Once they reach a certain age, many women begin to show the classic signs of osteoporosis: Diminishing height. Bones that break from a simple bump or fall. Maybe even a dowager's hump that signifies a collapsing spine.

Men, too, can suffer from this condition that breaks down bone and makes fractures a daily hazard.

Osteoporosis is debilitating, sometimes fatal, and it's common among seniors. The National Osteoporosis Foundation estimates that 9 million adults in the United States have osteoporosis. Another 48 million have low bone mass, which means they're at risk for osteoporosis and broken bones. This group includes nearly 60 percent of Americans age 60 and older.

But there's good news: For those who are diagnosed with osteoporosis, there's more hope than ever. Researchers are developing new medications, physicians are learning how to make the old medications cause fewer side effects, and doctors are beginning to combine drugs for a one-two punch that can be twice as effective.

Spotting the problem

First, though, those patients have to be identified. That's always been a bit tricky, said Dr. Robert Gagel, head of internal medicine at the University of Texas M.D. Anderson Cancer Center and the new board president of the National Osteoporosis Foundation.

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Here's how to prevent - or at least postpone - osteoporosis:

1. Build bone mass: Don't put off thinking about osteoporosis until you're in your 60s. The earlier you start building up your bone mass, the better.

2. Nutrition: Eat a balanced diet that includes dairy, fish and fruits and vegetables. Be sure your diet has adequate calcium and vitamin D, which are crucial to bones.

3. Workouts: Exercise regularly. Focus on muscle-strengthening exercises (weight lifting, using elastic exercise bands) and on weight-bearing exercises (aerobics, dancing, jogging, hiking, tennis, using cardio equipment at the gym). You also can do balance and posture exercises to increase your strength and improve the way you move.

4. Habits: Don't smoke, and limit your drinking; both can lead to bone loss.

Source: National Osteoporosis Foundation

"Osteoporosis is a silent disease," Gagel said. "The bone loss has no symptom until it fractures."

And even then, sometimes doctors don't pick up on the signs. Only about 20 percent of patients who show up in emergency rooms with an osteoporosis-related fracture - a break in the spine, hip, wrist or humerus, for instance - get an evaluation for bone-density problems, Gagel said. People who have one fracture are likely to have another, but they're not getting the intervention they need to prevent those future breaks. "This is the group of patients who are perhaps most needy, not being cared for," he said.

So the bone community has "refocused" Gagel said, and hospitals around the country are starting to make changes. Instead of relying on emergency-room doctors to identify patients with osteoporosis, some hospitals are developing "fracture liaison systems."

The Kaiser Permanente health care system in California has been a leader in this, Gagel said. Every day, he said, the fracture liaison gets a printout of all patients who have come in with a fracture and looks for the ones who are at risk, making sure they get evaluated for osteoporosis. In Houston, Gagel and his colleagues are hoping to set up a fracture liaison system that could span the Texas Medical Center. The plan is still in the proposal stage - "time will tell," Gagel said - but it's a possibility.

Identifying osteoporosis after the first fracture may prevent a second fracture, which can prevent more pain and save money.

Emerging treatments

Until a couple of decades ago, there were no good treatments for osteoporosis. Now there's a strong group of medications and a couple of promising new ones in the pipeline.

The first drug (besides estrogen) to treat osteoporosis came out nearly 20 years ago, when the FDA approved an alendronate sodium marketed as Fosamax. And the old arsenal of medications - Fosamax, Boniva and a few others - is still in heavy use, said Dr. Sandesh Nagamani, assistant professor of molecular and human genetics at Baylor College of Medicine and director of Baylor's Clinic for Metabolic and Genetic Disorders of Bone. These bisphosphonates are designed to stop or slow the breakdown of bone tissue, making bones less likely to weaken and fracture.

These drugs have shown some side effects in patients who take them for five years or longer. A few patients have developed fractures in their long bones - bones that don't typically break because of osteoporosis, such as the femur in the leg. And a small percentage of patients on these drugs have developed osteonecrosis of the jaw, in which part of the jawbone becomes dead and exposed inside the mouth.

