Osteoporosis: Symptoms, Risk Factors & Treatment

What Is Osteoporosis?

Osteoporosis is a bone disease characterized by decreased bone density and deterioration of bone tissue, leading to increased fragility and risk of fractures. The name literally means "porous bones." Approximately 200 million people worldwide are affected by osteoporosis, with 1 in 3 women and 1 in 5 men over age 50 experiencing osteoporotic fractures in their lifetime.

Osteoporosis develops when the body loses too much bone, makes too little bone, or both. As a result, bones become weak and may break from a minor fall or, in severe cases, from simple actions like sneezing or bumping into furniture. Healthy bone has a honeycomb-like structure under a microscope. In osteoporosis, the holes and spaces in this honeycomb become much larger, meaning the bone has lost density and the outer shell has become thinner.

The condition is often called a "silent disease" because you cannot feel your bones getting weaker, and many people don't know they have osteoporosis until they break a bone. The most common fractures associated with osteoporosis occur in the hip, spine (vertebrae), and wrist, though other bones can also be affected. These fractures can have serious consequences: hip fractures often require hospitalization and major surgery, while vertebral fractures can cause severe back pain, loss of height, and a hunched posture.

Understanding the difference between normal bone loss that occurs with aging and pathological bone loss (osteoporosis) is important. Everyone loses some bone mass after reaching peak bone density around age 25-30, but osteoporosis occurs when this loss is excessive or when peak bone mass was never optimal. The rate of bone loss varies significantly between individuals and is influenced by genetics, hormones, nutrition, physical activity, and various lifestyle and medical factors.

Understanding Bone Remodeling

Your skeleton is constantly being broken down and rebuilt through a process called bone remodeling. Specialized cells called osteoclasts break down old bone tissue, while osteoblasts build new bone. In healthy young adults, bone formation and resorption are balanced. However, starting around age 30, bone resorption gradually begins to exceed bone formation, leading to a slow decrease in bone density.

Several hormones regulate this process, including estrogen, testosterone, parathyroid hormone, and vitamin D. When these hormones are imbalanced—such as the dramatic drop in estrogen during menopause—bone loss can accelerate significantly. This is why postmenopausal women are at particularly high risk for osteoporosis.

Primary vs. Secondary Osteoporosis

Primary osteoporosis is the most common form and includes age-related bone loss (senile osteoporosis) and postmenopausal osteoporosis. This type develops without an obvious underlying cause and is largely influenced by genetic factors, hormonal changes, and lifestyle.

Secondary osteoporosis occurs as a result of another medical condition or its treatment. Common causes include long-term use of corticosteroid medications, hyperthyroidism, hyperparathyroidism, celiac disease, inflammatory bowel disease, rheumatoid arthritis, and certain cancers. Identifying and treating the underlying cause is essential in managing secondary osteoporosis.

What Are the Symptoms of Osteoporosis?

Osteoporosis typically has no symptoms in its early stages—it is often called the "silent disease." Most people don't know they have osteoporosis until they experience a fracture. Warning signs that may indicate osteoporosis include a broken bone from a minor fall, loss of height over time, developing a stooped or hunched posture, and back pain caused by a fractured or collapsed vertebra.

The silent nature of osteoporosis makes it particularly dangerous. Unlike many other conditions that cause pain or discomfort as warning signs, osteoporosis can progress significantly before any symptoms appear. This is why screening and early detection are so crucial, especially for those with risk factors.

When symptoms do occur, they are typically related to fractures or the consequences of bone loss over time. Understanding these signs can help you recognize when to seek medical evaluation.

Fractures from Minor Trauma

The hallmark sign of osteoporosis is experiencing a fragility fracture—a bone break that occurs from minimal trauma that wouldn't normally cause a fracture in healthy bone. This might include falling from standing height or lower, or in severe cases, fracturing a bone while coughing, sneezing, or performing everyday activities.

The most common sites for osteoporotic fractures are:

• Hip: Often the most serious type of osteoporotic fracture, hip fractures usually require hospitalization and surgery, and can lead to loss of independence and increased mortality risk, especially in older adults
• Spine (vertebrae): Vertebral compression fractures can occur without any obvious injury. They may cause sudden back pain, or in some cases, minimal or no pain. Multiple vertebral fractures lead to loss of height and the characteristic hunched posture
• Wrist: Often the result of trying to catch oneself during a fall. Wrist fractures are common and may be the first sign of underlying osteoporosis
• Upper arm (humerus): Can occur from falling on an outstretched hand or directly onto the shoulder

Loss of Height

Gradual loss of height is an important warning sign that shouldn't be ignored. This occurs when the vertebrae in the spine weaken and compress over time. You should be evaluated for possible osteoporosis if:

• You have lost more than 3 centimeters (about 1.2 inches) in height if you are under 70 years old
• You have lost more than 5 centimeters (about 2 inches) in height if you are over 70 years old

Regular height measurements at medical appointments can help track changes over time and identify potential vertebral fractures.

Postural Changes

As vertebrae weaken and compress, the spine may begin to curve forward, creating a hunched or stooped posture often called a "dowager's hump" (medical term: kyphosis). This curvature develops gradually and can cause:

• Difficulty standing fully upright
• A protruding abdomen due to the curved spine
• Chronic back pain and muscle fatigue
• Reduced mobility and balance problems
• Breathing difficulties in severe cases, as the compressed spine can affect lung capacity

Back Pain

While osteoporosis itself doesn't cause pain, vertebral fractures can cause significant discomfort. This pain may:

• Come on suddenly and be severe, especially with a new fracture
• Be relatively mild or even absent—some vertebral fractures are discovered incidentally on imaging
• Worsen with standing or walking and improve with rest
• Become chronic as multiple fractures accumulate over time

What Causes Osteoporosis and Who Is at Risk?

Osteoporosis is caused by an imbalance between bone formation and bone resorption, leading to net bone loss over time. Risk factors include being female, advancing age, family history, low body weight, smoking, excessive alcohol, certain medications (especially corticosteroids), and conditions affecting nutrient absorption. Women are particularly vulnerable after menopause due to declining estrogen levels.

Understanding the causes and risk factors for osteoporosis is essential for prevention and early intervention. While some risk factors cannot be changed (like age and genetics), many can be modified through lifestyle changes or medical management.

Non-Modifiable Risk Factors

These are factors you cannot change, but knowing about them helps you understand your risk and the importance of screening:

Sex: Women have a significantly higher risk of osteoporosis than men. This is due to several factors: women generally have smaller, thinner bones to begin with, and they experience rapid bone loss during menopause when estrogen levels drop dramatically. By age 65, women have typically lost 30-50% of their bone density.

Age: The risk of osteoporosis increases with age. After reaching peak bone mass around age 25-30, everyone begins to lose bone gradually. This loss accelerates after age 50, and significantly so in women after menopause. By age 80, most people have lost substantial bone density.

Family History: Genetics play an important role in determining your bone density. Having a parent or sibling with osteoporosis or a history of hip fracture puts you at increased risk. Studies suggest that genetics account for 60-80% of the variation in peak bone mass between individuals.

Body Frame Size: People with small body frames tend to have a higher risk because they may have less bone mass to draw from as they age. This is one reason why osteoporosis is more common in certain ethnic groups.

Ethnicity: White and Asian individuals have the highest risk of osteoporosis. However, the condition affects people of all ethnic backgrounds, and African American and Hispanic women remain at significant risk.

Modifiable Risk Factors

These are factors you can potentially change to reduce your risk:

Physical Inactivity: Regular weight-bearing exercise is essential for building and maintaining bone strength. People who spend a lot of time sitting have a higher risk of osteoporosis than those who are more active. Exercise benefits bones throughout life—from childhood (building peak bone mass) to old age (slowing bone loss and reducing fall risk).

Smoking: Tobacco use contributes to weak bones through multiple mechanisms. Smoking interferes with calcium absorption, decreases estrogen levels, impairs osteoblast function, and reduces blood supply to bones. Smokers typically have lower bone density and higher fracture rates than non-smokers.

Excessive Alcohol: Regularly drinking more than two alcoholic drinks per day increases the risk of osteoporosis. Alcohol interferes with the body's ability to absorb calcium and vitamin D, affects hormones that regulate bone metabolism, and increases the risk of falls.

Poor Nutrition: A diet low in calcium and vitamin D significantly increases osteoporosis risk. Calcium is a crucial building block of bone, and vitamin D is essential for calcium absorption. Other nutritional factors that affect bone health include adequate protein intake and maintaining a healthy body weight—being significantly underweight is a risk factor.

Medical Conditions That Increase Risk

Several medical conditions can contribute to bone loss:

• Hormonal disorders: Hyperthyroidism, hyperparathyroidism, Cushing's syndrome, and hypogonadism (low sex hormones)
• Digestive disorders: Celiac disease, inflammatory bowel disease, and conditions that cause malabsorption
• Autoimmune conditions: Rheumatoid arthritis and systemic lupus erythematosus (SLE)
• Eating disorders: Anorexia nervosa significantly reduces bone density
• Chronic kidney or liver disease
• Multiple myeloma and certain cancers

Medications That Can Cause Bone Loss

Corticosteroids (such as prednisone) are the most common medications causing secondary osteoporosis. Long-term use—generally defined as more than three months—significantly increases fracture risk. Other medications that can affect bone health include:

• Certain anti-seizure medications
• Long-term heparin therapy
• Aromatase inhibitors (used for breast cancer)
• Androgen deprivation therapy (used for prostate cancer)
• Proton pump inhibitors (long-term use)
• Some antidepressants (SSRIs)

How Is Osteoporosis Diagnosed?

Osteoporosis is diagnosed primarily through a DXA scan (dual-energy X-ray absorptiometry), which measures bone mineral density. Results are reported as a T-score: normal is -1.0 or above, osteopenia (low bone mass) is between -1.0 and -2.5, and osteoporosis is -2.5 or below. Additional tests may include blood work and the FRAX tool to calculate your 10-year fracture risk.

Because osteoporosis has no symptoms until a fracture occurs, diagnosis typically involves either routine screening based on risk factors or evaluation following a suspected fragility fracture. Early diagnosis is crucial for preventing future fractures.

Medical History and Physical Examination

Your doctor will begin by taking a comprehensive medical history, asking about:

• Previous fractures and how they occurred
• Family history of osteoporosis or fractures, especially hip fractures in parents
• Medications you take, particularly corticosteroids
• Medical conditions that can affect bone health
• Lifestyle factors: diet, exercise, smoking, alcohol use
• For women: menstrual history and menopausal status

The physical examination includes measuring your height and comparing it to previous measurements. Your posture will be assessed for signs of vertebral fractures (kyphosis). Your doctor may also evaluate your balance and muscle strength, as these affect fall risk.

Bone Density Testing (DXA Scan)

The DXA scan (also written as DEXA) is the gold standard for diagnosing osteoporosis. This painless, non-invasive test uses very low-dose X-rays to measure bone mineral density, typically at the hip and spine—the areas most likely to experience osteoporotic fractures.

No special preparation is needed for a DXA scan. You'll lie on a padded table while a scanning arm passes over your body. The test takes about 10-20 minutes and involves much less radiation than a standard X-ray or CT scan.

Results are reported as T-scores, which compare your bone density to that of a healthy 30-year-old adult of the same sex:

FRAX Tool

The FRAX (Fracture Risk Assessment Tool) is a computer-based algorithm developed by the World Health Organization that calculates your 10-year probability of having a major osteoporotic fracture (spine, hip, forearm, or upper arm) and your 10-year probability of hip fracture specifically.

FRAX uses clinical risk factors either alone or combined with bone density measurements. This tool helps doctors decide who needs treatment, particularly for patients with osteopenia who might not meet the traditional definition of osteoporosis but have high fracture risk due to other factors.

Additional Tests

Your doctor may order additional tests to identify underlying causes of bone loss or to rule out other conditions:

Blood tests may include:

• Calcium and phosphorus levels
• Vitamin D level (25-hydroxyvitamin D)
• Thyroid function tests
• Parathyroid hormone (PTH)
• Kidney and liver function tests
• Complete blood count
• In some cases, markers of bone turnover

Vertebral imaging using X-ray or DXA lateral spine imaging may be performed to detect vertebral fractures that haven't caused symptoms. Many vertebral fractures are asymptomatic but still indicate significant osteoporosis and predict future fracture risk.

