Approximately 10 million Americans have osteoporosis and another 44 million have low bone density, placing them at increased risk. Every year, osteoporosis causes more than 2 million fractures in the United States — a hip fracture, a crushed vertebra, a broken wrist — many of which lead to chronic pain, disability, and loss of independence. Osteoporosis is often called a “silent disease” because bone loss occurs without symptoms until a fracture happens. By that point, significant skeletal deterioration has already occurred. The good news: this condition is both detectable and treatable, and prevention strategies can begin at any age. For a broader view of chronic health conditions, visit our medical conditions guide.
What Is Osteoporosis?
Osteoporosis literally means “porous bone.” It is a skeletal disorder characterized by decreased bone mass and deterioration of bone tissue microarchitecture, leading to increased bone fragility and susceptibility to fracture. According to the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS), healthy bone is constantly being remodeled — old bone is broken down (resorption) by cells called osteoclasts and new bone is formed by osteoblasts. In osteoporosis, resorption outpaces formation, resulting in net bone loss.
Bone density peaks in the late 20s to early 30s. After that, bone mass gradually declines. In women, the rate of bone loss accelerates sharply in the first 5 to 7 years after menopause due to estrogen withdrawal. Men lose bone more gradually but are not immune — approximately 20 percent of those affected by osteoporosis are men.
Osteoporosis is diagnosed using dual-energy X-ray absorptiometry (DEXA scan), which measures bone mineral density (BMD) and expresses it as a T-score. A T-score of -1.0 or above is normal. A T-score between -1.0 and -2.5 indicates osteopenia (low bone mass). A T-score of -2.5 or below indicates osteoporosis. The World Health Organization established these diagnostic thresholds, and they remain the standard worldwide.
Causes and Risk Factors
Osteoporosis can be primary (related to aging and hormonal changes) or secondary (caused by medical conditions or medications). Primary osteoporosis includes postmenopausal osteoporosis (type I), driven primarily by estrogen deficiency, and age-related osteoporosis (type II), affecting both men and women over 70 as both hormonal and age-related factors converge.
Non-modifiable risk factors include female sex, older age, small body frame, Caucasian or Asian ethnicity, and family history of osteoporosis or hip fracture. According to the Mayo Clinic, women are four times more likely to develop osteoporosis than men due to lower peak bone mass and the accelerated bone loss associated with menopause.
Modifiable risk factors include inadequate calcium and vitamin D intake, sedentary lifestyle, cigarette smoking, excessive alcohol consumption (more than 2 drinks daily), and low body weight. Secondary causes include long-term corticosteroid use (the most common medication-related cause), hyperthyroidism, hyperparathyroidism, celiac disease, inflammatory bowel disease, rheumatoid arthritis, chronic kidney disease, type 1 diabetes, premature menopause, and eating disorders such as anorexia nervosa.
Certain medications beyond corticosteroids can also accelerate bone loss: aromatase inhibitors used in breast cancer treatment, proton pump inhibitors (with long-term use), some anti-seizure medications, depo-medroxyprogesterone acetate (Depo-Provera), and androgen deprivation therapy for prostate cancer.
Symptoms and Fracture Risk
Osteoporosis itself produces no symptoms until a fracture occurs — which is why screening is essential. The most common osteoporotic fractures affect the spine (vertebral compression fractures), hip, and wrist. According to the National Osteoporosis Foundation, a woman’s lifetime risk of an osteoporotic fracture is approximately 50 percent — greater than her combined risk of heart attack, stroke, and breast cancer.
Vertebral compression fractures are the most common osteoporotic fracture and often occur without a clear traumatic event — simply bending, lifting, or even coughing can cause a weakened vertebra to collapse. Two-thirds of vertebral fractures are asymptomatic initially but can cause progressive height loss, kyphosis (forward curvature of the upper spine, sometimes called “dowager’s hump”), and chronic back pain.
Hip fractures are the most devastating consequence of osteoporosis. Approximately 300,000 hip fractures occur annually in the United States, and the outcomes are sobering: 20 to 30 percent of hip fracture patients die within one year, and up to 50 percent never regain their pre-fracture level of function. Wrist fractures (distal radius fractures), often caused by falling on an outstretched hand, tend to occur earlier — frequently in the 50s and 60s — and may serve as an early warning of osteoporosis.
