What Is Osteoporosis?
 

Osteoporosis is a condition in which bones become less dense and structurally weaker, increasing the risk of fractures. It is often called a “silent disease” because bone loss usually causes no symptoms until a fracture occurs.

Osteopenia (low bone mass) means bone density is below normal but has not reached the severe level used to diagnose osteoporosis.

Osteoporosis-related fractures most commonly involve the hip, spine (vertebrae), and wrist, although other bones can also be affected.

Routine Screening
 

Bone density screening with a DEXA scan is generally recommended for:
 

• Women age 65 and older

• Postmenopausal women younger than 65 who have an increased risk of osteoporosis or fracture based on clinical risk assessment

• Men are not universally screened at one specific age by all organizations; however, testing is commonly considered in men age 70 and older and in younger men with significant risk factors.

• Adults of any age may need testing when certain diseases, medications, or previous fractures substantially increase osteoporosis risk.

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A DXA (DEXA) scan is a quick, painless, low-radiation test that measures bone mineral density (BMD), usually at the hip and lumbar spine.

Understanding Your DXA Results:

T-Score
 

The T-score compares your bone density with that of a healthy young adult.
 

• Normal: T-score −1.0 or higher

• Osteopenia/low bone mass: T-score between −1.0 and −2.5

• Osteoporosis: T-score −2.5 or lower

A lower T-score generally indicates lower bone density and greater fracture risk.

In postmenopausal women and men age 50 and older, the T-score is generally used for diagnostic classification.

Z-Score
 

The Z-score compares your bone density with what is expected for someone of similar age and sex. Z-scores are particularly useful in premenopausal women, men younger than 50, and children. A Z-score of −2.0 or lower is considered below the expected range for age and may prompt evaluation for an underlying cause of low bone density.

FRAX Tool: Estimating Fracture Risk
 

The FRAX calculator estimates a person's 10-year probability of hip fracture and major osteoporotic fracture using factors such as age, sex, weight, previous fractures, smoking, steroid use, rheumatoid arthritis, alcohol use, and—when available—femoral neck bone density. FRAX can be especially useful when a patient's DXA shows osteopenia, because some people with osteopenia have enough overall fracture risk to benefit from medication.

What Increases the Risk?
 

• Old age

• Menopause

• Low body weight or low BMI

• Previous low-trauma or fragility fracture

• Parent with a history of hip fracture

• Long-term corticosteroid use, such as prednisone

• Smoking

• Heavy alcohol use

• Physical inactivity

• Low calcium or vitamin D intake

• Malabsorption, including celiac disease or inflammatory bowel disease

• History of bariatric surgery

• Rheumatoid arthritis and certain other inflammatory diseases

• Hyperthyroidism or excessive thyroid hormone replacement

• Hyperparathyroidism

• Chronic kidney or liver disease

• Hypogonadism or low sex-hormone levels

• Certain medications, including some antiseizure medications and cancer treatments

What Is a Fragility Fracture?
 

A fragility fracture is a fracture resulting from trauma that would not normally be expected to break healthy bone, such as falling from standing height or less.

A fragility fracture—especially of the hip or vertebrae—can be evidence of osteoporosis even when a DXA T-score is not ≤ −2.5.

Vertebral compression fractures may sometimes occur with little or no recognized trauma and may cause:
 

• Sudden or persistent back pain

• Loss of height

• Stooped or hunched posture

• Reduced mobility

Some vertebral fractures cause few or no symptoms and are discovered incidentally on imaging.

Looking for an Underlying Cause

When osteoporosis or unexpectedly low bone density is identified, evaluation may be needed for secondary osteoporosis. Depending on the patient's history, testing may include:
 

• Calcium

• Kidney and liver function

• CBC

• Vitamin D

• Thyroid testing

• Parathyroid hormone (PTH)

• Phosphorus

• Testosterone in appropriate male patients

• Testing for celiac disease or other causes of malabsorption when indicated

• Additional blood or urine testing based on the clinical situation

Identifying an underlying cause is especially important when osteoporosis occurs at a younger-than-expected age, is unusually severe, or occurs without typical risk factors.

Preventing Bone Loss
 

-Calcium
 

Most adults should obtain approximately 1,000–1,200 mg of calcium per day, depending on age and sex.
 

Food sources are generally preferred and include:
 

• Milk, yogurt, and cheese

• Calcium-fortified foods and beverages

• Sardines or salmon with edible bones

• Certain leafy green vegetables

• Tofu prepared with calcium

-Vitamin D

Vitamin D is necessary for normal calcium absorption and bone health. Requirements vary with age and individual circumstances. Vitamin D supplementation may be recommended when dietary intake or sun exposure is inadequate or when blood testing demonstrates deficiency.

-Exercise

Regular physical activity helps preserve bone and muscle strength.

Helpful exercise includes:
 

• Weight-bearing exercise: walking, jogging, stair climbing, dancing

• Resistance/strength training: weights, resistance bands, body-weight exercises

• Balance training: particularly important for reducing falls in older adults

-Other Important Measures
 

• Avoid smoking.

• Avoid excessive alcohol consumption.

• Maintain adequate nutrition and protein intake.

• Address vision problems and medications that increase dizziness or fall risk.

• Reduce household fall hazards.

• Maintain muscle strength and balance.

When Is Medication Recommended?
 

Medication may be recommended for patients with a sufficiently high risk of fracture, including many patients with:
 

• Hip or vertebral fragility fracture

• T-score ≤ −2.5 at an appropriate skeletal site

• Osteopenia with sufficiently high estimated fracture risk

• Certain other fragility fractures or high-risk medical conditions

Treatment decisions should consider the person's overall fracture risk rather than the DXA number alone.

Medications for Osteoporosis
 

Bisphosphonates — Antiresorptive Medications
 

Bisphosphonates are usually first-line treatment for osteoporosis. They slow the cells that break down bone, allowing bone density to stabilize or increase and reducing fracture risk.
 

Common bisphosphonates include:

• Alendronate (Fosamax) – oral tablet, usually taken once weekly.

• Risedronate (Actonel) – oral tablet available in weekly or monthly regimens.

• Ibandronate (Boniva) – oral tablet usually taken once monthly, or IV injection every 3 months. It primarily has evidence for reducing vertebral fractures and is generally not preferred when hip-fracture prevention is a major goal.

• Zoledronic acid (Reclast) – IV infusion, usually given once yearly.

Oral bisphosphonates are generally taken first thing in the morning on an empty stomach with plain water. The patient must remain upright afterward—usually for at least 30 minutes for alendronate and risedronate and 60 minutes for ibandronate—to reduce irritation of the esophagus.

How Long Are Bisphosphonates Taken?
 

Bisphosphonates remain in bone for a long time, so they do not necessarily need to be continued indefinitely.

Fracture risk is commonly reassessed after approximately:

• 5 years of oral bisphosphonate therapy, or

• 3 years of IV zoledronic acid

Patients who remain at high or very high fracture risk may continue treatment longer. Patients whose fracture risk has become low-to-moderate may be able to take a temporary bisphosphonate drug holiday, with periodic reassessment.
 

Rare complications of long-term bisphosphonate therapy include osteonecrosis of the jaw (ONJ) and atypical femur fractures. These complications are uncommon at osteoporosis doses, and for patients at substantial fracture risk, the fracture-prevention benefits generally outweigh these risks.

Denosumab (Prolia) — Antiresorptive Medication
 

Denosumab is a RANK ligand (RANKL) inhibitor.
 

• Given as a subcutaneous injection every 6 months

• Reduces vertebral, hip, and nonvertebral fractures

• May be used when bisphosphonates are inappropriate or when a patient's fracture risk warrants this treatment
   

How Long Is Denosumab Taken?
 

There is no routine drug holiday for denosumab. Treatment can be continued for years when the benefits continue to outweigh the risks, with fracture risk periodically reassessed. Denosumab should not be stopped or significantly delayed without a plan for another osteoporosis medication. Its effect wears off relatively quickly, which can cause rapid bone loss and an increased risk of multiple vertebral fractures.

If denosumab is discontinued, an antiresorptive medication—often a bisphosphonate—is generally given afterward to reduce this rebound bone loss.

Teriparatide (Forteo), ​Abaloparatide (Tymlos)— Anabolic/Bone-Building Medication
 

Teriparatide is a parathyroid hormone (PTH) analog. Abaloparatide is a parathyroid hormone-related protein (PTHrP) analog.
 

• Given as a subcutaneous injection once daily

• Generally reserved for patients at very high fracture risk, such as those with severe osteoporosis or certain vertebral fractures

• Treatment is generally limited to about 2 years, although longer use may be considered in selected patients who remain at very high fracture risk.

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Romosozumab (Evenity) — Bone-Building and Antiresorptive Medication
 

Romosozumab is a sclerostin inhibitor.
 

• Given as two subcutaneous injections once monthly

• Treatment is limited to 12 monthly doses

• Generally reserved for patients at very high fracture risk

After the 12-month course, an antiresorptive medication should be started to maintain the bone-density gains. Romosozumab carries a warning regarding possible cardiovascular risk and should not be started in patients who have had a heart attack or stroke within the previous year. Cardiovascular risk should be considered when deciding whether it is appropriate.

Raloxifene (Evista) — Selective Estrogen Receptor Modulator (SERM)
 

Raloxifene is a selective estrogen receptor modulator (SERM). It acts like estrogen on bone while having different effects in other tissues.
 

• Taken as an oral tablet once daily

• Used only in postmenopausal women

• Primarily reduces the risk of vertebral fractures

• Does not have established benefit for reducing hip fractures

• May be particularly useful in selected women who could also benefit from its reduction in the risk of estrogen-receptor-positive invasive breast cancer

There is no standard fixed treatment duration or drug holiday. Treatment is periodically reassessed based on benefits and risks. Raloxifene increases the risk of venous blood clots and should not be used in women with a history of venous thromboembolism.

Menopausal Hormone Therapy — Estrogen ± Progestogen
 

Estrogen therapy is a hormone treatment, not a traditional osteoporosis medication. Estrogen decreases bone breakdown and can prevent bone loss and fractures.

It may be considered primarily in younger postmenopausal women who also have bothersome menopausal symptoms and who do not have contraindications to hormone therapy. Treatment duration is individualized and periodically reassessed according to menopausal symptoms, age, cardiovascular and breast-cancer risk, and other individual factors. Hormone therapy is not usually started solely as long-term osteoporosis treatment in older women when other osteoporosis medications are more appropriate.
 

Monitoring Bone Density
 

Repeat DXA testing may be performed to evaluate changes in bone density and response to treatment.

The appropriate interval depends on:
 

• Initial bone density

• Age

• Fracture risk

• Whether osteoporosis medication has been started

• Medical conditions or medications affecting bone

DXA testing does not usually need to be repeated every year in otherwise stable, low-risk patients. Whenever possible, follow-up scans should be performed using the same facility and DXA machine, because measurements can vary between machines.

When to Seek Medical Attention
 

Seek urgent medical evaluation after a significant fall or when a fracture is suspected, particularly when there is severe pain, inability to bear weight, deformity, weakness/numbness, or loss of bowel or bladder control.

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