Who Should Be Screened?

Bone density screening is generally recommended for:

• All women age 65 and older
• All men age 70 and older
• Postmenopausal women under 65 with risk factors
• Men ages 50-69 with risk factors
• Anyone who has had a fracture after age 50
• Anyone taking medications known to cause bone loss
• Anyone with medical conditions associated with bone loss

How Can I Prevent Osteoporosis?

Prevention of osteoporosis involves building strong bones in youth and minimizing bone loss as you age. Key strategies include regular weight-bearing and muscle-strengthening exercises, adequate calcium (1,000-1,200 mg daily) and vitamin D (600-800 IU daily, more if deficient) intake, avoiding smoking, limiting alcohol, and maintaining a healthy body weight. Prevention should start early—bone health habits in childhood and young adulthood significantly impact lifelong bone strength.

While some risk factors for osteoporosis cannot be changed, many can be modified through lifestyle choices. Prevention strategies are most effective when started early in life but can benefit bone health at any age.

Physical Activity and Exercise

Regular physical activity is one of the most effective ways to build and maintain strong bones. Exercise benefits bones in several ways: it stimulates bone formation, helps maintain existing bone mass, improves muscle strength and balance (reducing fall risk), and promotes overall health.

The best exercises for bone health include:

Weight-bearing exercises: Activities where your bones and muscles work against gravity as your feet and legs bear your weight. Examples include walking, jogging, hiking, dancing, stair climbing, and tennis. These exercises are especially good for the bones in the lower body.

Resistance training: Using weights, resistance bands, or your own body weight to strengthen muscles. Strong muscles help protect bones and improve balance. Examples include weightlifting, using resistance bands, push-ups, and squats.

Balance and coordination exercises: Activities like tai chi, yoga, and specific balance training can significantly reduce the risk of falls. This is particularly important for older adults and those already diagnosed with osteoporosis.

Aim for at least 30 minutes of weight-bearing exercise most days of the week, plus muscle-strengthening activities at least twice a week. If you haven't been active, start slowly and build up gradually. A physical therapist can help design a safe and effective exercise program, especially if you already have osteoporosis.

Nutrition for Bone Health

Calcium is the primary building block of bone. The recommended daily intake varies by age and sex:

• Adults 19-50: 1,000 mg per day
• Women over 50: 1,200 mg per day
• Men over 70: 1,200 mg per day

Good dietary sources of calcium include dairy products (milk, cheese, yogurt), fortified plant-based milk alternatives, leafy green vegetables (kale, bok choy, broccoli), fortified foods (cereals, orange juice), canned fish with bones (sardines, salmon), and tofu made with calcium sulfate.

Vitamin D is essential for calcium absorption. Without adequate vitamin D, your body cannot effectively use the calcium you consume. Recommended daily intake is 600-800 IU (15-20 mcg), though many experts recommend higher amounts, especially for those at risk of deficiency.

Vitamin D sources include sunlight exposure (about 10-30 minutes of midday sun several times per week for most people), fatty fish (salmon, mackerel, sardines), fortified foods (milk, cereals, some orange juice), egg yolks, and supplements when dietary intake is insufficient.

Lifestyle Modifications

Quit smoking: If you smoke, quitting is one of the most important things you can do for your bone health (and overall health). Smoking accelerates bone loss and increases fracture risk. The benefits of quitting begin immediately and continue to accrue over time.

Limit alcohol: If you drink alcohol, do so in moderation—no more than one drink per day for women and two for men. Excessive alcohol interferes with calcium balance and bone formation.

Maintain a healthy weight: Being underweight (BMI below 18.5) is a risk factor for osteoporosis. However, extreme weight loss or gain should be avoided, as both can negatively affect bone health.

Building Strong Bones in Youth

The best time to build bone is during childhood and adolescence, when bones are growing rapidly. Peak bone mass is typically reached by age 25-30, and the greater your peak bone mass, the more "bone in the bank" you have as you age.

Young people can maximize their bone health through regular physical activity (especially activities that stress the bones), adequate calcium and vitamin D intake through diet, and avoiding smoking and excessive alcohol. Parents should encourage children to participate in weight-bearing sports and activities and ensure they consume calcium-rich foods.

How Is Osteoporosis Treated?

Treatment for osteoporosis aims to reduce fracture risk through a combination of lifestyle measures and medications. Medications include bisphosphonates (most common first-line treatment), denosumab, selective estrogen receptor modulators (SERMs), and bone-building agents like teriparatide and romosozumab. All medication treatments require adequate calcium and vitamin D intake to be effective. The choice of treatment depends on individual risk factors and preferences.

The goals of osteoporosis treatment are to prevent fractures, stabilize or increase bone density, and relieve symptoms of fractures when they occur. Treatment decisions are based on your fracture risk, bone density measurements, and individual factors.

Medications for Osteoporosis

Several types of medications are available to treat osteoporosis. They work in different ways—some slow bone breakdown (antiresorptive drugs), while others stimulate bone formation (anabolic drugs).

Bisphosphonates are the most commonly prescribed medications for osteoporosis. They slow down the cells that break down bone (osteoclasts), allowing bone density to increase. Common bisphosphonates include:

• Alendronate (Fosamax): Taken as a weekly or daily pill
• Risedronate (Actonel): Weekly or monthly pill
• Ibandronate (Boniva): Monthly pill or quarterly injection
• Zoledronic acid (Reclast): Annual intravenous infusion

Bisphosphonates can reduce the risk of vertebral fractures by 40-70% and hip fractures by 40-50%. They are generally taken for 3-5 years, after which your doctor will reassess whether to continue treatment.

Denosumab (Prolia) is a monoclonal antibody given as an injection every six months. It works by blocking a protein involved in bone breakdown. Denosumab is effective at increasing bone density and reducing fracture risk. However, bone loss can occur rapidly if the medication is stopped, so careful management is needed.

Selective Estrogen Receptor Modulators (SERMs): Raloxifene (Evista) mimics estrogen's beneficial effects on bone in postmenopausal women while blocking estrogen in other tissues. It reduces the risk of vertebral fractures and is also used in women at high risk for breast cancer.

Anabolic (Bone-Building) Agents:

• Teriparatide (Forteo): A form of parathyroid hormone that stimulates bone formation. Given as daily self-injections for up to two years
• Abaloparatide (Tymlos): Similar to teriparatide, given as daily injections
• Romosozumab (Evenity): Monthly injections that both build bone and slow bone breakdown. Used for 12 months in patients at very high fracture risk

Anabolic agents are typically reserved for patients at very high fracture risk or those who haven't responded to other treatments. They are usually followed by an antiresorptive medication to maintain the bone density gained.

Calcium and Vitamin D Supplementation

Adequate calcium and vitamin D are essential for any osteoporosis medication to work effectively. Your doctor will assess your dietary intake and may recommend supplements to ensure you're getting enough. The usual recommendation during treatment is 1,000-1,200 mg of calcium and 800-2,000 IU of vitamin D daily, though individual needs vary.

Treating Secondary Osteoporosis

If your osteoporosis is caused by an underlying condition or medication, treating that cause is an important part of management. For example:

• If you have celiac disease, following a strict gluten-free diet improves calcium absorption
• If you have hyperthyroidism, treating it helps prevent further bone loss
• If you take corticosteroids, your doctor may prescribe bone-protective medication prophylactically

Monitoring Treatment

After starting treatment, your doctor will monitor your response through:

• Follow-up DXA scans: Usually performed every 1-2 years to track bone density changes
• Bone turnover markers: Blood or urine tests that can show whether treatment is working, sometimes used to monitor response before changes are visible on DXA
• Clinical assessment: Regular evaluation of symptoms, side effects, and any new fractures

How Can I Prevent Falls and Fractures?

For people with osteoporosis, preventing falls is just as important as treating bone loss. Fall prevention strategies include removing tripping hazards from your home, improving lighting, installing grab bars and handrails, wearing appropriate footwear, using assistive devices if needed, having regular vision and hearing checks, reviewing medications that may affect balance, and participating in exercise programs that improve strength and balance.

