Osteoporosis

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 3 Aug 2025

Last updated: 15 Apr 2025

Osteoporosis is asymptomatic until fracture occurs.

Diagnosis is based on a history of prior fragility fracture or low bone mineral density, which is defined as a T-score ≤-2.5.

Screening is based on individual risk factors, including female sex, maternal history of fragility fracture/osteoporosis, older age, low body mass index (<20 kg/m²), diabetes, rheumatoid arthritis, sarcopenia, androgen deprivation treatment (in males), aromatase inhibitor treatment (in females), corticosteroid use, tobacco use, and excessive alcohol intake.

Adequate calcium and vitamin D intake is recommended for all patients. Bisphosphonates are first-line pharmacologic therapy for most postmenopausal women and men.

All patients treated with teriparatide, abaloparatide, denosumab, or romosozumab should receive sequential therapy with antiresorptive osteoporosis treatment to prevent rapid bone loss.

In postmenopausal women, estrogen is considered only for those at high risk for whom nonestrogen drugs are inappropriate.

Definition

Osteoporosis is a complex skeletal disease characterized by low bone density and microarchitectural defects in bone tissue, resulting in increased bone fragility and susceptibility to fracture.[1][2][3][4]

History and exam

Key diagnostic factors

asymptomatic

Full details

Other diagnostic factors

back pain
kyphosis
height loss
vertebral tenderness

Full details

Risk factors

prior fragility fracture
female sex
white ancestry
older age (>50 years for women and >65 years for men)
low BMI
loss of height
family history of maternal hip fracture
postmenopause
secondary amenorrhea
primary hypogonadism
tobacco use
excessive alcohol use
prolonged immobilization
low calcium intake
vitamin D deficiency
diabetes
rheumatoid arthritis
sarcopenia
glucocorticoid excess
corticosteroid use
proton-pump inhibitor use
hyperthyroidism
heparin use
anticonvulsant use
androgen deprivation treatment (men)
aromatase inhibitor treatment (women)
use of drugs associated with an increased risk of falls

Full details

Diagnostic tests

1st tests to order

dual-energy x-ray absorptiometry (DXA)-bone mineral density (BMD)

Full details

Tests to consider

Fracture Risk Assessment Tool (FRAX)
vertebral fracture assessment (DXA-VFA)
trabecular bone score
quantitative ultrasound (QUS) of the heel
x-ray (wrist, heel, spine, and hip)
quantitative CT
biochemical markers of bone resorption and bone formation
serum alkaline phosphatase
serum calcium
serum albumin
serum creatinine
serum phosphate
serum 25-hydroxy vitamin D
serum parathyroid hormone
thyroid function tests
urinary free cortisol
serum testosterone (men)
urine protein electrophoresis
serum protein electrophoresis

Full details

Treatment algorithm

ONGOING

not glucocorticoid-induced: women

not glucocorticoid-induced: men

glucocorticoid-induced

Contributors

Authors

Khashayar Sakhaee, MD

Professor in Internal Medicine

Division Chief of Mineral Metabolism

Center for Mineral Metabolism and Clinical Research

UT Southwestern Medical Center at Dallas

Dallas

Disclosures

KS declares that he has no competing interests.

Alireza Zomorodian, MD

Research Associate

Charles and Jane Pak Center for Mineral Metabolism and Clinical Research

UT Southwestern Medical Center

Dallas

Disclosures

AZ declares that he has no competing interests.

Acknowledgements

Dr Khashayar Sakhaee and Dr Alireza Zomorodian would like to gratefully acknowledge Dr Alberto V Cabo-Chan Jr and Dr Lisa Leinau, the previous contributors to this topic. AVCC and LL declare that they have no competing interests.

Disclosures

AVCC declares that he has no competing interests. LL declares that she has no competing interests.

Peer reviewers

Kimberly Olson, MD

Internist

Veterans Administration Hospital

Minneapolis

Disclosures

KO declares that she has no competing interests.

David Reid, MBBS

Head of Division of Applied Medicine & Professor of Rheumatology

School of Medicine & Dentistry

University of Aberdeen

Aberdeen

Disclosures

DMR has attended meetings sponsored by or been paid speaker fees by Amgen, Merck, Novartis, Procter & Gamble, Roche, and Servier. He has been a paid advisor to Amgen, Merck, Novartis, Procter & Gamble, Roche, Servier, and Shire Pharmaceuticals. He has undertaken research studies funded by Amgen, Merck, Novartis, Procter & Gamble, and Roche.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

ACOG Committee on Clinical Practice Guidelines–Gynecology. Osteoporosis prevention, screening, and diagnosis: ACOG clinical practice guideline no. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506. Abstract

LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022 Oct;33(10):2049-102.Full text Abstract

ACOG Committee on Clinical Practice Guidelines–Gynecology. Management of postmenopausal osteoporosis: ACOG clinical practice guideline no. 2. Obstet Gynecol. 2022 Apr 1;139(4):698-717. Abstract

Humphrey MB, Russell L, Danila MI, et al. 2022 American College of Rheumatology guideline for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Rheumatol. 2023 Dec;75(12):2088-102.Full text Abstract

Eastell R, Rosen CJ, Black DM, et al. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society* clinical practice guideline. J Clin Endocrinol Metab. 2019 May 1;104(5):1595-622.Full text Abstract

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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Osteoporosis

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic tests

1st tests to order

Tests to consider

Treatment algorithm

not glucocorticoid-induced: women

not glucocorticoid-induced: men

glucocorticoid-induced

Contributors

Authors

Khashayar Sakhaee, MD

Disclosures

Alireza Zomorodian, MD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Kimberly Olson, MD

Disclosures

David Reid, MBBS

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice