Are you at Risk of Osteoporosis? What You Need to Know Before a Fracture Tells You First

Most people don't think about their bones until one breaks.

And that's exactly the problem. Osteoporosis is one of the most common and most preventable conditions affecting women and men over 50, yet it gives almost no warning until the damage is done. No pain. No obvious symptoms. Just a fracture that happens too easily, from a fall that shouldn't have been that serious, or sometimes from something as minor as a cough or a twist.

The good news is that if you are reading this now, before a fracture, you have a real opportunity to change what happens next. Because osteoporosis, when caught early, is highly actionable.

Who is at risk of osteoporosis?  This Isn't Just an "Old Woman" Problem

Let's start by dismantling one of the most dangerous myths about osteoporosis: that it only happens to frail, elderly, thin women.

It doesn't.

Osteoporosis affects 200 million people worldwide. About 1 in 3 women and 1 in 5 men over age 50 have it. Men get it. Younger women get it. Active people get it. People who eat well and exercise get it because bone loss is driven by far more than lifestyle alone.

Risk rises with age, low bone mineral density, a prior fracture as an adult, a family history of hip fracture, low body weight, smoking, excess alcohol use (more than 3 drinks per day), a tendency to fall, and postmenopausal status. But here's what most people don't know: bone density alone doesn't tell the whole story. Older adults fracture more often than younger adults with the same bone density, because age-related changes in bone quality and fall risk matter too. That's why guidelines now use both DXA scans and clinical risk tools like FRAX and not just a single number to assess fracture risk accurately.

Medical conditions that quietly steal bone add risk of osteoporosis

You may be at higher risk than you realize, not because of anything you've done, but because of a medical condition that affects bone health in ways many may not know about.

This is called secondary osteoporosis- bone loss caused or amplified by an underlying disease, not just by aging or menopause. And it's far more common than most people assume.

• Hormonal and endocrine conditions that can affect bone include hyperparathyroidism, untreated hyperthyroidism, Cushing syndrome, diabetes, hypogonadism, and premature menopause before age 45.

• Digestive and absorption conditions can prevent your body from absorbing the nutrients bone needs. These include celiac disease, inflammatory bowel disease, Crohn's disease, prior bariatric surgery, pancreatic disease, and other malabsorption syndromes.

• Other conditions that can lower bone strength or raise fracture risk include chronic kidney disease, chronic lung disease, rheumatoid arthritis, lupus, ankylosing spondylitis, multiple myeloma, HIV, neurological diseases such as Parkinson's disease and stroke, eating disorders, immobility, and a history of recurrent falls.

  
  

Some of these conditions damage bone directly. Others raise fracture risk through inflammation, endocrine disruption, poor nutrition, low body weight, weakness, dizziness, or increased fall risk. If any of these apply to you, that conversation with your doctor just became more urgent.

Medications that may be affecting your bones and risk of osteoporosis

Glucocorticoids are the classic and most important medication cause of secondary osteoporosis, especially at prednisone-equivalent doses of 5 mg daily or more for 3 months or longer. They suppress bone formation, increase bone resorption, and raise fracture risk quickly, which is why several guidelines recommend bone-protective treatment at the time long-term glucocorticoids are started in high-risk patients rather than waiting for a later fracture.

Many readers find it easier to understand bone risk when they can see not just the drug class, but also what the medication is typically prescribed for. The table below pairs common bone-affecting medication classes with their usual indication and the main way they can harm bone or raise fracture risk.

Medication class	Indication	Potential bone/fracture risk
Glucocorticoids, such as prednisone	Asthma and COPD flares, autoimmune disease, inflammatory disorders, transplant medicine, and some cancer regimens	Strongly linked to rapid bone loss and fractures because they reduce bone formation, increase bone resorption, and impair calcium balance
Aromatase inhibitors, such as anastrozole, letrozole, and exemestane	Hormone-sensitive breast cancer treatment in postmenopausal women	Lower estrogen levels and accelerate bone loss, which can substantially increase fracture risk
Androgen deprivation therapy, such as GnRH agonists or antagonists	Prostate cancer treatment	Suppresses testosterone and downstream estrogen, leading to bone loss and higher fracture risk
Anticonvulsants, such as phenytoin, phenobarbital, carbamazepine, and some others	Seizure disorders, neuropathic pain, migraine prevention, and some psychiatric indications	Some agents alter vitamin D metabolism, calcium handling, or balance and can contribute to bone loss and falls
Proton pump inhibitors, such as omeprazole and pantoprazole	Reflux, peptic ulcer disease, gastritis, Barrett esophagus, and GI protection in selected patients ​	Long-term use has been associated with higher fracture risk, possibly through impaired calcium absorption or other mechanisms
Selective serotonin reuptake inhibitors, such as sertraline or escitalopram	Depression and anxiety disorders ​	Associated with lower bone density and increased falls or fractures in some studies, although causality is not always clear
Thiazolidinediones, such as pioglitazone and rosiglitazone	Type 2 diabetes	Can shift marrow biology away from bone formation and are linked to higher fracture risk, especially in women
Long-term heparin	Prevention or treatment of blood clots in selected settings ​	Prolonged exposure can reduce bone formation and contribute to osteoporosis ​
Calcineurin inhibitors, such as tacrolimus and cyclosporine	Organ transplantation and some autoimmune diseases	Can contribute to bone loss, especially in the setting of transplant-related illness and concurrent steroid exposure
Excess thyroid hormone replacement	Hypothyroidism when replacement is over-titrated or TSH is intentionally suppressed after thyroid cancer	Too much thyroid hormone increases bone turnover and can accelerate bone loss
Depot medroxyprogesterone acetate	Contraception	Suppresses estrogen and can reduce bone density, particularly with long-term use
Chemotherapy or other cancer therapies that induce hypogonadism	Breast cancer, hematologic malignancies, and other cancers depending on regimen	May impair ovarian or testicular hormone production, which weakens bone over time
Sedatives and other centrally acting medications	Insomnia, anxiety, pain, muscle spasm, or seizure control, depending on the drug ​	May not damage bone directly but can raise fall risk, which meaningfully raises fracture risk in older adults

The point here is not that everyone on these medications needs osteoporosis treatment. The point is that these exposures should prompt a conversation about calcium and vitamin D status, fall prevention, and whether earlier bone density testing makes sense for you. If you're on any of these medications and also have other risk factors, that combination often moves someone into a higher-risk category.  These should all be discussed with your doctor.

When should you get a bone density scan to screen for the risk of osteoporosis

The 2025 U.S. Preventive Services Task Force (USPSTF) recommends screening all women age 65 years and older with central DXA, with or without formal fracture-risk assessment. It also recommends screening postmenopausal women younger than 65 when one or more risk factors are present and clinical risk assessment suggests elevated fracture risk.

For men, the USPSTF states that evidence is insufficient to recommend for or against routine screening, but other societies commonly advise testing higher-risk men, especially those age 70 and older or men age 50 to 69 with risk factors. The Bone Health and Osteoporosis Foundation (BHOF) similarly recommends BMD testing in women age 65 and older, men age 70 and older, postmenopausal women and men age 50 to 69 based on risk profile, and all adults age 50 and older with an adult-age fracture.

Repeat testing is individualized. USPSTF-reviewed cohort studies suggest that repeating BMD at 4- to 8-year intervals does not meaningfully improve fracture prediction in average-risk screening populations, while BHOF recommends repeating DXA 1 to 2 years after starting or changing therapy and then spacing follow-up according to risk, baseline BMD, and whether the person remains fracture-free.

Who gets osteoporosis treatment?

Many people assume treatment is only for those with a formal osteoporosis diagnosis. That's not how it works.

The Bone Health and Osteoporosis Foundation recommends considering treatment in postmenopausal women and men age 50 and older who have any of the following:

• A hip or vertebral fracture, regardless of bone density

• A T-score of -2.5 or lower at the hip, spine, or sometimes the radius

• Osteopenia with a FRAX-calculated 10-year risk of at least 3% for hip fracture, or at least 20% for major osteoporotic fracture

  
  

This matters because many fractures happen in people with osteopenia and not full osteoporosis based on their T-score alone. Fracture history and overall risk often matter more than the number.

People at very high risk, such as those with recent vertebral fractures, multiple fractures, very low T-scores, or high-dose glucocorticoid exposure, may be candidates for an anabolic-first treatment approach rather than starting with a standard antiresorptive drug. To learn more, see my blog on bone density and osteoporosis prevention:

Osteoporosis Prevention

What you can do right now

Osteoporosis is not inevitable. It is not just a natural part of aging. And it is not something to wait on.

Start here:

• If you've had a bone fracture, or have any of the medical conditions or medications listed above, ask your doctor about a DXA scan, especially if under age 65

• If you're 65 or older, schedule your DXA scan- it's covered by insurance

• Get your FRAX score online to understand your 10-year fracture risk (frax.shef.ac.uk)

• Ask your doctor to evaluate your calcium and vitamin D intake, your fall risk, your medications, and whether any labs are needed to rule out secondary contributors

  
  

For people who have already had a fragility fracture: prompt treatment matters. Fracture risk is highest in the first year after an initial fracture. Do not wait.

For people on bone-harming medications like glucocorticoids, aromatase inhibitors, or androgen deprivation therapy: the time to address modifiable risks is now — not after a fracture.

The Bottom Line

Osteoporosis is not just for inactive elderly people. There are many factors that can quietly raise your risk such as hormones, medications, medical history, and more. Most have nothing to do with how active or health-conscious you are.

The most important thing you can do is know your risk before a fracture forces the conversation. Take the information in this post, write down your questions, and bring them to your next appointment. You deserve to walk in informed.

If you'd like support making sense of your bone health, your symptoms, or how to translate your doctor's recommendations into a real action plan, a 55-minute Optimal Health Strategy Session is a great place to start.

Book your session at Reforming You

Strategy Session

References

1. Cosman F, de Beur SJ, LeBoff MS, et al. The clinician's guide to prevention and treatment of osteoporosis. Osteoporosis International. 2022. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC9546973/

2. U.S. Preventive Services Task Force. Osteoporosis to Prevent Fractures: Screening.2025. Available at: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening

3. International Osteoporosis Foundation. About Osteoporosis. Available at: https://www.osteoporosis.foundation/health-professionals/about-osteoporosis

4. Wellen. Secondary Causes of Osteoporosis: What You Should Know. 2024. Available at: https://www.getwellen.com/well-guide/secondary-causes-of-osteoporosis-what-you-should-know

5. Diab DL, Watts NB. Medication-induced osteoporosis: screening and treatment strategies. Therapeutic Advances in Musculoskeletal Disease. 2014. Available at: https://pmc.ncbi.nlm.nih.gov/articles/PMC4206646/

6. Osteoporosis Canada. Medications that can Cause Bone Loss, Falls and/or Fractures. 2020. Available at: https://osteoporosis.ca/medications-that-can-cause-bone-loss-falls-and-or-fractures/

7. Notts APC / NOGG-linked guidance. Osteoporosis Guidelines or Summary of main recommendations. Available at: https://www.nogg.org.uk/full-guideline/summary-main-recommendations

8. Khan AA, et al. Osteoporosis in Men: An Endocrine Society Clinical Practice Guideline. Journal of Clinical Endocrinology & Metabolism. 2012. Available at: https://academic.oup.com/jcem/article/97/6/1802/2536476

9. Cleveland Clinic Journal of Medicine. Drugs that may harm bone: Mitigating the risk. 2016. Available at: https://www.ccjm.org/content/83/4/281

10. NIH / National Institute of Arthritis and Musculoskeletal and Skin Diseases. Exercise for Your Bone Health. 2023. Available at: https://www.niams.nih.gov/health-topics/exercise-your-bone-health

11. Mayo Clinic. Exercising with osteoporosis: Stay active the safe way. 2025. Available at: https://www.mayoclinic.org/diseases-conditions/osteoporosis/in-depth/osteoporosis/art-20044989

12. Harvard Health Publishing. Effective exercises for osteoporosis. Available at: https://www.health.harvard.edu/healthy-aging-and-longevity/effective-exercises-for-osteoporosis