Health condition · Clinically reviewed
Osteoporosis, silent bone loss — until a fracture.
Reduced bone density that raises fracture risk — usually silent until a fall. Modern medications (bisphosphonates, denosumab, romosozumab) meaningfully reduce fracture risk.
Why trust this guide
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Clinically reviewed
Written by our editorial team and reviewed by a registered UK clinician before publication.
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Sourced from guidance
Every claim is checked against NICE, NOGG and peer-reviewed sources you can see at the end.
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Current for 2026
Reflects current UK guidance on fracture-risk assessment and modern bone-forming medications.
Key facts
Osteoporosis at a glance.
The essentials, in plain English — what osteoporosis is, how it is measured, and how modern bone-protective medications reduce fracture risk.
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Definition
A BMD T-score of -2.5 or lower on DEXA scanning — or a fragility fracture regardless of BMD.
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How common
Affects around 1 in 3 women and 1 in 5 men over the age of 50 in the UK.
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What matters
Fracture risk is the meaningful outcome — not the BMD number in isolation.
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FRAX
The FRAX score combines age, BMD and clinical factors to guide who should be treated.
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First-line
Oral bisphosphonates (alendronate, risedronate) are first-line for most patients.
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Bone-forming
Romosozumab and teriparatide are reserved for those at very high fracture risk.
Why this guide matters
The fracture is what matters — not the number.
Treatment decisions are driven by fracture risk, not by BMD alone — which is why FRAX and vertebral fracture assessment sit at the heart of the assessment.
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FRAX drives the decision
A 10-year fracture probability combines age, BMI, prior fracture, steroids and family history — not just the DEXA score.
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A fragility fracture is a diagnosis
A fall from standing height that breaks a bone is osteoporosis until proven otherwise — treat, do not just image.
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Modern medications work
Bisphosphonates, denosumab and romosozumab reduce vertebral, hip and non-vertebral fractures in randomised trials.
How the diagnosis is made
From first risk factor to a bone-protection plan.
The steps a UK clinician will normally follow, in order — so you know what to expect and why.
Phase 1 · Assessing
FRAX, DEXA and initial bloods
Phase 2 · Confirming
Secondary causes and vertebral fracture assessment
Phase 3 · Managing
Treatment tailored to risk
- 01
Assessing
Fracture-risk assessment (FRAX)
A 10-year probability of major osteoporotic and hip fracture, using age, sex, BMI and clinical risk factors.
- 02
Assessing
DEXA scan
Dual-energy X-ray absorptiometry of the hip and lumbar spine — the reference test for bone mineral density.
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Assessing
Bloods
Calcium, phosphate, vitamin D and PTH — with a myeloma screen if the picture is unexplained.
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Confirming
Secondary-cause screen
Coeliac serology, thyroid function and a review of steroid use — reversible causes matter.
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Confirming
Vertebral fracture assessment
VFA on the DEXA scanner picks up silent vertebral fractures that change the treatment threshold.
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Managing
Bone-health MDT if complex
For atypical presentations, very low BMD in young adults, or multiple secondary causes.
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Managing
Specialist referral
For atypical femoral fractures, poor response to first-line treatment, or consideration of bone-forming therapy.
Typical timeline: 4-8 weeks from first appointment to a settled treatment plan.
Symptoms
What osteoporosis actually shows.
Osteoporosis is usually silent — the first sign is often the fracture. These are the clues that should trigger assessment before that happens.
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Fragility fracture
A fracture after minimal trauma — a fall from standing height or less — is diagnostic regardless of BMD.
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Loss of height
A drop of more than 4 cm from peak adult height suggests occult vertebral fractures.
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Vertebral compression
Often silent, sometimes felt as sudden mid-back pain after a minor movement.
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Hip fracture history
A prior hip fracture is the strongest single predictor of a further osteoporotic fracture.
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Wrist (Colles) fracture
A common first fragility fracture — often after a fall onto an outstretched hand in a woman over 50.
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Chronic back pain
Persistent thoracic or lumbar pain, especially with height loss, warrants imaging for vertebral fractures.
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Kyphotic posture
A forward-stooped upper back can reflect stacked vertebral compression fractures.
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Red flag
Acute severe back pain with weight loss — rule out malignancy urgently before treating as osteoporosis.
Treatment
How osteoporosis is treated in the UK.
A stepped approach — foundations first, then targeted medication based on fracture risk, with falls prevention running alongside.
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Calcium + vitamin D
The foundation of any osteoporosis regimen — adequate calcium intake and vitamin D repletion are non-negotiable.
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Bisphosphonates (oral)
Alendronate and risedronate are first-line for most patients — taken weekly with careful dosing instructions.
