Last updated: September 18, 2023

Summarytoggle arrow icon

Osteoporosis is a skeletal condition in which the loss of bone mineral density (BMD) leads to decreased bone strength and increased susceptibility to fractures. Postmenopausal women and older adults are often affected, as an abrupt decrease in estrogen and age-related processes play a key role in the development of osteoporosis. Additional risk factors include physical inactivity, a diet low in calcium and vitamin D, smoking, and alcohol consumption. Osteoporosis usually remains asymptomatic until the first occurrence of a fragility fracture (typically following minor trauma). Patients may also present with thoracic hyperkyphosis and height loss secondary to multiple vertebral compression fractures. Diagnostic evaluation includes BMD assessment (e.g., dual-energy x-ray absorptiometry), fracture risk assessment, and workup for common causes of secondary osteoporosis. Fractures are usually confirmed through conventional x-ray. Pharmacotherapy is indicated in patients who fulfill the diagnostic criteria for osteoporosis. Bisphosphonates, which inhibit bone resorption and can significantly decrease the risk of fractures, are the preferred first-line treatment. Nonbisphosphonates are indicated in patients who are unable to take bisphosphonates and those in whom bisphosphonate therapy has been unsuccessful. Prevention mainly comprises of adequate calcium and vitamin D intake and regular physical activity with strengthening exercises to maintain or even increase bone mass and improve balance, thereby reducing the risk of falls and fragility fractures. High-risk individuals should be offered screening for osteoporosis and pharmacotherapy should be initiated in those with osteopenia at a high risk of fractures.

Definitiontoggle arrow icon

  • Osteoporosis: loss of trabecular and cortical bone mass which leads to bone weakness and increased susceptibility to fractures
  • Osteopenia: decreased bone strength but less severe than osteoporosis

Epidemiologytoggle arrow icon

  • Sex: > (∼ 4:1)
  • Age of onset: 50–70 years
  • Demographics: higher incidence in individuals of Asian, Hispanic, and northern European ancestry [1]

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Primary osteoporosis (most common)

Secondary osteoporosis

Additional risk factors [7]

Clinical featurestoggle arrow icon

Diagnosticstoggle arrow icon

Approach [10]

Osteoporosis is typically identified during screening in high-risk individuals (see “Screening for osteoporosis”).

Osteoporosis is diagnosed in patients with a T-score ≤ -2.5 SD and/or a fragility fracture. [10]

Bone mineral density (BMD) assessment [10][11]


Preferred modality: dual-energy x-ray absorptiometry

DXA measures BMD; at the lumbar spine and hip/femoral neck using two x-ray beams. Findings are represented in terms of BMD scores that compare results to a reference population.

BMD scores [10][11]
Postmenopausal women and men > 50 years of age
  • BMD is calculated using the T-score.
  • T-score ≤ -2.5 SD indicates osteoporosis [10][11]
  • T-score -1 to -2.5 SD indicates osteopenia [10][11]
  • T-score ≥ -1 SD is normal [10][11]
All other individuals
  • BMD is calculated using the Z-score.
  • Z-score < -2 indicates BMD likely lower than expected for age [10][11]

DXA evaluates bone quantity. The trabecular bone score uses data from DXA images to evaluate bone quality and may sometimes be used to further stratify fracture risk. [12]

Alternatives [11][13]

These studies are most commonly used when conventional DXA is unavailable.

Fracture risk assessment [10]

Laboratory studies [7][10]

Consider screening all patients with newly diagnosed osteoporosis for common causes of secondary osteoporosis and potential contraindications for certain pharmacotherapy.

Treat vitamin D deficiency and ensure at least 2 weeks of recommended daily intake of calcium before obtaining 24-hour urine calcium. [10]

Screening for vertebral fractures [10][11][16][17]

Vertebral fractures are common in patients with osteoporosis, asymptomatic in up to two-thirds of cases, and associated with a high risk of future fractures.

Imaging for other skeletal fractures [10][19]

Pathologytoggle arrow icon

  • Thin, disconnected trabecular structures
  • Attenuated, pitted cortical bone
  • Increased osteoclast number and activity

Differential diagnosestoggle arrow icon

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [7][10]

Pharmacotherapy for osteoporosis [10][23]

Indications [10]

General principles [10]

Bisphosphonates for osteoporosis [7][10]

Oral bisphosphonates should be taken in the morning with plenty of water at least 30 minutes before food and other medication, and the patient should maintain an upright position for at least 30 minutes after intake to prevent esophagitis. [14]

Alendronate, risedronate, and zoledronic acid reduce hip, vertebral, and nonvertebral fracture risk; ibandronate reduces vertebral fracture risk only. [7]

Nonbisphosphonates [7][10][20]

Nonbisphosphonates for the treatment of osteoporosis [7][10][20]
Specific indications [10][24] Mechanism of action Potential adverse effects
Denosumab [7][10]

PTH and PTH-related protein analogue

  • Teriparatide [7]
  • Abaloparatide [7]
Romosozumab [30]
  • Monoclonal antibody against sclerostin
  • Acts by increasing bone formation and reducing bone resorption
Raloxifene [7]
  • Can be used in patients at increased risk of breast cancer [31]
Calcitonin [10]
  • Inhibits bone resorption (monitor BMD) [33]
  • May increase overall cancer risk [7]
Hormonal therapy

Estrogen is not approved for the treatment of osteoporosis in women; if estrogen is prescribed to a patient with a uterus, it should always be combined with progesterone therapy to reduce the risk of endometrial hyperplasia. [10][20]

Monitoring and follow-up [10][14][20]

  • Regularly review patients to assess for problems with adherence; see “Managing chronic conditions.”
  • Consider BTMs to assess treatment efficacy and adherence. [10]
  • Measure height yearly; if there is a ≥ 2 cm height loss, repeat imaging for vertebral fractures.
  • Obtain DXA every 1–2 years for patients on treatment to monitor response. [10]
  • Markers of improvement: stable or increasing BMD, no new fractures, normal or low BTMs
  • If there is inadequate improvement : [10]
    • Consider alternative agents or reevaluate for secondary osteoporosis.
    • Consider referral to a clinical endocrinologist or osteoporosis specialist, if available.
Duration of pharmacotherapy for osteoporosis [10]
Duration of therapy Additional considerations
Abaloparatide, teriparatide
  • 2 years
  • 1 year
  • Indefinite
  • Transition to another antiresorptive agent.

The benefits of nonbisphosphonates are lost rapidly after discontinuation; initiate another treatment for osteoporosis after cessation. [10][14]

Preventiontoggle arrow icon

Screeningtoggle arrow icon


Screening recommendations vary. The following recommendations are mainly consistent with the 2018 US Preventive Services Task Force (USPSTF). [13]

  • Screening is recommended in:
    • Women ≥ 65 years of age
    • Women < 65 years of age at increased risk of osteoporosis as determined by a clinical risk assessment tool (e.g., osteoporosis risk assessment instrument, osteoporosis self-assessment tool, FRAX)
    • Individuals with a history of low-trauma fracture after 50 years of age [10]
  • There is insufficient evidence to recommend routine screening for osteoporosis in men; consider screening:

Screening modality and further management [13]

(in SD)

Suggested intervals for repeat BMD assessment [37]
-2.0 to -2.4 within 3 years
-1.5 to -1.9 3–5 years
-1.0 to -1.4 5–10 years
> -1.0 > 10 years

Short-interval (within 2–3 years) reassessment of BMD in individuals who do not fulfill the diagnostic criteria for osteoporosis is not routinely recommended. [7][37]

