Osteoporosis

Osteoporosis is a disease that weakens bones until they break from stresses that healthy bone would shrug off: a fall from standing height, a hard cough, lifting a grandchild. About 10 million Americans have it, and another 44 million have low bone mass that puts them at risk ¹. It causes roughly two million broken bones in the United States every year ¹.

The disease is often called silent because bone loss has no symptoms. There is no ache that announces thinning bone; for many people the first sign is the fracture itself, or the slow loss of height and stooping posture that come from small collapses in the spine. That silence is why screening matters, and why the practical story of osteoporosis is mostly about three things: finding it before a fracture, deciding honestly about medication, and keeping bones loaded and bodies upright in the meantime.

Who gets it#

Osteoporosis is heavily concentrated in women, but not exclusive to them. In federal NHANES survey data from 2017-2018, 19.6 percent of women 50 and older had osteoporosis at the hip or spine, compared with 4.4 percent of men; among women 65 and older the figure was 27.1 percent ². Another 43 percent of adults over 50 had osteopenia, the milder low-bone-mass zone between normal and osteoporosis ². Over a lifetime, about one in two women and up to one in four men 50 and older will break a bone because of osteoporosis ¹.

The reason women fare worse is largely hormonal. Estrogen restrains the cells that dissolve bone, and when estrogen falls at menopause, the balance between bone removal and bone rebuilding tips sharply toward removal. A woman can lose up to 20 percent of her bone density in the five to seven years after menopause ³. Men lose bone too, just later and more gradually, and men who reach their 70s and 80s with thinning bones break hips as well. Risk also runs with family history, small body frame, smoking, heavy alcohol use, long courses of steroid medications such as prednisone, and conditions including rheumatoid arthritis and celiac disease.

Sources for this section: [1] [2] [3]

Why the first symptom is often a broken bone#

The fracture that defines this disease is the broken hip, and it deserves plain language. In studies of older adults, roughly 15 to 30 percent of hip fracture patients die within a year of the injury, and fewer than half of survivors get back to the level of function they had before the fall ⁴. Many who lived independently before a hip fracture need a walker, home care, or a nursing home stay afterward. Spine fractures are more common and sneakier; some announce themselves with sudden back pain, but many are found only when a chest X-ray taken for another reason shows a collapsed vertebra, or when someone has quietly lost two inches of height.

None of this is meant to frighten; it is meant to explain why a painless screening test and an unglamorous prescription can be worth taking seriously. Osteoporosis treatment is really fracture prevention, and preventing the first hip or spine fracture is worth far more than treating the second.

Sources for this section: [4]

Screening: DEXA scans, T-scores, and FRAX#

The screening test is a DEXA scan (dual-energy X-ray absorptiometry), a painless, low-radiation scan of the hip and spine that takes about 10-20 minutes. In January 2025, the U.S. Preventive Services Task Force reaffirmed its screening advice: all women 65 and older should be screened, as should postmenopausal women under 65 who have at least one risk factor, such as a parent's hip fracture, smoking, low body weight, or heavy alcohol use ⁵. For men, the task force found the evidence insufficient to recommend for or against routine screening, which in practice means men with risk factors should raise the question with their doctors rather than wait for a policy to decide it ⁵. Medicare Part B covers a bone density test at no cost once every 24 months (more often when medically necessary) for people who qualify, including women judged estrogen-deficient and at risk ⁶.

DEXA results arrive as a T-score, which compares your bone density to that of a healthy young adult.

Osteopenia deserves a calm reading. It is not a disease and not an automatic prescription; it is a flag that says your fracture risk is elevated and worth calculating. That calculation is usually done with FRAX, a free tool that combines age, sex, weight, fracture history, family history, smoking, alcohol, steroid use, and bone density into a 10-year probability of breaking a hip or other major bone. Under the U.S. clinician guidelines, medication is generally offered when someone has osteoporosis on the scan, has already had a hip or spine fracture, or has osteopenia plus a FRAX result of at least 3 percent for hip fracture or 20 percent for major fractures over 10 years.

Sources for this section: [5] [6]

The medications, honestly#

Osteoporosis drugs have a public-relations problem: their rare side effects are vivid and widely shared, while the fractures they prevent are invisible. Both halves of the story deserve numbers.

Bisphosphonates, including alendronate (Fosamax), risedronate (Actonel), and once-yearly intravenous zoledronic acid (Reclast), are the usual first choice. They slow the cells that dissolve bone and substantially lower the risk of spine and hip fractures in people at high risk ⁷. Generic versions cost little.

The two feared complications are real but rare. Atypical femoral fracture, an unusual crack in the thigh bone, occurs on the order of 2 cases per 100,000 patient-years in the early years of treatment, rising toward roughly 100 per 100,000 with 8 or more years of continuous use ⁷. Osteonecrosis of the jaw, a failure of jawbone healing usually after a tooth extraction, occurs in an estimated 1 in 10,000 to 1 in 100,000 patients per year at the doses used for osteoporosis; it is far more common at the much higher doses used in cancer care, which is where its reputation comes from ⁷. Set against those odds, a high-risk woman's chance of a hip or spine fracture without treatment is measured in percentage points per year, not per hundred thousand. For people at genuinely high fracture risk, the arithmetic favors treatment by a wide margin; for people at low risk, it may not, which is exactly what FRAX is for. Because the rare risks rise with duration, doctors often reassess after 3 to 5 years and may pause therapy (a "drug holiday") in patients doing well; bisphosphonates linger in bone and keep working during a pause.

Denosumab (Prolia), an injection every six months, is an alternative that suppresses bone breakdown by a different route and is useful when kidneys cannot handle bisphosphonates. It has one behavior worth underlining: stopping it, or even significantly delaying a dose, releases the brakes and can trigger rapid bone loss and a burst of spine fractures. It must be continued on schedule or followed by a bisphosphonate, never simply dropped.

For severe cases, bone-building (anabolic) drugs, teriparatide (Forteo), abaloparatide (Tymlos), and romosozumab (Evenity), actually add new bone rather than slowing loss, and are typically used for one to two years before handing off to a maintenance drug. Romosozumab carries a warning about heart attack and stroke and is avoided in people with a recent history of either. These are specialist tools, but people with multiple fractures should know they exist.

Sources for this section: [7]

Calcium and vitamin D: food first#

Bones need raw materials, but supplements are not magic pills. The recommended calcium intake is 1,200 mg a day for women 51 and older and men 71 and older, and 1,000 mg for men 51-70 ⁸. Vitamin D, which the gut needs to absorb calcium, is recommended at 600 IU a day through age 70 and 800 IU after ⁸.

The consistent advice from the NIH and osteoporosis organizations is to get calcium from food first: dairy, canned salmon or sardines with bones, fortified juices and cereals, tofu, and leafy greens, with a supplement only to fill whatever gap remains. Supplements fill shortfalls; they are not treatment on their own, and high-dose calcium pills can cause constipation and contribute to kidney stones in some people. Getting enough matters; taking extra does not help. The safe daily limit for calcium from all sources is 2,000 mg for adults over 50, and 4,000 IU for vitamin D ⁸. Practical eating patterns that hit these targets are covered in nutrition for seniors.

Sources for this section: [8]

Exercise that actually loads bone#

Bone adapts to the demands placed on it, which is why the evidence favors two specific kinds of exercise. Weight-bearing activity, anything done on your feet against gravity, such as brisk walking, hiking, dancing, stair climbing, and pickleball, signals bone to maintain itself. Resistance training with weights, bands, or machines two to three times a week loads bone through muscle and is the part most older adults skip. Swimming and cycling, whatever their heart benefits, do not load bone much.

Exercise in later life produces modest gains in bone density, and its larger anti-fracture effect comes from strength and balance: strong legs and steady balance prevent the falls that break bones. Tai chi and similar balance training have good evidence for fall reduction. People who already have spine fractures or very low density should get guidance (often from a physical therapist) before starting anything that involves heavy loading or deep forward bending of the spine.

Fall-proofing the rest of your life#

More than 95 percent of hip fractures start with a fall, so everything that prevents falls is osteoporosis treatment by another name. That means an annual medication review for drugs that cause dizziness or sedation, regular vision care, and attention to the home: lighting, railings, grab bars, and loose rugs. The details live in the fall prevention and home modifications articles, and they matter as much as anything a pharmacy dispenses.

Note: A DEXA scan is quick, painless, and usually free under Medicare for those who qualify. If you are a woman 65 or older, or past menopause with risk factors, and have never had one, that is a one-line request at your next appointment.

RetiredWiki. (2026, July 6). Osteoporosis. https://retiredwiki.com/article/osteoporosis