Key points
- Osteoporosis weakens bone so that it breaks after a fall from standing height, or even from bending, lifting or coughing. It usually causes no symptoms until a bone breaks. The hip, spine and wrist are the most common sites.
- The International Osteoporosis Foundation (IOF) estimates that 1 in 3 women and 1 in 5 men over 50 worldwide will break a bone because of osteoporosis. World Osteoporosis Day is held on 20 October each year.
- Screening rules differ by country. The USPSTF (2025) recommends bone density testing for all women aged 65 and over, and for younger postmenopausal women at increased risk. NICE (UK, 2026) bases assessment on age, sex and risk factors, using FRAX or QFracture.
- A first fragility fracture is the strongest warning sign of the next one. Anyone aged 50 or over who breaks a bone from a minor fall should have their fracture risk assessed.
- Long-term glucocorticoids (steroid tablets) are a major, often missed cause of bone loss.
- Sudden back pain, loss of height or a new stoop can be a spinal (vertebral) fracture and should be checked.
What osteoporosis is
In osteoporosis, bone density and mass fall and the internal structure weakens, so bones break more easily. A fragility fracture is one caused by a force that would not normally break a healthy bone, such as a fall from standing height.
Fractures have serious consequences. The USPSTF notes that only 40% to 60% of people who break a hip recover their previous mobility and ability to manage daily activities.
Who is at risk
NIAMS lists these risk factors:
- Sex and age: women have smaller bones and lower peak bone mass. For many women, bone loss starts a year or two before menopause. Men are also at risk, especially after age 70.
- Body size: slim, small-boned people have less bone to lose.
- Family history: a parent with osteoporosis or hip fracture.
- Hormones: low oestrogen after menopause, missed periods from hormone disorders or extreme exercise, and low testosterone in men.
- Diet: low calcium and vitamin D, very restrictive dieting or poor protein intake.
- Lifestyle: inactivity or long periods of immobility, chronic heavy drinking and smoking.
Secondary causes: medicines and conditions
NICE NG259 lists conditions and medicines linked to higher fracture risk. They include:
- Glucocorticoids: NICE treats current or frequent use of 5 mg or more prednisolone daily (or equivalent) for more than 3 months, or repeated courses of higher doses, as a major risk factor. Replacement doses for adrenal insufficiency are excluded.
- Hormone-lowering cancer treatment: aromatase inhibitors for breast cancer and androgen deprivation therapy for prostate cancer.
- Other medicines: anticonvulsants, selective serotonin reuptake inhibitors (SSRIs), thiazolidinediones, proton pump inhibitors and antiretroviral medicines.
- Endocrine: early menopause or premature ovarian insufficiency, hypogonadism, hyperthyroidism, hyperparathyroidism, hyperprolactinaemia, Cushing's disease, and type 1 or type 2 diabetes.
- Gut and liver: coeliac disease, Crohn's disease and other inflammatory bowel disease, chronic liver disease, chronic pancreatitis and other causes of malabsorption.
- Other: rheumatoid arthritis and other inflammatory arthritis, multiple myeloma, chronic obstructive pulmonary disease, Parkinson's disease, stroke or multiple sclerosis causing immobility, anorexia nervosa or low BMI, and chronic kidney disease stages 4 and 5.
Treat the cause or review the medicine where possible. If long-term glucocorticoids are needed, NIAMS notes that medicines to prevent or treat osteoporosis can be taken alongside them.
Who should be assessed: guidance differs by country
USPSTF (United States, 2025)
- Women aged 65 and over: screen with a DXA bone density scan, with or without a fracture risk tool (grade B).
- Postmenopausal women under 65: first check for risk factors such as low body weight, a parent who broke a hip, smoking or excess alcohol. If one or more is present, use a risk tool to decide whether to scan (grade B).
- Men: evidence is insufficient to recommend for or against screening (I statement).
These recommendations are for people without known osteoporosis or previous fragility fractures. They do not cover secondary osteoporosis, such as bone loss from long-term glucocorticoids, cancer or metabolic bone disease, which needs assessment in its own right.
NICE (UK, NG259, 2026)
- Assess everyone aged 50 and over, and all postmenopausal women, who have had a previous fragility fracture or use systemic glucocorticoids as described above.
- Consider assessing all women aged 65 and over and all men aged 75 and over. Also consider it for people aged 50 to 74 and postmenopausal women under 65 who have 2 or more falls in the past year, a first-degree relative who broke a hip, a BMI below 18.5, current smoking, more than 14 units of alcohol a week, or another risk factor from the list above.
- Assess people under 50 (or premenopausal women) who have had a hip or vertebral fragility fracture, or 2 or more major osteoporotic fractures.
How fracture risk is measured
FRAX estimates the 10-year probability of a hip fracture or a major osteoporotic fracture for people aged 40 to 90, using clinical risk factors with or without bone density at the hip. Country-specific versions exist. The USPSTF notes that FRAX combined with bone density predicts risk better than either alone. NICE recommends FRAX or QFracture, the same tool throughout a person's care, and QFracture for people aged 30 to 39.
A DXA scan measures bone mineral density, usually at the hip and spine. In postmenopausal women and men aged 50 and over, the result is a T-score (NIAMS):
- -1 or higher: normal bone density
- between -1 and -2.5: low bone density (osteopenia)
- -2.5 or lower: osteoporosis range
Fracture risk rises 1.5 to 2 times with each 1-point fall in T-score. In premenopausal women and men under 50 a Z-score is used, and a Z-score of -2.0 or less suggests bone loss from another cause.
Treatment principles
NICE advises a shared decision based on the 10-year fracture risk, bone density, the number and site of past fractures, and other risk factors. It advises considering treatment, for example, in people aged 50 and over or postmenopausal women with a previous hip or vertebral fragility fracture, a T-score of -2.5 or less, or very high-dose glucocorticoids (15 mg prednisolone daily or more for 3 months or longer). Medicine classes approved by the FDA include bisphosphonates, denosumab (a RANKL inhibitor), parathyroid hormone analogues, a sclerostin inhibitor, a selective oestrogen receptor modulator and, for prevention, oestrogen-based hormone therapy (NIAMS). Calcium, vitamin D and exercise remain part of treatment with any medicine.
Two label points matter for safety:
- Oral bisphosphonates (such as alendronate) must be taken on an empty stomach with plain water at least 30 minutes before food, drink or other medicines, staying upright for at least 30 minutes. They are contraindicated with oesophageal disorders that delay emptying, inability to sit or stand upright for 30 minutes, and uncorrected low calcium. Osteonecrosis of the jaw and atypical thigh-bone fractures are rare reported harms.
- Denosumab is given every 6 months. Stopping it without switching to another bone medicine has been followed by multiple vertebral fractures, so doses should not be missed and any stop should be planned. It is contraindicated in pregnancy and in uncorrected low calcium, and severe low calcium can occur in advanced kidney disease (eGFR below 30).
Preventing falls and protecting bone
- Exercise: the USPSTF (2024) recommends exercise to prevent falls in adults aged 65 and over at increased risk (grade B). Most effective programmes include gait, balance and functional training, often with strength training.
- Review the whole person: the USPSTF advises offering, case by case, an assessment of balance, gait, vision, standing blood pressure, medicines, home hazards, cognition and mood.
- Diet: calcium from dairy, leafy greens such as bok choy, tinned fish with bones or fortified foods, plus enough vitamin D and protein. NIAMS gives 1,200 mg calcium a day for women from age 51 and for everyone over 70, with 800 IU vitamin D over 70.
- Lifestyle: stop smoking and limit alcohol.
- People with osteoporosis should avoid high-impact exercise.
Red flags: when to get checked
- sudden or severe back pain, or pain spreading around the ribs, with no clear cause or after minor strain, lifting or coughing: possible vertebral fracture
- loss of height (NICE uses more than 4 cm as a sign), or a new stoop or rounded back
- any broken bone after a fall from standing height at age 50 or over
- new thigh or groin pain while taking a bisphosphonate or denosumab (possible atypical femoral fracture), or new jaw problems (osteonecrosis of the jaw has been reported)
- a missed or overdue denosumab injection
Frequently asked questions
Does osteoporosis hurt?
Not on its own. It is called a silent disease because it usually causes no symptoms until a bone breaks. Pain, height loss or a stoop can mean a fracture has already happened.
I broke my wrist in a simple fall. Should I have a bone scan?
Ask for a fracture risk assessment. A previous fragility fracture is one of the strongest predictors of another one, and NICE advises assessment for everyone aged 50 and over who has had one.
Can men get osteoporosis?
Yes, especially after age 70 or with low testosterone, steroid use or prostate cancer hormone treatment. The USPSTF has not found enough evidence for routine screening of men, but men with risk factors or a fragility fracture should be assessed.
Do steroid inhalers count?
The NICE risk factor refers to systemic glucocorticoids, meaning tablets or injections, at 5 mg prednisolone daily or more for over 3 months, or repeated higher-dose courses. If you are unsure whether your treatment counts, ask your prescriber.
Sources
- US Preventive Services Task Force. Osteoporosis to Prevent Fractures: Screening, 14 January 2025. uspreventiveservicestaskforce.org
- US Preventive Services Task Force. Falls Prevention in Community-Dwelling Older Adults: Interventions, 4 June 2024. uspreventiveservicestaskforce.org
- NICE. Osteoporosis: risk assessment (NG259), 2026. nice.org.uk/guidance/ng259
- US National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS). Osteoporosis. niams.nih.gov
- NIAMS. Osteoporosis: Diagnosis, Treatment, and Steps to Take. niams.nih.gov
- NIAMS. Bone Mineral Density Tests: What the Numbers Mean. niams.nih.gov
- International Osteoporosis Foundation. About osteoporosis. osteoporosis.foundation
- US FDA-approved labeling: alendronate sodium (Binosto) and denosumab (Prolia). DailyMed, Prolia; DailyMed, Binosto
This article is for education and does not replace advice from a doctor or pharmacist who knows your history, medicines and local guidance.
