PCOS and Osteoporosis

Individuals with PCOS may have an increased risk of osteoporosis, a condition associated with reduced bone mineral density (BMD) to the point where bones become weak and brittle.[1] In this article we explore the link between PCOS and Osteoporosis.

Loss of BMD occurs naturally after it reaches it peak between the ages of 25 and 30 it is estimated that 1/3 of adults over the age of 50 have some degree of bone density loss.[2] Untreated, the loss of BMD can progress to osteoporosis, increasing the risk of breaking a bone, especially from falls.[3]

PCOS is linked to lower BMD overall through a number of potential mechanisms:

Reduced estrogen levels leads to increased bone resorption at a higher rate than bone formation and therefore a net loss in BMD;[4],[5]
Insulin resistance, alone or in combination with hyperinsulinemia, elevated levels of circulating insulin in the blood, can interfere with the usual bone formation response to weight-bearing activities leading to reduced bone density;[6],[7]
Obesity, particularly central adiposity (accumulation of fat around the middle), is associated with increased risk of lower BMD although increased body weight can strengthen bones due to the biomechanical forces exerted on the bones;[8],[9]
Chronic low-grade inflammation results in increased bone resorption and reduced bone formation;[10],[11]
Vitamin D deficiency resulting in a failure to utilize calcium effectively to build and maintain bone structure;[12]
Potassium deficiency has been linked with lower BMD as potassium is believed to prevent calcium loss from bone;[13] and
Magnesium deficiency leads to decreased osteoblastic and osteoclastic activity and is linked with reduced BMD.[14]

Some aspects of PCOS partially counteract these effects by contributing to increased BMD:

During adolescence, elevated androgen levels increase longitudinal and radial bone growth, leading to increased bone mass;[15]
Throughout adult life, elevated androgen levels increase osteoblast differentiation, the process whereby bone marrow mesenchymal stem/stromal cells form cells that grow and heal bones, assisting with maintenance and repair of bone tissue;[16],[17] and
Hyperinsulinemia, elevated levels of circulating insulin in the blood, can stimulate bone growth.[18]

Other risk factors for osteoporosis include:[19]

Increasing age, with individuals over the age of 50 most at risk;
Being female, with women being at significantly increased risk;
Being of Caucasian or Asian ethnicity;
Having a family history of osteoporosis;
Having a small body frame with less bone mass to draw from as aging;
Being post-menopausal, with the corresponding drop in estrogen levels;
Smoking or using tobacco products;
Consuming more than two alcoholic drinks per day;
Conditions that are associated with a lack of calcium in the diet and therefore depletion of calcium from bones, including eating disorders, malnutrition, being post gastrointestinal surgery and calcium deficiency;[20]
Vitamin D deficiency and certain medications such as proton pump inhibitors (PPIs), used to treat acid reflux, can lead to reduced calcium absorption;
Chronic kidney disease (CKD), where the kidney’s ability to regulate calcium, phosphorus and vitamin D is compromised;[21]
Cushing’s syndrome and other conditions associated with elevated cortisol lead to decreased bone formation and increased bone resorption and therefore net loss in bone mass;[22]
Hyperthyroidism, an elevated level of thyroid hormones, or overtreatment of hypothyroidism can accelerate bone remodeling and lead to a net loss in bone mass;[23]
Rheumatoid arthritis and other autoimmune conditions associated with chronic inflammation (particularly in the joints) as well as some of the medications used to treat them such as corticosteroids can lead to increased bone resorption;[24],[25]
Diuretics, used to reduce fluid buildup in the body, and other medications that cause calcium to be excreted in urine can lead to decreased bone formation and increased bone resorption and therefore net loss in bone mass;[26],[27]
Anti-seizure medications (ASMs), used to treat epilepsy, can increase the metabolism of vitamin D and lead to reduced calcium absorption;[28]
Hormone therapy for prostate cancer reduces testosterone levels and can lead to decreased bone formation and increased bone resorption and therefore net loss in bone mass;[29]
Hormone therapy for breast cancer reduces estrogen levels and increases the risk of osteopenia;[30] and
Anticoagulants such as warfarin reducing blood clotting by interfering with the action of vitamin K and are therefore believed to result in reduced bone density.[31]

Prior to fracture, osteoporosis doesn’t have any symptoms and is diagnosed via a bone density scan called dual-energy x-ray absorptiometry (DXA).[32] A BMD score of less than -2.5 is classified as osteoporosis and a score between -1 and -2.5 is classified as osteopenia.[33]

The first line treatment for osteoporosis is often lifestyle modifications, including:[34]

Increasing calcium, vitamin D and protein intake in your diet;
Reducing or eliminating tobacco, alcohol and caffeine intake;
Reviewing medications for potential risk factors for bone loss and/or falls;
Introducing or increasing weight bearing, strength training and balance exercises;[35] and
Fall prevention measures including modifications to the home environment and up to date vision care.

Medications that can be used to treat osteoporosis include:

Calcium and vitamin D supplements;[36]
Bisphosponates such as denosumab and calictonin, medications that reduce the activity of osteoclasts, thereby slowing bone resorption;[37] and
Hormone replacement therapy (HRT) for postmenopausal women to maintain estrogen levels.[38]

A number of medical devices are available or under development for the treatment of osteopenia and/or osteoporosis:

Bone stimulators such as the SpinalStim Spinal Fusion Therapy by Orthofix® provide stimulation to accelerate post-surgical recovery;[39]
Osteoboost has developed a vibrating belt that promotes bone growth to reduce the loss of bone density on people affected by osteopenia;[40] and
KAT Innovation is developing OSTAAT™, smart clothing that integrates electrical stimulation to promote bone growth and increase bone density. [41]

Reviewed by Marcel Maroist, CEO and founder of KAT Innovation

PARTNER SPOTLIGHT

KAT Innovation develops and markets cutting-edge technologies to address unmet healthcare needs. OSTAAT™ smart clothing is a novel non-invasive treatment for osteopenia and osteoporosis that delivers low-frequency electrical stimulation to increase bone density.

Reviewed by Marcel Maroist, CEO and founder of KAT Innovation

PARTNER SPOTLIGHT

Sources

[23] chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://healthybonesaustralia.org.au/wp-content/uploads/2022/10/hba-fact-sheet-thyroid.pdf

PCOS and Osteoporosis