Referencestoggle arrow icon

  1. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014; 25 (10): p.2359-2381.doi: 10.1007/s00198-014-2794-2 . | Open in Read by QxMD
  2. Jeremiah MP, Unwin BK, Greenawald MH, Casiano VE. Diagnosis and Management of Osteoporosis. Am Fam Physician. 2015; 92 (4): p.261-8.
  3. Buckley L, Humphrey MB. Glucocorticoid-Induced Osteoporosis. N Engl J Med. 2018; 379 (26): p.2547-2556.doi: 10.1056/nejmcp1800214 . | Open in Read by QxMD
  4. Curry SJ, Krist AH, et al. Screening for Osteoporosis to Prevent Fractures. JAMA. 2018; 319 (24): p.2521-2531.doi: 10.1001/jama.2018.7498 . | Open in Read by QxMD
  5. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis—2020 Update. Endocr Pract. 2020; 26 (Supp 1): p.1-46.doi: 10.4158/gl-2020-0524suppl . | Open in Read by QxMD
  6. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2012; 97 (6): p.1802-1822.doi: 10.1210/jc.2011-3045 . | Open in Read by QxMD
  7. Choksi P, Gay BL, Reyes-Gastelum D, Haymart MR, Papaleontiou M. Understanding Osteoporosis Screening Practices in Men: A Nationwide Physician Survey. Endocr Pract. 2020; 26 (11): p.1237-1243.doi: 10.4158/EP-2020-0123 . | Open in Read by QxMD
  8. Joseph SY, Nidhi GK, Michael GF et al. Osteoporosis and Bone Mineral Density. J Am Coll Radiol. 2022.
  9. Leslie WD, Crandall CJ. Serial Bone Density Measurement for Osteoporosis Screening. JAMA. 2021; 326 (16): p.1622.doi: 10.1001/jama.2021.9858 . | Open in Read by QxMD
  10. American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 141: management of menopausal symptoms. Obstet Gynecol. 2014; 123 (1): p.202-16.doi: 10.1097/01.AOG.0000441353.20693.78 . | Open in Read by QxMD
  11. Stuenkel CA, Davis SR, Gompel A, et al. Treatment of Symptoms of the Menopause: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2015; 100 (11): p.3975-4011.doi: 10.1210/jc.2015-2236 . | Open in Read by QxMD
  12. Percentage of Adults Aged 65 and Over With Osteoporosis or Low Bone Mass at the Femur Neck or Lumbar Spine: United States, 2005–2010. . Accessed: November 6, 2020.
  13. Karlamangla AS, Burnett-Bowie SAM, Crandall CJ. Bone Health During the Menopause Transition and Beyond. Obstet Gynecol Clin North Am. 2018; 45 (4): p.695-708.doi: 10.1016/j.ogc.2018.07.012 . | Open in Read by QxMD
  14. Pouresmaeili F, Kamali Dehghan B, Kamarehei M, Yong Meng G. A comprehensive overview on osteoporosis and its risk factors. Ther Clin Risk Manag. 2018; Volume 14: p.2029-2049.doi: 10.2147/tcrm.s138000 . | Open in Read by QxMD
  15. Juvenile Osteoporosis. Updated: October 1, 2018. Accessed: November 5, 2020.
  16. Rozenberg S, Bruyère O, Bergmann P, et al. How to manage osteoporosis before the age of 50. Maturitas. 2020; 138: p.14-25.doi: 10.1016/j.maturitas.2020.05.004 . | Open in Read by QxMD
  17. Panday K, Gona A, Humphrey MB. Medication-induced osteoporosis: screening and treatment strategies. Ther Clin Risk Manag. 2014; 6 (5): p.185-202.doi: 10.1177/1759720x14546350 . | Open in Read by QxMD
  18. Rogerson D. Vegan diets: practical advice for athletes and exercisers. J Int Soc Sports Nutr. 2017; 14 (1).doi: 10.1186/s12970-017-0192-9 . | Open in Read by QxMD
  19. Piccirilli E, Cariati I, Primavera M, Triolo R, Gasbarra E, Tarantino U. Augmentation in fragility fractures, bone of contention: a systematic review. BMC Musculoskelet Disord. 2022; 23 (1).doi: 10.1186/s12891-022-06022-0 . | Open in Read by QxMD
  20. Harvey NC, Glüer CC, Binkley N, et al. Trabecular bone score (TBS) as a new complementary approach for osteoporosis evaluation in clinical practice.. Bone. 2015; 78: p.216-24.doi: 10.1016/j.bone.2015.05.016 . | Open in Read by QxMD
  21. Bauer DC. Clinical Use of Bone Turnover Markers. JAMA. 2019; 322 (6): p.569-570.doi: 10.1001/jama.2019.9372 . | Open in Read by QxMD
