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How does PCOS impact bone health? 

According to the 2014 study on Bone Mineral Density in Women with PCOS, individuals with PCOS have significantly lower bone mineral density. 


Individuals with PCOS may have an increased risk of osteopenia and osteoporosis, conditions associated with reduced bone mineral density (BMD).[1]  Osteoporosis is where osteopenia progresses to the point where bones become weak and brittle.[2]  In this article we explore the link between PCOS and Bone Health. 

 

Loss of BMD occurs naturally after it reaches it peak between the ages of 25 and 30 and it is estimated that 1/3 of adults over the age of 50 have some degree of bone density loss.[3]  Untreated, osteopenia can progress to osteoporosis, increasing the risk of breaking a bone, especially from falls.[4] 

 

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

  • Reduced estrogen level leads to increased bone resorption at a higher rate than bone formation and therefore a net loss in BMD;[5][6] 

  • Insulin resistance, alone or in combination with hyperinsulinemia, an elevated level of circulating insulin in the blood, can interfere with the usual bone formation response to weight-bearing activities leading to reduced BMD;[7][8] 

  • 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;[9][10] 

  • Chronic low-grade inflammation results in increased bone resorption and reduced bone formation;[11][12] 

  • Vitamin D deficiency results in a failure to utilize calcium effectively to build and maintain bone structure;[13]  

  • Potassium deficiency has been linked with lower BMD as potassium is believed to prevent calcium loss from bone;[14] and 

  • Magnesium deficiency leads to decreased osteoblastic and osteoclastic activity and is linked with reduced BMD.[15] 

 

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;[16] 

  • 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;[17][18] and 

  • Hyperinsulinemia, elevated levels of circulating insulin in the blood, can stimulate bone growth.[19] 

 

Other risk factors for bone health include:[20][21] 

  • Increasing age, with individuals over the age of 50 most at risk; 

  • Being female, with women at 4x increased risk of developing osteopenia; 

  • 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 and calcium deficiency;[22] 

  • 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;[23] 

  • 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;[24] 

  • Hyperthyroidism, an elevated level of thyroid hormones, or overtreatment of hypothyroidism can accelerate bone remodeling and lead to a net loss in bone mass;[25] 

  • 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;[26][27] 

  • Use of 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;[28][29] 

  • Use of anti-seizure medications (ASMs), used to treat epilepsy, can increase the metabolism of vitamin D and lead to reduced calcium absorption;[30] 

  • Hormone therapy for breast cancer reduces estrogen levels and increases the risk of osteopenia[31] (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);[32] 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.[33] 

 

Osteopenia doesn’t have any symptoms and is diagnosed via a bone density scan called dual-energy x-ray absorptiometry (DXA).[34]  A BMD score of between -1 and -2.5 is classified as osteopenia and a score less than -2.5 is classified as osteoporosis.[35] 

 

The first line treatment for osteopenia or osteoporosis is often lifestyle modifications, including:[36][37] 

  • Increasing calcium, vitamin D3 (a type of vitamin D found mainly in animal products) and protein intake in your diet;[38] 

  • 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;[39] and 

  • Fall prevention measures including modifications to the home environment and up to date vision care. 

 

Medications that can be used to treat osteopenia and osteoporosis include: 

  • Calcium and vitamin D3 supplements;[40]  

  • Bisphosphonates such as denosumab and calcitonin, medications that reduce the activity of osteoclasts, thereby slowing bone resorption;[41] and  

  • Hormone replacement therapy (HRT) for postmenopausal women to maintain estrogen levels.[42] 

 

Sources
[1] https://pmc.ncbi.nlm.nih.gov/articles/PMC4245449/ 
[2] https://www.sciencedirect.com/science/article/abs/pii/S0024320523009153 
[3] https://my.clevelandclinic.org/health/diseases/21855-osteopenia 
[4] https://my.clevelandclinic.org/health/diseases/21855-osteopenia 
[5] https://pmc.ncbi.nlm.nih.gov/articles/PMC4245449/ 
[6] https://pmc.ncbi.nlm.nih.gov/articles/PMC3424385/ 
[7] https://onlinelibrary.wiley.com/doi/10.1002/jbmr.2083 
[8] https://www.reuters.com/article/business/healthcare-pharmaceuticals/insulin-resistance-linked-to-lower-bone-density-idUSKBN1AA1S5/ 
[9] https://pmc.ncbi.nlm.nih.gov/articles/PMC7493444/ 
[10] https://www.sciencedirect.com/science/article/pii/S0015028299002034 
[11] https://www.sciencedirect.com/science/article/abs/pii/S1094695022000117 
[12] https://pmc.ncbi.nlm.nih.gov/articles/PMC1308846/ 
[13] https://pubmed.ncbi.nlm.nih.gov/16907998/ 
[14] https://pmc.ncbi.nlm.nih.gov/articles/PMC6997142/ 
[15] https://www.sciencedirect.com/science/article/pii/S0002916523050293 
[16] https://academic.oup.com/edrv/article-abstract/25/3/389/2355220 
[17] https://www.sciencedirect.com/science/article/pii/S0015028202029680 
[18] https://pubmed.ncbi.nlm.nih.gov/33307974/ 
[19] https://www.sciencedirect.com/science/article/pii/S2589936824000628 
[20] https://my.clevelandclinic.org/health/diseases/21855-osteopenia 
[21] https://www.mayoclinic.org/diseases-conditions/osteoporosis/symptoms-causes/syc-20351968 
[22] https://www.niams.nih.gov/health-topics/calcium-and-vitamin-d-important-bone-health# 
[23] https://www.niddk.nih.gov/health-information/kidney-disease/mineral-bone-disorder 
[24] https://pubmed.ncbi.nlm.nih.gov/9648484/ 
[25] chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://healthybonesaustralia.org.au/wp-content/uploads/2022/10/hba-fact-sheet-thyroid.pdf 
[26] https://pmc.ncbi.nlm.nih.gov/articles/PMC8476196/ 
[27] https://www.hss.edu/conditions_rheumatoid-arthritis-bone-health-osteoporosis-what-you-need-know.asp 
[28] https://pubmed.ncbi.nlm.nih.gov/16355285/ 
[29] https://osteoporosis.ca/medications-that-can-cause-bone-loss-falls-and-or-fractures/ 
[30] https://www.uptodate.com/contents/antiseizure-medications-and-bone-disease 
[31] https://www.endocrine.org/patient-engagement/endocrine-library/breast-cancer-and-bone-loss 
[32] https://www.nejm.org/doi/full/10.1056/NEJMoa2308836 
[33] https://www.ahajournals.org/doi/10.1161/JAHA.119.013845 
[34] https://www.ncbi.nlm.nih.gov/books/NBK499878/ 
[35] https://www.ncbi.nlm.nih.gov/books/NBK499878/ 
[36] https://www.health.harvard.edu/womens-health/osteopenia-when-you-have-weak-bones-but-not-osteoporosis# 
[37] https://theros.org.uk/information-and-support/osteopenia/ 
[38] https://www.webmd.com/diet/foods-high-in-vitamin-d3 
[39] https://www.getwellen.com/well-guide/the-best-osteopenia-exercises 
[40] https://my.clevelandclinic.org/health/diseases/21855-osteopenia  
[41] https://myhealth.alberta.ca/Health/pages/conditions.aspx?Hwid=te7592 
[42] https://pubmed.ncbi.nlm.nih.gov/11910657/ 

Causes - Bone

PCOS and Bone Health

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