Osteoporosis risk factors: who should be screened, and why
Bone loss has no symptoms. For most people the first sign is a broken bone — which is exactly the thing screening exists to prevent. Here is what actually raises your risk, and who the current guidance says should be tested.
Texas Bone Health Specialists Editiorial
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Why bone loss goes unnoticed
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Risk factors you can't change
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Medical conditions linked to bone loss
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Medications that affect bone
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Risk factors you can change
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Who should be screened
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Why men get missed
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What screening involves
Why bone loss goes unnoticed
Osteoporosis is often described as a silent disease, and the description is accurate. Bone density can decline for years — decades, in some cases — without pain, stiffness, or any sign that something is changing. There is nothing to notice.
What that means in practice is that the first indication is usually a fracture: a wrist caught in a fall, a hip, or a vertebra that compresses without any fall at all. By that point the bone loss has already happened, and the question has shifted from prevention to management.
This is the entire argument for screening. Not because everyone needs treatment, but because a number measured early gives you options that a fracture takes away.
Risk factors you can't change
Some risk is structural. You can't act on these, but knowing where you sit tells you how closely to pay attention.
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Age. Bone density declines with age in everyone. It is the single strongest predictor, and it is why screening guidance is built around age thresholds.
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Menopause. Estrogen protects bone, and its decline accelerates loss sharply. The years immediately after menopause are when bone is lost fastest. Early or surgical menopause brings that forward.
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Family history. A parent or sibling with osteoporosis raises your risk. A parent who fractured a hip is a particularly strong signal.
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Previous fracture. If you have broken a bone after age 50 from a fall at standing height or less, that is a fragility fracture. It is one of the clearest predictors of another one, and on its own a reason to be assessed.
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Body frame. A small or slender build means less bone mass to begin with, so a given amount of loss matters more.
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Sex. Women lose bone faster and start with less, which is why guidance focuses on women. Men are not exempt — see below.
Medical conditions linked to bone loss
A number of conditions affect bone either directly or by interfering with how nutrients are absorbed. If you have one of these, bone health is worth raising with whoever manages it.
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Absorption disorders — coeliac disease, Crohn's disease, and conditions affecting the gut's ability to take up calcium and vitamin D.
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Hormonal conditions — overactive thyroid or parathyroid, and low testosterone in men.
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Inflammatory conditions — rheumatoid arthritis and lupus, both through the disease itself and often through the medications used to treat it.
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Diabetes. Type 1 in particular, though type 2 carries fracture risk that density testing can understate.
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Chronic kidney disease, which affects mineral balance directly.
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Cancer treatment. Chemotherapy, radiation, and hormone-blocking therapies for breast and prostate cancer all affect bone.
Medications that affect bone
This is the category people are least likely to know about, and the one most worth checking. Several common long-term medications affect bone density.
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Oral corticosteroids such as prednisone, taken for three months or longer. This is the best-established drug-related risk factor, and the threshold is lower than most people expect.
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Proton pump inhibitors for acid reflux, taken long-term, which can reduce calcium absorption.
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Anti-seizure medications, some of which affect vitamin D metabolism.
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Thyroid hormone replacement, where the dose is higher than needed.
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Long-term heparin, and certain hormone therapies used in cancer treatment.
Risk factors you can change
These matter less individually than age or menopause, but they are the ones you have leverage over, and they compound.
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Smoking, which has a direct effect on bone density.
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Alcohol above roughly two drinks a day on a regular basis.
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Low dietary calcium — little dairy, few leafy greens, no fortified foods.
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Low vitamin D, which is more common than people assume, including in sunny places, because most of us are indoors.
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Inactivity, and specifically a lack of weight-bearing load. Bone responds to being loaded. Swimming and cycling are good for you but do comparatively little for bone.
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Significant unintentional weight loss — ten pounds or more in a year without trying.
The one worth dwelling on is loading. Bone is living tissue that remodels in response to the forces placed on it, so resistance work and impact are what actually signal it to rebuild. Walking helps. Lifting something heavy helps more.
Who should be screened
The US Preventive Services Task Force updated its osteoporosis screening recommendation in January 2025.
One meaningful change in the 2025 update: for women under 65, the assessment now prioritises fracture risk rather than bone density alone (USPSTF, 2025). That shift matters, because density is only part of what determines whether a bone breaks.
Why men get missed
Osteoporosis is widely treated as a women's condition, and the consequence is that men are screened far less often. The USPSTF's position is that the evidence is insufficient — not that screening is unhelpful, but that the trials needed to judge it have not been done in men.
Other bodies are considerably more specific. The Bone Health and Osteoporosis Foundation recommends bone density testing for all men aged 70 and older regardless of risk factors, and for men aged 50 to 69 who have risk factors (LeBoff et al., Osteoporosis International, 2022). The Endocrine Society's guideline on osteoporosis in men takes the same line: age 70 is on its own a sufficient reason to test, and younger men should be tested if other risk factors are present (Watts et al., JCEM, 2012).
The gap matters because the risk is not small. Around one in four men over 50 will break a bone as a result of osteoporosis — and men who fracture a hip have worse outcomes afterward than women do.
In practice: men who have fractured after 50, who take steroids long-term, who have low testosterone, or who have a family history are worth assessing regardless of what the population-level guidance says.
What screening involves
Less than most people expect. A bone density scan is painless, takes about twenty minutes, and you stay in your own clothes throughout.
The output is a set of numbers — bone density, a T-score, and in the case of a REMS scan a fragility score and a five-year fracture risk estimate — reviewed with you so you know what they mean. If you want to know what those numbers look like before you have them, we have a full guide to reading a bone density report.
Screening does not commit you to treatment. It gives you a baseline, and a baseline is what makes it possible to tell later whether anything is changing.
References
Pisani P, et al. Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years. Aging Clinical and Experimental Research, 2023. PubMed
Adami G, et al. Radiofrequency echographic multi spectrometry for the prediction of incident fragility fractures: a 5-year follow-up study. Bone, 2020. PubMed
Di Paola M, et al. Radiofrequency echographic multispectrometry compared with dual X-ray absorptiometry for osteoporosis diagnosis. Osteoporosis International, 2019. PubMed
World Health Organization. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. WHO Technical Report Series 843, 1994. WHO
Icătoiu E, et al. Radiofrequency echographic multi spectrometry: a novel tool in the diagnosis of osteoporosis and prediction of fragility fractures — a systematic review. Diagnostics, 2025. PubMed
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