  22. Ward RJ, Roberts CC, Bencardino JT, et al. ACR Appropriateness Criteria ® Osteoporosis and Bone Mineral Density. J Am Coll Radiol. 2017; 14 (5S): p.S189-S202.doi: 10.1016/j.jacr.2017.02.018 . | Open in Read by QxMD
  23. McCarthy J, Davis A. Diagnosis and Management of Vertebral Compression Fractures.. Am Fam Physician. 2016; 94 (1): p.44-50.
  24. Tegola L, Mattera M, Cornacchia S, Cheng X, Guglielmi G. Diagnostic imaging of two related chronic diseases: Sarcopenia and Osteoporosis.. J Frailty Sarcopenia Falls. 2018; 3 (3): p.138-147.doi: 10.22540/JFSF-03-138 . | Open in Read by QxMD
  25. Guglielmi G, Muscarella S, Bazzocchi A. Integrated Imaging Approach to Osteoporosis: State-of-the-Art Review and Update. RadioGraphics. 2011; 31 (5): p.1343-1364.doi: 10.1148/rg.315105712 . | Open in Read by QxMD
  26. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society* Clinical Practice Guideline. J Clin Endocrinol Metab. 2019; 104 (5): p.1595-1622.doi: 10.1210/jc.2019-00221 . | Open in Read by QxMD
  27. Shane E, Burr D, Abrahamsen B, et al. Atypical Subtrochanteric and Diaphyseal Femoral Fractures: Second Report of a Task Force of the American Society for Bone and Mineral Research. J Bone Miner Res. 2013; 29 (1): p.1-23.doi: 10.1002/jbmr.1998 . | Open in Read by QxMD
  28. Grossman DC, Curry SJ, et al. Interventions to Prevent Falls in Community-Dwelling Older Adults. JAMA. 2018; 319 (16): p.1696.doi: 10.1001/jama.2018.3097 . | Open in Read by QxMD
  29. Qaseem A, Hicks LA, Etxeandia-Ikobaltzeta I, et al. Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med. 2023; 176 (2): p.224-238.doi: 10.7326/m22-1034 . | Open in Read by QxMD
  30. Chotiyarnwong P, McCloskey EV. Pathogenesis of glucocorticoid-induced osteoporosis and options for treatment. Nat. Rev. Endocrinol.. 2020; 16 (8): p.437-447.doi: 10.1038/s41574-020-0341-0 . | Open in Read by QxMD
  31. Kennel KA, Drake MT. Adverse Effects of Bisphosphonates: Implications for Osteoporosis Management. Mayo Clinic Proceedings. 2009; 84 (7): p.632-638.doi: 10.1016/s0025-6196(11)60752-0 . | Open in Read by QxMD
  32. Dubois EA, Rissmann R, Cohen AF. Denosumab. Br J Clin Pharmacol. 2011; 71 (6): p.804-806.doi: 10.1111/j.1365-2125.2011.03969.x . | Open in Read by QxMD
  33. Hodsman AB, Bauer DC, Dempster DW, et al. Parathyroid Hormone and Teriparatide for the Treatment of Osteoporosis: A Review of the Evidence and Suggested Guidelines for Its Use. Endocr Rev. 2005; 26 (5): p.688-703.doi: 10.1210/er.2004-0006 . | Open in Read by QxMD
  34. Thompson JC, Wanderman N, Anderson PA, Freedman BA. Abaloparatide and the Spine: A Narrative Review. Clin Interv Aging. 2020; 15: p.1023-1033.doi: 10.2147/cia.s227611 . | Open in Read by QxMD
  35. Shoback D, Rosen CJ, Black DM, Cheung AM, Murad MH, Eastell R. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. The Journal of Clinical Endocrinology & Metabolism. 2020; 105 (3): p.587-594.doi: 10.1210/clinem/dgaa048 . | Open in Read by QxMD
  36. Cummings SR, Eckert S, Krueger KA, et al. The Effect of Raloxifene on Risk of Breast Cancer in Postmenopausal Women. JAMA. 1999; 281 (23): p.2189.doi: 10.1001/jama.281.23.2189 . | Open in Read by QxMD
  37. Knopp-Sihota JA, Newburn-Cook CV, Homik J, Cummings GG, Voaklander D. Calcitonin for treating acute and chronic pain of recent and remote osteoporotic vertebral compression fractures: a systematic review and meta-analysis. Osteoporos Int. 2011; 23 (1): p.17-38.doi: 10.1007/s00198-011-1676-0 . | Open in Read by QxMD
  38. Naot D, Musson DS, Cornish J. The Activity of Peptides of the Calcitonin Family in Bone. Physiol Rev. 2019; 99 (1): p.781-805.doi: 10.1152/physrev.00066.2017 . | Open in Read by QxMD
  39. Manolagas SC, O’Brien CA, Almeida M. The role of estrogen and androgen receptors in bone health and disease. Nat Rev Endocrinol. 2013; 9 (12): p.699-712.doi: 10.1038/nrendo.2013.179 . | Open in Read by QxMD

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer