessarily routine when we're in our forties. Her decision on whether to have a DEXA or the urine test, I said, would depend on why she wanted the information and how she intended to use it. If bone loss was suspected, either because of a fracture or a very low estrogen level, a bone study might provide important additional information.

Right then there was no immediate red flags that said Mary should have a bone study. But her low estrogen and progesterone levels (both may affect bone loss), combined with the fact that she rarely exercised, raised her own concern that her bones could be thinning. She did take calcium to supplement a diet that wasn't always the healthiest. Now it was as if the attention she had focused on her perimenopausal mood changes and her drop in sex drive had also piqued her curiosity about her overall health.

Since she had had her hormones measured with the simple saliva test, she said, the urine test to measure bone loss appealed to her. She could do it the same way¡ªat home, without missing time at the office. I said I appreciated her wanting to save time, but that time spent on her health would be an investment she could easily justify. I wasn't necessarily advocating that she have the DEXA, which requires a visit to a medical facility, instead of the urine test; I just wanted to reinforce the point that we are never "too busy" to monitor our health.
The results of Mary's urine test showed that the rate of her bone breakdown was not excessive¡ªsomething she was relieved to hear. Her bones didn't show any damage that she needed to try to reverse. So she could look at the gradual lifestyle changes she was making in her eating and exercise routines as a means of maintaining good health.

Faith also had the urine test to detect bone loss because we had more to be concerned about in her case. If you recall, her mother had severe osteoporosis and suffered a broken rib. In addition, Faith's saliva test for progesterone and estradiol levels showed that she was very deficient in both hormones. The results of her urine test for bone breakdown weren't what we would have preferred. Normal values are between 3 and 6.5, and anything above 6.5 indicates abnormally rapid bone breakdown. At age 40, Faith's results were right at 6.5, the very highest we would want them to be. She looked stricken as we talked about her test results. Almost in a whisper she asked, "Will I have to be careful about having my son hug me, just like my mother?"

Not in the least, I assured her. "There's plenty we can do right now, not only to slow the rate of bone breakdown but to build back some of the bone you've lost." I told her about some self-care options she could begin that day: extra calcium, more weight-bearing exercise, follow-up testing in a month, and if bone breakdown continued to accelerate, natural progesterone. She asked me for an extra copy of these steps. "I want to send it to my mother," she said. "I don't know if she's been made aware of all of these things." Faith felt encouraged about her ability to strengthen her body, and she was also going to network within her own family to be sure her mother had all the information and options she did.