Osteoporosis and bone health: tests and treatment
Osteoporosis means bones have become less dense and more fragile, so a low-energy fall or bump can cause a fracture. It is often silent until a wrist, hip, spine or upper-arm fracture happens. Bone health is not just calcium tablets: the useful plan is to assess fracture risk, check whether a DXA scan is needed, address reversible causes, build strength and balance, and use osteoporosis medicines when the fracture risk is high enough.14
Key facts
- NHS guidance says osteoporosis weakens bones and makes them more likely to break, often developing slowly over several years.1
- A fragility fracture after a fall from standing height or less is a major clue that bone strength should be assessed.
- NICE recommends fracture-risk assessment in all women aged 65 and over and all men aged 75 and over, and in younger adults with relevant risk factors.4
- Risk tools such as FRAX or QFracture help decide whether a DXA scan or treatment discussion is needed.4
- Oral bisphosphonates such as alendronic acid, ibandronic acid and risedronate are NICE-recommended options for treating osteoporosis when criteria are met.5
What osteoporosis means
Bone is living tissue. It is constantly broken down and rebuilt. Osteoporosis develops when breakdown outpaces rebuilding over time, leaving bone architecture weaker.6 A DXA scan can estimate bone mineral density, but fracture risk is more than density alone. Age, previous fractures, falls, medicines, body weight, smoking, alcohol, family history and medical conditions all change risk.
The common fracture sites are wrist, hip and spine. Vertebral fractures can cause sudden back pain, height loss, a stooped posture or sometimes very few symptoms. Hip fractures can be life-changing, especially in older age, because they combine pain, surgery risk, immobility, muscle loss and loss of independence.
Osteopenia is lower-than-average bone density that does not meet the osteoporosis threshold. It is not a disease by itself, but it can still matter if overall fracture risk is high. Conversely, someone can have osteoporosis-range bone density but need a nuanced treatment conversation based on age, fracture history and preferences.
Who should be assessed
NICE says fracture-risk assessment should be considered in all women aged 65 and older and all men aged 75 and older. It should also be considered in younger adults with risk factors such as previous fragility fracture, current or frequent recent oral or systemic glucocorticoids, history of falls, family history of hip fracture, other causes of secondary osteoporosis, low BMI, smoking, or alcohol intake above 14 units per week.4
Secondary causes matter because treating them can reduce further harm. Examples include early menopause, hypogonadism, overactive thyroid or over-treatment with thyroid hormone, coeliac disease, inflammatory bowel disease, rheumatoid arthritis, chronic kidney disease, long-term steroids, some cancer treatments, eating disorders, very low body weight, malabsorption and high alcohol intake.
| Clue | Why it matters | Useful next step |
|---|---|---|
| Fracture after a low-energy fall | Possible fragility fracture | Fracture risk assessment and DXA consideration |
| Loss of height or sudden mid-back pain | Possible vertebral fracture | Clinical review and imaging if suspected |
| Long-term steroid use | Major secondary osteoporosis risk | Risk assessment before or during treatment |
| Early menopause or low sex hormones | Lower oestrogen or testosterone accelerates bone loss | Hormone and fracture-risk discussion |
| Repeated falls | Fracture risk is load plus fall risk | Falls assessment, strength and balance work |
DXA, FRAX and blood tests
DXA measures bone mineral density, usually at the hip and spine, and reports a T-score. A T-score of -2.5 or lower is often used to define osteoporosis, but treatment decisions should combine DXA with overall fracture risk. NICE recommends estimating 10-year fracture risk with FRAX or QFracture in eligible adults, and says bone mineral density should not be routinely measured without prior risk assessment unless people are over 50 with a history of fragility fracture.4
Blood tests do not diagnose osteoporosis on their own, but they can look for contributors: calcium, phosphate, vitamin D, kidney function, liver function, thyroid function, full blood count, inflammatory markers, coeliac screen, parathyroid hormone, testosterone in selected men, and other tests based on the story. A young adult with osteoporosis or a person with multiple fractures deserves a stronger search for secondary causes.
Do not reduce bone health to one vitamin D result. Vitamin D matters for bone and muscle, but normalising vitamin D does not automatically rebuild fragile bone if steroid exposure, low body weight, menopause, low protein, falls risk or untreated osteoporosis are the main drivers.
Exercise, protein, calcium and vitamin D
NHS prevention guidance recommends regular exercise, healthy eating with enough calcium and vitamin D, stopping smoking and limiting alcohol as part of osteoporosis prevention.2 The exercise signal bones respond to is loading: resistance training, impact where safe, stairs, brisk walking, balance work and whole-body strength. The right level depends on age, fracture history, pain, falls risk and confidence.