Screening and Diagnosis
The USPSTF recommends bone density screening with DEXA scan for all women aged 65 and older and for younger postmenopausal women whose fracture risk is equal to or greater than that of a 65-year-old white woman (typically assessed using the FRAX tool). For men, screening guidelines are less standardized, but most experts recommend DEXA scanning for men aged 70 and older or younger men with significant risk factors.
The FRAX tool (developed by the University of Sheffield) calculates the 10-year probability of a major osteoporotic fracture and hip fracture based on clinical risk factors with or without BMD data. In the United States, treatment is generally recommended when the 10-year probability of a major fracture exceeds 20 percent or the 10-year probability of a hip fracture exceeds 3 percent.
Beyond DEXA, additional evaluation may include blood tests to assess calcium, vitamin D, thyroid function, parathyroid hormone, kidney function, and markers of bone turnover. Vertebral fracture assessment (VFA), a low-dose lateral spine image obtained during DEXA scanning, can detect vertebral compression fractures that may not have been clinically recognized. These silent fractures, if present, change the treatment threshold regardless of T-score.
Prevention: Building and Preserving Bone
Prevention begins in childhood and adolescence, when maximizing peak bone mass through adequate nutrition and physical activity lays the foundation for lifelong skeletal health. According to the NIAMS, approximately 90 percent of peak bone mass is acquired by age 18 in girls and age 20 in boys.
Calcium is the primary mineral in bone, and adequate intake is essential throughout life. The National Academy of Medicine recommends 1,000 mg daily for adults aged 19 to 50 and men aged 51 to 70, and 1,200 mg daily for women over 50 and all adults over 70. Food sources — dairy products, fortified plant milks, leafy greens, sardines, and tofu — are preferred over supplements. When supplements are needed, calcium carbonate (taken with food) and calcium citrate (can be taken on an empty stomach) are the most common forms.
Vitamin D is critical for calcium absorption. The recommended daily intake is 600 IU for adults up to age 70 and 800 IU for those over 70, though many experts recommend 1,000 to 2,000 IU daily, particularly for individuals with limited sun exposure or known deficiency. Vitamin D deficiency is remarkably common, affecting an estimated 40 percent of American adults.
Weight-bearing exercise (walking, jogging, dancing, stair climbing) and resistance training (weightlifting, resistance bands) both stimulate bone formation and slow bone loss. Balance and coordination exercises such as tai chi reduce fall risk — and since falls are the proximate cause of most fractures, fall prevention is as important as bone strengthening. Avoiding smoking and limiting alcohol are additional evidence-based prevention strategies.
Pharmacological Treatment
When prevention is insufficient and osteoporosis is diagnosed, medication can significantly reduce fracture risk. The Endocrine Society and other professional organizations recommend pharmacological treatment for postmenopausal women and men over 50 who have a hip or vertebral fracture, a T-score of -2.5 or below at the hip or spine, or a T-score between -1.0 and -2.5 with a FRAX-calculated fracture risk meeting treatment thresholds.
Antiresorptive Medications
Bisphosphonates are the most commonly prescribed first-line agents. Alendronate (Fosamax), risedronate (Actonel), and ibandronate (Boniva) are oral bisphosphonates, while zoledronic acid (Reclast) is given as an annual intravenous infusion. Bisphosphonates reduce spine and hip fracture risk by 40 to 70 percent. They work by inhibiting osteoclast activity, slowing bone resorption. Oral bisphosphonates must be taken on an empty stomach with a full glass of water and the patient must remain upright for 30 to 60 minutes to prevent esophageal irritation.
Denosumab (Prolia) is a monoclonal antibody given as a subcutaneous injection every 6 months. It inhibits RANK ligand, a key mediator of osteoclast formation. Denosumab is highly effective and does not require renal dose adjustment, making it a good option for patients with kidney impairment. However, discontinuation of denosumab can lead to a rapid rebound in bone loss and an increased risk of vertebral fractures, so transition to another agent is necessary if denosumab is stopped.
Anabolic Medications
Teriparatide (Forteo) and abaloparatide (Tymlos) are parathyroid hormone analogs that stimulate new bone formation rather than simply slowing breakdown. They are given as daily subcutaneous injections for up to 2 years and are typically reserved for patients with severe osteoporosis, multiple fractures, or those who fail bisphosphonate therapy. Romosozumab (Evenity) is a sclerostin inhibitor with both bone-building and antiresorptive properties, given as monthly injections for 12 months. It produces the largest gains in bone density of any available agent but carries a cardiovascular safety signal and is not recommended for patients at high cardiovascular risk.