For most patients, the benefits of these medications are going to far outweigh the risks, Nagamani said; they still prevent far more fractures than they cause. But there's still cause for concern.

"Both of these are very rare conditions, but the more we are using these drugs - and the longer we are using these drugs - we're starting to see some side effects with long-term treatment," said Dr. Morali Sharma, an associate professor in endocrinology, diabetes and metabolism at Baylor College of Medicine who treats patients with osteoporosis.

But that doesn't mean patients should avoid them. In the past few years, doctors have found a way to avoid these side effects: They're giving patients a "drug holiday" after five years - taking them off the drug for at least a year, maybe two or three years to let the bone recover.

Bisphosphonates are "the most prescribed drugs by far for osteoporosis," Nagamani said, but they're not the only options. Other types of drugs have come along in the past 10 or 12 years: Teriparatide (marketed as Forteo) helps build bone, while denosumab (marketed as Prolia) reduces bone loss. All of these drugs can work well on their own, but physicians are finding that combining them can be even better.

"We're entering the era of combinatorial therapy," Gagel said. Combined medications can prevent bone breakdown and rebuild what's lost already, creating results that are "significantly better" than a single drug can produce.

There's just one problem: money.

"Keep in mind, (combining therapies) adds to the cost," Gagel said, and insurance companies may balk at some drug combinations - especially when there aren't generic versions. Denosumab and teriparatide make a promising combination with consistent results, Gagel said, but since those drugs aren't yet available as generics, the treatment could run between $1,500 and $2,000 a month.

New drugs

Here's some good news: Two new osteoporosis drugs are in the pipeline, and both are expected to be on the market within a couple of years.

First in line is odanacatib, which will likely get FDA approval within a year.

The drug increases bone mineral density by inhibiting cathepsin K, an enzyme that breaks down bone and cartilage. When odanacatib was tested in humans, the study's data safety monitoring committee shut down the study, Gagel said - not because of some disastrous side effect, but because the drug was so much more effective than placebo, the committee wanted everybody in the study to be given it.

That bodes well for the drug's effectiveness, and physicians are excited about the possibilities.

"This drug continues to build bone mass beyond the first three years of therapy," said Dr. Felicia Cosman, the National Osteoporosis Foundation's senior clinical director. "Most of our drugs result in a plateau of bone density after three years, but this one does not seem to - at least over a five, six-year period of time. We're really excited about that."

The second new drug, romosozumab, is expected to be available in the next couple of years. It's an antibody that targets sclerostin, a protein that inhibits bone formation. "If you get rid of the inhibitor, bone formation starts to occur very quickly," Gagel said. In human studies, the drug - given monthly by injection - has increased patients' spine density by an average of 10 percent.

"For bone, 10 percent is a lot," Gagel said. So far, romosozumab doesn't show much benefit after that first year, but it might be effective when combined with other drugs.

Because it builds bone so quickly, romosozumab could be especially helpful to patients with severe osteoporosis, said Cosman, who's medical director of the Clinical Research Center at Helen Hayes Hospital in New York.

"Within one year," she said, "you get some of the benefits with this drug you might not get for five years with most of the drugs out on the market today."

Prevention helps

Even though treatments are promising, physicians still stress the importance of prevention and early detection.

If you're a woman, you should get checked for osteoporosis at age 65. If you're a man, get checked at age 70 unless you have a bone fracture before that. Men aren't immune to osteoporosis: As life expectancy for men increases, more men are living long enough to develop bone-density problems.

Of course, some bone breakdown is inevitable with age: "As you grow older, your bone quality will decrease," said Dr. Aravind Athiviraham, an assistant professor at Baylor College of Medicine in the orthopedic surgery department. But that doesn't mean everyone will have fragile, fractured bones.

"It depends on what (bone quality) you start off with," he said. "If you can start off with a full cup, it may not be as problematic."

And the younger you start, Athiviraham said, the more you'll benefit from vigorous exercise and a healthy diet. For women, exercise before menopause will help build bone mass better than post-menopausal efforts ever could.

"If you can kind of invest in that when you're young and build up your bone mass, it's like a retirement fund," he said. "You can delve into it later on."