For someone with severe osteoporosis or vertebral fractures, the answer is not aggressive twisting, loaded flexion or random high-impact exercise. It is supervised progression, hip and back strength, posture, balance, safe lifting technique and falls prevention. For younger or fitter people with low bone density, heavier resistance training and appropriate impact may be useful when built gradually.
Calcium is best treated as a dietary target first. Dairy, fortified plant milks, calcium-set tofu, tinned fish with bones, yoghurt, cheese, leafy greens and fortified foods can all contribute. Supplements are useful when diet is insufficient or advised, but high-dose calcium without a reason is not automatically better. Vitamin D supports calcium absorption and muscle function, and UK adults are commonly advised to consider 10 micrograms daily in autumn and winter, or all year if at higher risk, according to NHS vitamin D advice.2
| Lever | Why it helps | Common mistake |
|---|---|---|
| Progressive resistance training | Builds muscle and loads bone | Only walking and never loading the skeleton |
| Balance work | Reduces falls risk | Ignoring falls while focusing only on DXA score |
| Protein | Supports muscle and recovery | Eating too little during weight loss or ageing |
| Calcium | Provides mineral substrate for bone | Supplementing heavily without checking dietary intake |
| Vitamin D | Supports calcium absorption and muscle function | Using mega-doses without monitoring |
Medicines
If fracture risk is high, lifestyle alone may not be enough. NHS treatment guidance says osteoporosis treatment depends on age, sex, fracture risk, previous injury, other conditions and medicines, and includes options such as bisphosphonates, denosumab, parathyroid hormone treatments, romosozumab, HRT and raloxifene depending on the person.3
Bisphosphonates reduce bone breakdown. NICE technology appraisal guidance recommends oral bisphosphonates such as alendronic acid, ibandronic acid and risedronate, and intravenous bisphosphonates such as ibandronic acid and zoledronic acid, as options for treating osteoporosis in adults when criteria are met.5 They require correct dosing instructions, especially oral tablets, because they can irritate the oesophagus if taken incorrectly.
Side-effect anxiety is common. NHS guidance notes that osteonecrosis of the jaw is a rare side effect linked with bisphosphonates, most often with high-dose intravenous bisphosphonate treatment for cancer rather than osteoporosis.3 A dental check and good oral hygiene are sensible, but fear of rare side effects should be weighed against the much more common harm of fractures in high-risk people.
Safety point: do not stop denosumab or long-term osteoporosis medicines without a planned transition. Some treatments need careful sequencing to avoid rebound fracture risk or loss of bone gains.
A practical plan
Start with the risk question: have you had a fragility fracture, are you in the NICE age group for risk assessment, or do you have risk factors such as steroids, early menopause, low BMI, falls, smoking, alcohol, family hip fracture, inflammatory disease or malabsorption? If yes, ask for formal fracture-risk assessment rather than guessing from age alone.
Then build the foundation: protein at each meal, calcium from food where possible, vitamin D at an appropriate dose, progressive strength training, balance work, smoking cessation, alcohol moderation, vision and footwear review, and home fall hazards fixed. If a medicine is recommended, ask what fracture risk it is trying to reduce, how long treatment is planned for, and when review or repeat DXA is expected.
The health library can help compare osteoporosis with vitamin D deficiency, sarcopenia, menopause, thyroid disease and falls risk. Use start here to prepare a short risk-factor timeline, insights to weigh supplement claims, and the stack builder if calcium, vitamin D, magnesium, vitamin K or bone formulas are stacking up.
- Do I meet NICE criteria for fracture-risk assessment with FRAX or QFracture?
- Should I have a DXA scan, vertebral fracture assessment or blood tests for secondary causes?
- What is my 10-year fracture risk, and how much would treatment reduce it?
- How much calcium and vitamin D do I actually need from diet and supplements?
- If medicine is recommended, what are the dosing rules, side effects, duration and review plan?
References
- NHS, 2025. Osteoporosis. link
- NHS, 2022. Osteoporosis prevention. link
- NHS, 2022. Osteoporosis treatment. link
- NICE, 2017, reviewed 2026. Osteoporosis: assessing the risk of fragility fracture, CG146 recommendations. link
- NICE, 2017. Bisphosphonates for treating osteoporosis, TA464. link
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, 2024. Osteoporosis. link
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This article is educational and does not constitute medical advice, diagnosis, or a treatment recommendation. Medication uses described as “off-label” are not licensed for that purpose in the UK and should only be considered under qualified clinical supervision. Always speak to your GP, pharmacist, or a registered specialist before starting, stopping, or changing any treatment. If you have severe or alarm symptoms - unintentional weight loss, blood in your stool, difficulty swallowing, persistent vomiting, a fever, or severe pain - seek urgent medical care.