The Silent Disease That Announces Itself With a Fracture
Bone is living tissue. It is broken down and rebuilt continuously, and until roughly the age of 30 the rebuilding wins. After that the balance slowly tips the other way, and in women it tips sharply for about a decade after menopause when oestrogen — the hormone that restrains bone breakdown — falls away. Osteoporosis is what happens when enough bone has been lost that ordinary force starts to break it.
There are no symptoms along the way. No ache warns you, no stiffness signals it. The first sign is usually a fracture of the wrist, spine or hip from a fall that should not have broken anything — or a stoop and loss of height from spinal fractures that were never even noticed.
Who Should Be Screened
Because it is silent, osteoporosis is found by testing the right people rather than by waiting for symptoms. A bone density scan is warranted if you are:
- A woman aged 65 or over, or a man aged 70 or over
- Postmenopausal and under 65 with a risk factor — early menopause, low body weight, smoking or a family history of hip fracture
- Anyone who has broken a bone after the age of 50 from a minor fall
- On steroids for three months or more, or on long-term anti-epileptics, aromatase inhibitors or androgen deprivation therapy
- Living with rheumatoid arthritis, coeliac disease, inflammatory bowel disease, chronic kidney or liver disease
- Affected by an overactive thyroid or parathyroid, low testosterone, Cushing’s syndrome or long-standing type 1 diabetes
- Losing height, developing a stoop or having unexplained back pain
Alongside the scan we check calcium, phosphate, alkaline phosphatase, vitamin D, parathyroid hormone, kidney function, thyroid function and, in men, testosterone. Roughly a third of osteoporosis has a treatable secondary cause, and finding it changes the treatment entirely.
Reading a DEXA Scan
A DEXA scan measures bone density at the hip and spine and reports a T-score — how far your density sits from that of a healthy young adult, in standard deviations.
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| T-Score | Category | What Usually Follows |
|---|---|---|
| −1.0 or above | Normal | Calcium, vitamin D and weight-bearing exercise; rescan in 5 years if at risk |
| −1.0 to −2.5 | Osteopenia | Lifestyle measures; medication only if fracture risk is high on assessment |
| −2.5 or below | Osteoporosis | Treatment is indicated, alongside calcium, vitamin D and fall prevention |
| −2.5 or below with a fracture | Severe osteoporosis | Treatment is urgent; a further fracture is most likely in the first two years |
The score is not the whole picture. A fracture risk assessment that also weighs age, previous fractures, steroid use, smoking and family history sometimes justifies treating osteopenia, and sometimes justifies watching osteoporosis in a low-risk patient. In people under 50 and in premenopausal women a Z-score is used instead of a T-score.
Building and Protecting Bone Naturally
Calcium and Vitamin D
Adults need roughly 1000 to 1200 mg of calcium a day, ideally from food: milk, curd, paneer, ragi, sesame, almonds, leafy greens and small fish eaten with bones. Supplements are added only where diet falls short, because excessive supplemental calcium brings its own problems. Vitamin D must be corrected first — without it, calcium is simply not absorbed.
Load-Bearing Exercise
Bone strengthens in response to force. Walking, stair climbing, and above all resistance training two or three times a week stimulate bone formation. Swimming and cycling are excellent for the heart but do essentially nothing for bone density. Balance work — yoga, tai chi, single-leg standing — matters just as much, because it prevents the fall that causes the fracture.
What Actively Costs You Bone
- Smoking, which reduces bone density and slows fracture healing
- More than two alcoholic drinks a day
- Very low body weight or crash dieting without resistance training
- Long-term steroid use — bone protection should start alongside the steroid, not after a fracture
- Excess caffeine and very high salt intake, both of which increase calcium loss
Medical Treatment
Treatment falls into two groups. Antiresorptive medicines slow the cells that break bone down — bisphosphonates taken weekly, monthly or as a yearly infusion, and denosumab given as a six-monthly injection. Anabolic medicines actively build new bone and are reserved for severe osteoporosis or for patients who fracture despite treatment; they are given for a limited period and must always be followed by an antiresorptive to hold the gain.
Two practical points matter more than the choice of drug. Bisphosphonates must be taken correctly — on an empty stomach with a full glass of water, staying upright for 30 minutes — or they neither work nor are tolerated. And denosumab must never simply be stopped: missing doses causes rapid bone loss and spinal fractures, so a follow-on plan is essential. Menopausal hormone therapy is an option in younger postmenopausal women where symptoms also need treating. Our bone and calcium disorders service manages all of this, including the parathyroid conditions that sometimes lie behind it.
Preventing the Fall Itself
Most fractures need two ingredients: weak bone and a fall. Treating only the first leaves half the problem. Practical measures make a measurable difference — good lighting on stairs and at night, removing loose rugs and clutter, grab rails and a non-slip mat in the bathroom, well-fitting footwear rather than loose chappals, an annual eye check, and a review of any medication that causes dizziness or drowsiness. Correcting vitamin D also improves muscle strength and balance, which is a second reason it comes first.
Key Points to Remember
- Osteoporosis has no symptoms — screening, not waiting, is what finds it.
- Any fracture after 50 from a minor fall should trigger a bone density scan.
- A T-score of −2.5 or below means osteoporosis; a fracture alongside it makes treatment urgent.
- Vitamin D must be corrected before calcium and bone medication can work properly.
- Resistance and balance training protect bone and prevent the fall — swimming and cycling do not build bone.
When to See an Endocrinologist
Book a review if you have broken a bone from a minor fall, if you are losing height or developing a stoop, if you are on long-term steroids, if a DEXA scan shows osteopenia or osteoporosis, if your calcium or parathyroid readings are abnormal, or if you had an early menopause. Assessment looks for the treatable causes before committing you to years of medication.
Conclusion
Osteoporosis is not an unavoidable part of ageing. It is a measurable, treatable condition — and the tragedy is that it is usually diagnosed after the fracture rather than before it.
If you are in a risk group, ask for the scan. Correct the vitamin D, get the calcium from your plate, add resistance and balance work, and treat when the numbers say so. Every one of those steps is easier than recovering from a hip fracture.
FAQs
No. Roughly one in five people affected is a man, and men do worse after a hip fracture. Low testosterone, steroid use, smoking and alcohol are the usual contributors, and men are screened far less often than they should be.
No. Calcium and vitamin D are the foundation, not the treatment. Once density has fallen into the osteoporotic range, supplements alone do not reduce fracture risk — specific bone medication does.
Bisphosphonates are usually given for three to five years, after which a treatment break is considered depending on risk and repeat density. Denosumab is different and must not be stopped without a follow-on plan, as bone loss rebounds quickly.
Correctly prescribed exercise strengthens bone and reduces falls. What is avoided in established osteoporosis is heavy forward bending, twisting of the spine and high-impact jumping — resistance and balance work remain firmly recommended.
Usually every one to two years while on treatment, and every three to five years for monitoring at lower risk. Repeating it sooner rarely helps, as real change in bone density takes time to register.
Dr. K.S. Ranganayakulu
Consultant Diabetologist & Endocrinologist, MRCP (London), CCT (UK). 22 years across the NHS and India, now practising at True Med Diagnostics & Clinics, Kondapur, Hyderabad. Read full profile →