How healthy are your bones?
Diagnostic tests to find what causes osteoporosis
by Dr. Susan Brown, PhD
One of the basic principles of the Better Bones Program® is that
all osteoporosis, all excessive bone loss, or all real increased risk of low-trauma
fracture has a cause. There are a number of medical problems that can cause, or
contribute to, bone loss. To better understand any undetected causes of bone
loss, it is important to obtain a medical work-up — that is, further tests
that can help find the causes of osteoporosis. A simple osteoporosis work-up consisting
of tests for the most common conditions leading to bone loss can be ordered by your
physician. At the Center for Better Bones, in addition to the standard DEXA bone
density test, we like to see the following tests included in an osteoporosis work-up.
We suggest that our clients discuss these tests with their doctor to see which ones
are appropriate for them and take a look at our article on Understanding
Your Osteoporosis Test Results for further information.
Vitamin D 25(OH)D blood test
This test determines your blood level of vitamin D. The results of
this test allow us to know the amount of vitamin D supplementation needed to reach
a therapeutic blood level of vitamin D, which is important for adequate calcium
absorption and basic bone support.
Ionized calcium test
This is a simple blood test to measure the level of free calcium — that is, the metabolically
active portion of calcium not bound to proteins in the blood. This test is not meant
to assess the appropriateness of your calcium intake as much as it is meant as an
indirect test of parathyroid functioning (see below). It can also indirectly tell
us some things about vitamin D status.
Intact parathyroid hormone blood test (iPTH)
High parathyroid hormone levels are associated with excessive bone loss, as an overactive
parathyroid gland draws calcium from bone. The medical reasons for this overactivity
need to be addressed to halt the excessive bone loss. Also, a normal parathyroid
reading in the face of vitamin D deficiency can indicate magnesium inadequacy, as
I discuss in one of my on-line blog posts on the topic of Parathyroid Hormone
24-hour urine calcium excretion test
This test looks at how much calcium is being excreted in the urine. For this test,
you collect all your urine over 24 hours in a large container for laboratory analysis
to measure the amount of calcium in the total volume of urine. Excessive urinary
calcium excretion is a common cause of bone loss and osteoporosis.
Thyroid hormone function test (TSH)
TSH testing is a measure of thyroid function, which can screen for under- or overactive
thyroid conditions. Thyroid hormone levels that are too high or too low can contribute
to osteoporosis, as can a dose of thyroid medication that is too high.
Markers of bone resorption tests
Bone resorption (or breakdown) tests measure the amount of one specific bone protein
in the urine or blood. As one loses bone this bone protein fragment shows up in
the urine and blood in increased amounts. At the Center for Better Bones, we generally
use the N-telopeptides crosslinks (NTx) urine test from Osteomark, but there are
several other reliable urine and blood tests now available. One commonly used test
is the urine Dpd test (deoxypyridinium crosslinks test). There is also an NTx serum
test and a newer test, the CTX serum test, which is often used in research these
As there can be a great deal of day-to-day variation in urine bone breakdown markers,
we have developed at the Center for Better Bones a two-day collection procedure
for bone resorption testing for greater accuracy. These instructions can
be used for either the urine NTx or the Dpd test. For further details on bone resorption
testing, see my article on assessing bone breakdown and loss.
Vertebral deformity assessment
Just as the bone density test, this is another x-ray test for bone. This test, however,
images each vertebral body of the spine and looks to see if there are deformities
or fractures. The Vertebral Deformity Assessment can be done on newer bone density
testing machines, with special software that takes a “lateral” view of the spine.
This new spine x-ray can also be done and interpreted by knowledgeable radiologists
using other x-ray technology.
Free cortisol test (blood or saliva)
Cortisol is a corticosteroid hormone produced by the adrenal cortex, which is part
of the adrenal glands. It is usually referred to as the “stress hormone” as it is
involved in response to anxiety and stress. Abnormally high cortisol levels are
damaging to bone and as such represent a major risk factor for osteoporosis and
DHEA test (blood or saliva)
Dehydroepiandrosterone (DHEA) is a hormone produced by both the adrenal glands and
the ovaries. DHEA helps to neutralize the effects of cortisol. DHEA helps to protect
and increase bone density. Stress reduction activities like yoga and meditation
can help maintain youthful DHEA level as we age. Low levels of DHEA are a risk factor
C-reactive protein test (high sensitivity if possible)
C-reactive protein is a plasma protein that is held to be a marker of general inflammation
within the body. It is a known risk factor for heart disease because heart disease
is largely an inflammatory disorder. Osteoporosis is also inflammatory in nature
and this test is helpful in detecting unwanted inflammation, which may contribute
to bone health problems.
Homocysteine test (plasma or serum)
Homocysteine is a non-dietary amino acid, a product of the metabolism of a dietary
amino acid, methionine. In the absence of adequate B vitamins, homocysteine can
accumulate in the body. High levels of this substance damage collagen and represent
powerful risk factors for both cardiovascular disease and for osteoporotic fractures.
Celiac disease and gluten sensitivity tests
Full-blown celiac disease, or even just sensitivity to gluten, can lead to inflammation
of the gut. This inflammation is related to a complex inflammatory cascade which
can increase bone loss. Also, those with celiac disease suffer from weak indigestion
and malabsorption of many nutrients including vitamins A, K, and D. These deficiencies
in turn damage bone. If there is any suggestion of gluten sensitivity or celiac
disease, appropriate testing should be considered. For a detailed update on gluten
sensitivity as a cause of bone loss, see The Whole-Body Approach to Osteoporosis
by R. Keith McCormick, New Harbinger Publications, 2008.
Sex hormone tests
Post-Menopausal Females: Progesterone, Estrogen
Female sex hormones drop naturally at menopause among all women, so we at the Center
for Better Bones do not generally suggest testing of these hormones. Those interested
in this type of hormone testing, or those taking hormone replacement medications,
should be tested for hormone levels by their physician.
Pre-Menopausal Females (hormone testing in the reproductive years): Progesterone,
For women from their teens to menopause, proper levels of sex hormones are very
important to bone health. Low levels of either estrogen or progesterone can limit
development of optimum peak bone mass. Irregular, or frequently missed, periods
should be studied by a knowledgeable physician. According to noted progesterone
researcher, endocrinologist Dr. Jerilynn Prior, some 25% of young women in the US
and Canada fail to develop optimum peak bone mass due to undetected ovulatory disturbances
which result in low progesterone levels. Testing of estrogen and progesterone can
be helpful in pre-menopausal women with a bone health concern.
Sex Hormone Testing in Males: Testosterone and, at times, Estrogen
A common cause of osteoporosis in men is low testosterone; thus a medical work-up
for osteoporosis in men almost always includes a test for testosterone. Interestingly
enough, estrogen also plays a role in male bone health and at times the physicians
will test for estrogen in men with osteoporosis.
Everyone deserves the full story on their health
It seems like healthcare has become a knee-jerk reaction of “see a symptom, take
a pill,” but we believe that everyone deserves better than that. Your bone loss
is a symptom of something that’s just not right in your body — and rather than treating
the symptom with medications (and living with the side effects involved, some of
which are plain frightening!), we encourage everyone to dig deeper and find out
the source of the problem.
The Personal Program for Better Bones: the approach I recommend for naturally strong bones.
At the Center for Better Bones we promote an all-natural approach to bone regeneration
and repair that includes nutrition, diet, exercise, lifestyle guidance, and support.
The Personal Program for Better Bones is a convenient,
at-home version of this approach that was developed with Women to Women, one of America's premiere on-line women's
health websites. Working together, we've developed the most comprehensive approach
to bones health available today, and based on the 25 years of Dr. Brown's leading-edge
research in the field.
Questions about the Personal Program for Better Bones? Call toll-free at
Original Publication Date: 01/20/2010
Principal Author: Dr. Susan E. Brown, PhD