Osteoporosis is a skeletal condition in which the loss of bone mineral density leads to decreased bone strength and an increased susceptibility to fractures. The disease typically affects postmenopausal women and the elderly, as an abrupt decrease in estrogen and age-related processes play a key role in the development of osteoporosis. Further risk factors include inactivity, smoking, and alcohol consumption. Osteoporosis usually remains asymptomatic until the first occurrence of fragility fractures (following minor trauma), particularly of the vertebrae. After repeated vertebral fractures, patients may also develop thoracic hyperkyphosis and lose height. Osteoporosis is diagnosed through a bone density test ( ), while fractures are usually confirmed through conventional x-ray. Management of osteoporosis includes prophylactic measures and medical therapy. The prophylaxis consists mainly of adequate intake of calcium and vitamin D and regular physical activity with strengthening exercises. Both help to maintain or even increase bone mass and improve balance, thereby reducing the risk of falling. Medical therapy is indicated in cases of severely reduced bone density or osteoporotic fractures. The most commonly used drugs are bisphosphonates, which inhibit bone resorption and can significantly decrease the risk of fractures. There are several other possible medical therapies (e.g., teriparatide, raloxifene), which may be indicated in special cases (e.g., severe osteoporosis, breast cancer prophylaxis required) or if patients have contraindications to bisphosphonates.
Primary osteoporosis (most common form)
- Type I (postmenopausal osteoporosis): postmenopausal women 
- Type II (senile osteoporosis): gradual loss of bone mass as patients age (especially > 70 years)
- Idiopathic osteoporosis
- Most commonly due to systemic long-term therapy with corticosteroids (e.g., in patients with autoimmune disease) 
- Long-term therapy involving: 
- Endocrine/metabolic: hypercortisolism, hypogonadism, hyperthyroidism, hyperparathyroidism, renal disease
- Multiple myeloma
- Excessive alcohol consumption
- Risk factor for osteoporosis
- Mostly asymptomatic
Fragility fractures: that are caused by everyday-activities (e.g., bending over, sneezing) or minor trauma (e.g. falling from standing height) 
- Common locations: vertebral (most common) > femoral neck > distal radius () > other long bones (e.g., humerus)
- Definition: : a noninvasive technique that calculates bone mineral density (BMD) by using two x-ray beams 
- Measurement sites: lumbar spine and femoral neck
- Indications 
- Results: T-score is defined as the difference in standard deviations between the patient's BMD and the BMD of a young adult female reference mean.
- If osteoporosis is diagnosed: Radiographic assessment of the whole skeletal system is recommended, particularly if a fracture is already suspected or height loss has occurred.
- Increased radiolucency is detectable in cortical bones once 30–50% of bone mineral has been lost 
- Osteoporosis can be diagnosed if vertebral compression fractures are present ; commonly an incidental finding because such fractures are typically asymptomatic.
Used for the measurement of true bone volume density in g/cm3
Usually normal findings, but some markers may be used for assessing the risk of fracture . See “” for more information.
- Urine: ↑ cross-links (e.g., deoxypyridinoline) , markers of bone turnover 
- Blood tests 
- Thin, disconnected trabecular structures
- Attenuated, pitted cortical bone
- Increased osteoclast number and activity
The differential diagnoses listed here are not exhaustive.
Medical therapy 
- History of fragility fractures
- T-scores ≤ -2.5
- T-score between -1 and -2.5 with severely increased risk of fracture
Drug of choice
- Bisphosphonates: e.g., alendronate, risedronate
Bisphosphonates should be taken in the morning and evening at least 30 minutes before meals, with plenty of water, and the patient should maintain an upright position for at least 30 minutes following intake to prevent esophagitis. 
Alternative drugs 
Used in the case of contraindications/unresponsiveness to bisphosphonates.
Teriparatide: parathyroid hormone analog
- Mechanism of action: increases osteoblastic activity → increased bone growth
- Mainly used for the treatment of osteoporosis and as an alternative for severe osteoporosis (T-score ≤ -3.5) or for patients with contraindications to bisphosphonates 
- Administered in a pulsatile fashion
- Side effects
- Raloxifene: (selective estrogen receptor modulator, SERM) for patients with contraindications to bisphosphonates or those who also require breast cancer prophylaxis (but increases the risk of thromboembolism) 
- Denosumab (monoclonal antibody against RANKL)
- Rarely used today due to the availability of more effective alternatives 
- Indicated in postmenopausal osteoporosis
- Hormonal therapy 
Denosumab makes you dance.