Last reviewed: September 2018
Last updated: March  2018



History and exam

Other diagnostic factors

  • back pain
  • kyphosis
  • impaired vision
  • impaired gait, imbalance, and lower-extremity weakness
  • vertebral tenderness

Risk factors

  • prior fragility fracture
  • female gender
  • white ancestry
  • older age (>50 years for women and >65 years for men)
  • low BMI
  • loss of height
  • FHx of maternal hip fracture
  • postmenopause
  • secondary amenorrhea
  • primary hypogonadism
  • tobacco use
  • excessive alcohol use
  • prolonged immobilization
  • low calcium intake
  • vitamin D deficiency
  • glucocorticoid excess
  • corticosteroid use
  • hyperthyroidism
  • heparin use
  • anticonvulsant use
  • weight loss >10% body weight
  • androgen deprivation treatment (men)
  • aromatase inhibitor treatment (women)

Diagnostic investigations

Investigations to consider

  • DXA
  • quantitative ultrasound (QUS) of the heel
  • x-ray (wrist, heel, spine, and hip)
  • quantitative CT
  • biochemical markers of bone resorption and bone formation
  • serum alk phos
  • 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


Authors VIEW ALL

Professor in Internal Medicine

Division Chief of Mineral Metabolism

Center for Mineral Metabolism and Clinical Research

UT Southwestern Medical Center at Dallas




KS declares that he has no competing interests.

Assistant Professor

Internal Medicine

University of Texas Southwestern




AVCC declares that he has no competing interests.

Dr Khashayar Sakhaee and Dr Alberto V Cabo Chan Jr. would like to gratefully acknowledge Dr Lisa Leinau, a previous contributor to this monograph. LL declares that she has no competing interests.

Peer reviewers VIEW ALL


Veterans Administration Hospital




KO declares that she has no competing interests.

Head of Division of Applied Medicine & Professor of Rheumatology

School of Medicine & Dentistry

University of Aberdeen




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.

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