After completing a course of anabolic therapy, patients must transition to an antiresorptive agent (typically a bisphosphonate or denosumab) to maintain the bone density gains achieved. Understanding the cost landscape of these medications is relevant, as anabolic agents are significantly more expensive than bisphosphonates.
Fall Prevention
Since most fractures result from falls, a comprehensive osteoporosis management plan must include fall prevention. The CDC reports that one in four Americans aged 65 and older falls each year, and falls are the leading cause of injury-related death in this age group.
Home safety modifications include removing tripping hazards (loose rugs, clutter, electrical cords), installing grab bars in bathrooms, improving lighting, and using non-slip mats. Regular vision checks are important, as impaired vision increases fall risk. Medication review is essential — sedatives, antihypertensives, and polypharmacy are all associated with increased fall risk. Footwear matters: well-fitting, low-heeled shoes with non-slip soles are safer than slippers, socks, or high heels.
Exercise programs that incorporate balance training have been shown to reduce fall rates by approximately 23 percent. Tai chi, in particular, has strong evidence supporting its effectiveness in fall prevention among older adults. Physical therapy can help individuals with gait or balance impairments develop personalized exercise plans.
Frequently Asked Questions
Can osteoporosis be reversed?
Medications can significantly increase bone density and reduce fracture risk, but they don’t fully restore bone to its peak-density state. Anabolic agents like teriparatide and romosozumab produce the most substantial density gains — some patients see improvements large enough to reclassify from osteoporosis to osteopenia. Even bisphosphonates increase bone density modestly while dramatically reducing fracture risk. “Reversal” may not be the right word, but meaningful, clinically important improvement is absolutely achievable.
How often should I get a bone density test?
For women beginning screening at age 65 with normal bone density, repeat testing in 10 to 15 years is generally adequate. For women with osteopenia, the interval depends on the degree of bone loss — mild osteopenia may warrant retesting in 3 to 5 years, while more significant osteopenia warrants retesting in 1 to 2 years. If you’re on treatment for osteoporosis, your doctor will typically repeat DEXA every 1 to 2 years to monitor response.
Do men get osteoporosis?
Yes. Approximately 2 million American men have osteoporosis, and up to 25 percent of hip fractures occur in men. Men tend to develop osteoporosis later than women because they start with higher peak bone mass and don’t experience the abrupt hormonal decline of menopause. However, age-related testosterone decline, long-term corticosteroid use, hypogonadism, and other secondary causes contribute to male osteoporosis. It is underdiagnosed and undertreated in men.
Are there side effects of osteoporosis medications?
All medications carry potential side effects. Oral bisphosphonates can cause gastrointestinal irritation — taking them correctly (empty stomach, upright position, full glass of water) minimizes this. Rare but serious side effects of long-term bisphosphonate and denosumab use include osteonecrosis of the jaw (estimated at 1 in 10,000 to 100,000 patient-years for oral bisphosphonates) and atypical femur fractures. These rare risks must be weighed against the well-documented benefits of fracture prevention. Your doctor will help you navigate this balance.
Is osteopenia the same as osteoporosis?
No. Osteopenia is a category between normal bone density and osteoporosis — a T-score between -1.0 and -2.5. It indicates lower-than-normal bone density but doesn’t always require medication. Many people with osteopenia manage well with lifestyle measures: adequate calcium and vitamin D, weight-bearing exercise, and fall prevention. However, if FRAX scoring indicates high fracture risk, or if there’s a history of fragility fracture, medication may be appropriate even with osteopenia.
Protecting Your Bones: What to Do Now
If you’re a woman over 65, a man over 70, or a younger adult with risk factors, get a DEXA scan if you haven’t already. If you’ve been diagnosed with osteoporosis or osteopenia, work with your doctor to develop a comprehensive plan that addresses both bone health and fall prevention. Don’t wait for a fracture to take action — the consequences of hip and vertebral fractures are too significant to leave to chance.
Regardless of your current bone density, the fundamentals apply at every age: get enough calcium and vitamin D (from food first, supplements as needed), engage in regular weight-bearing and resistance exercise, don’t smoke, limit alcohol, and create a safe home environment. If you’re taking corticosteroids or other bone-depleting medications, discuss bone protection strategies with your prescribing physician.
Osteoporosis may be silent, but the fractures it causes are anything but. With current screening tools, effective medications, and evidence-based prevention strategies, this is a disease where early intervention and consistent management can preserve your mobility, independence, and quality of life for years to come.