More than 90% of hip fractures are caused by falls, most often by falling sideways. For someone with osteoporosis, even a minor fall can result in a serious fracture. Therefore, a comprehensive approach to osteoporosis must include fall prevention strategies.

Make Your Home Safer

Many falls happen at home, and simple modifications can significantly reduce risk:

• Remove tripping hazards: Secure or remove loose rugs, clear clutter from floors, and tape down electrical cords
• Improve lighting: Ensure all areas are well-lit, use night lights in hallways and bathrooms, and keep a flashlight beside your bed
• Install safety features: Add grab bars near toilets and in showers/bathtubs, ensure stairways have secure handrails on both sides
• Use non-slip surfaces: Place non-slip mats in bathtubs and on bathroom floors, consider non-slip strips on stairs
• Organize your space: Keep frequently used items within easy reach to avoid climbing or reaching overhead
• Be prepared: Keep a phone within reach in case of falls, and consider a medical alert device if you live alone

Improve Balance and Strength

Regular exercise that focuses on balance and leg strength can significantly reduce fall risk. Consider:

• Tai chi: This ancient Chinese practice has been shown to reduce fall risk by up to 45%
• Balance training: Simple exercises like standing on one foot or heel-to-toe walking
• Strength training: Particularly for the legs, to improve stability and the ability to catch yourself if you trip
• Physical therapy: A physical therapist can design a personalized program addressing your specific needs

Review Your Medications

Some medications can increase fall risk by causing dizziness, drowsiness, or blood pressure changes. Ask your doctor to review all your medications (including over-the-counter ones) and discuss any that might affect your balance or alertness.

Check Your Vision and Hearing

Poor vision and hearing impairment both increase fall risk. Have regular eye exams and keep your prescription current. If you have hearing aids, wear them—hearing helps with spatial awareness and balance.

Wear Appropriate Footwear

Choose shoes with low heels, non-slip soles, and good support. Avoid walking in stockinged feet or loose slippers. In winter, use ice grips or studded overshoes to prevent slipping on ice.

What Is It Like Living with Osteoporosis?

Living with osteoporosis involves making ongoing adjustments to protect your bones while maintaining quality of life. This includes taking medications as prescribed, continuing regular exercise adapted to your condition, maintaining good nutrition, attending follow-up appointments, and implementing fall prevention strategies. With proper management, most people with osteoporosis can remain active and independent.

A diagnosis of osteoporosis can feel overwhelming, but understanding your condition and actively participating in your care can help you live well with the disease. Many people with osteoporosis maintain active, fulfilling lives by making informed choices about their health.

Staying Active Safely

Exercise remains important after an osteoporosis diagnosis, but some modifications may be needed:

• Continue weight-bearing and resistance exercises unless your doctor advises otherwise
• Avoid high-impact activities or those with a high risk of falls if you have severe osteoporosis or have had fractures
• Work with a physical therapist to develop a safe, effective exercise program
• Focus on exercises that strengthen the back and improve posture
• Include balance training to prevent falls

Protecting Your Spine

If you have osteoporosis, particularly in your spine, certain movements can increase fracture risk:

• Avoid bending forward from the waist—bend at the knees and hips instead
• Don't twist your spine while lifting
• Use proper lifting techniques: keep objects close to your body, and avoid lifting heavy weights
• Be careful with exercises that involve rounding or flexing the spine

Emotional Well-being

Living with a chronic condition can affect mental health. It's normal to feel worried about fractures or frustrated by limitations. Consider:

• Joining a support group to connect with others who understand your experience
• Speaking with a counselor if anxiety or depression becomes a problem
• Staying socially active and engaged in activities you enjoy
• Focusing on what you can do rather than limitations

Regular Follow-up Care

Ongoing medical care is essential:

• Keep all scheduled appointments with your healthcare provider
• Take medications exactly as prescribed
• Report any new pain, changes in height, or concerns promptly
• Have periodic bone density tests as recommended
• Discuss any barriers to treatment adherence with your doctor