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IV zoledronate (yearly)
A yearly infusion for those who cannot tolerate oral bisphosphonates or have absorption concerns.
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Denosumab (6-monthly)
A twice-yearly injection that reduces vertebral, hip and non-vertebral fractures — never stop abruptly.
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Romosozumab (very high risk)
A bone-forming monthly injection for 12 months, reserved for very high fracture risk.
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Teriparatide (rebuilding bone)
A daily anabolic injection for up to 24 months — builds new bone in severe osteoporosis.
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HRT (perimenopausal women)
Hormone replacement can preserve bone density in symptomatic perimenopausal women when the balance favours it.
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Falls-prevention programme
Strength, balance and home-safety work — reducing falls is as important as the medication itself.
What this guide is based on
The sources behind every claim on this page.
UK national guidance and specialist society standards, current at the time of last review.
Key references
Guidelines and standards we relied on.
A quiet reminder
This guide is for information, not medical advice.
Your GP or bone-health team knows your history and can tell you which parts apply to you. If in doubt, get seen.
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NICE. Osteoporosis: assessing the risk of fragility fracture (NG213).
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Royal Osteoporosis Society. Clinical guidelines and patient information.
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European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO). Guidance for the diagnosis and management of osteoporosis.
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National Osteoporosis Guideline Group (NOGG). UK clinical guideline for the prevention and treatment of osteoporosis.
Red flags
When bone loss becomes urgent.
Most osteoporosis is managed patiently. These are the situations where the story changes and specialist input matters.
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Vertebral collapse with red-flag features
Neurological signs, saddle anaesthesia or bladder disturbance — urgent spinal imaging.
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Severe back pain with weight loss
Consider malignancy or myeloma before attributing to osteoporosis.
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Bilateral atypical femoral fracture
A rare but recognised complication of long-term bisphosphonate use — urgent orthopaedic review.
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Osteonecrosis of the jaw
Non-healing oral lesion on a bisphosphonate or denosumab — stop and refer to maxillofacial.
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Rebound fracture after stopping denosumab
Never stop denosumab without transitioning to a bisphosphonate — rebound vertebral fractures can be devastating.
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Steroid-induced osteoporosis
Anyone on 7.5 mg prednisolone or more for 3 months needs bone-protection assessment.
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Post-transplant
Rapid bone loss in the first year — protect early, do not wait for a DEXA change.
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Bariatric-related bone loss
Malabsorption after gastric bypass needs vitamin D, calcium and DEXA monitoring.
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Poor response after 3-year bisphosphonate
A new fracture on treatment — reconsider adherence, absorption and specialist referral.
Living with it
A long-term condition, but a very manageable one.
Four things that make the biggest difference day to day — movement, nutrition, falls prevention and staying on top of treatment reviews.
A quiet reminder
Consistency beats intensity, every time.
Small, steady changes — kept up for months — do more than a heroic week that does not last.
- 01 Movement
Weight-bearing matters
Regular weight-bearing and resistance exercise preserve bone and reduce falls.
- 02 Nutrition
Calcium and vitamin D
Aim for adequate dietary calcium and check vitamin D — supplement if low.
- 03 Falls
Prevent the fall
A home-safety review, good lighting and sensible footwear can prevent the fracture entirely.
- 04 Reviews
Treatment reviews
Bisphosphonate courses are reviewed at 3-5 years — do not assume treatment is forever.
Frequently asked
Everything we get asked about osteoporosis.
Quick answers on DEXA, FRAX, bisphosphonates, denosumab and what to do after a fragility fracture.
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What is osteoporosis?
Osteoporosis is a condition where bones become weaker and more likely to fracture. It is defined by a low bone mineral density (T-score of -2.5 or lower on DEXA) or by a fragility fracture after minimal trauma.
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How is osteoporosis diagnosed?
By fracture-risk assessment (FRAX) combined with a DEXA scan of the hip and spine. Blood tests look for reversible causes, and vertebral fracture assessment picks up silent fractures that change treatment.
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What is a T-score?
A T-score compares your bone mineral density to that of a healthy young adult. A T-score at or below -2.5 defines osteoporosis; between -1 and -2.5 is osteopenia.
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Are bisphosphonates safe?
For most people, yes. Osteonecrosis of the jaw and atypical femoral fractures are rare, and the fracture-prevention benefit usually far outweighs the risks — but treatment is reviewed at 3-5 years.
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What happens if I stop denosumab?
Denosumab should never be stopped abruptly. Bone turnover rebounds and vertebral fractures can occur. It is always transitioned to a bisphosphonate under specialist guidance.
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How urgent is treatment after a fragility fracture?
A fragility fracture is the strongest single predictor of another. Treatment should be started within weeks, not months — a fracture liaison service can arrange this.
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