Osteoporosis: Symptoms, Diagnosis & NHS Treatment

Osteoporosis is a condition that weakens bones, making them fragile and more likely to break. It affects approximately 3.5 million people in the UK, with over 500,000 osteoporotic fractures occurring each year — that’s one every minute. Despite its prevalence, osteoporosis is often called the “silent disease” because there are no symptoms until a fracture occurs. Hip fractures due to osteoporosis are a leading cause of death and disability in older people in the UK — approximately 1 in 3 women and 1 in 5 men over 50 will suffer an osteoporotic fracture in their lifetime.

Understanding Bone Health

Bone is a living tissue that is continuously broken down and rebuilt. Peak bone mass is reached in your late 20s; after that, bone density gradually declines. Osteoporosis occurs when bone loss outpaces bone formation, leaving bones porous and brittle. The NHS and WHO define osteoporosis by bone mineral density (BMD) measured using a DEXA scan — a T-score of −2.5 or below indicates osteoporosis; between −1.0 and −2.5 is “osteopenia” (low bone density, not yet osteoporosis).

Risk Factors for Osteoporosis

Non-Modifiable Risk Factors

  • Sex — women are 4 times more likely to develop osteoporosis than men (oestrogen protects bones)
  • Age — risk increases with age; most fractures occur in people over 65
  • Early menopause or premature ovarian insufficiency (POI) — oestrogen loss accelerates bone loss
  • Family history — parental history of hip fracture increases risk
  • Previous fractures — particularly vertebral fractures
  • Small body frame

Modifiable Risk Factors

  • Low calcium intake — calcium is essential for bone mineralisation
  • Vitamin D deficiency — needed for calcium absorption; very common in the UK; see our vitamin D deficiency guide
  • Physical inactivity — weight-bearing exercise is essential for bone strength
  • Smoking
  • Excessive alcohol — more than 2 units/day
  • Low body weight (BMI under 19)
  • Long-term corticosteroid use — prednisolone ≥7.5mg/day for 3+ months significantly increases fracture risk; NICE recommends bone protection for all such patients

Medical Conditions Associated With Osteoporosis

  • Rheumatoid arthritis — see our RA guide
  • Coeliac disease (impaired calcium absorption) — see our coeliac guide
  • Inflammatory bowel disease (Crohn’s, ulcerative colitis)
  • Hyperthyroidism and primary hyperparathyroidism
  • Chronic kidney disease — see our CKD guide
  • Type 1 diabetes

Diagnosis: The DEXA Scan

Bone density is measured using dual-energy X-ray absorptiometry (DEXA) — a quick, painless scan that measures bone density at the hip and spine. Results are expressed as a T-score (compared to young adult peak bone density) and a Z-score (compared to age-matched peers).

The NHS uses FRAX — the WHO fracture risk assessment tool — to identify who should have a DEXA scan and who should receive treatment, based on 10-year fracture probability. FRAX incorporates clinical risk factors with or without BMD. Your GP can calculate your FRAX score. People with a FRAX 10-year major osteoporotic fracture risk above the UK intervention threshold should be offered treatment.

Who Should Have a DEXA Scan on the NHS?

  • Women aged 65+ (routine screening in many areas)
  • Men aged 75+
  • Younger people with significant clinical risk factors (including long-term steroids, early menopause, fragility fractures)
  • After any low-trauma fracture (fragility fracture) — a fracture from a fall from standing height or less

NHS Treatment for Osteoporosis

1. Calcium and Vitamin D Supplementation

Essential foundation of osteoporosis management. NICE recommends:

  • Calcium — 1,000–1,200mg/day from diet and supplements combined; dairy, fortified plant milks, leafy greens, tinned fish with bones
  • Vitamin D — 800–1,000 IU/day (10–25 micrograms) supplementation recommended for all people over 65 and anyone with osteoporosis; often prescribed as Adcal-D3 or Calcichew-D3

2. Bisphosphonates (First-Line Treatment)

  • Alendronic acid (Fosamax) — 70mg once weekly; most prescribed; NHS first-line; must be taken on an empty stomach, standing upright, with a full glass of water, and no food or lying down for 30 minutes
  • Risedronate — alternative if alendronic acid not tolerated
  • Ibandronate — monthly oral option
  • Zoledronic acid (Aclasta) — annual IV infusion; excellent option for those who cannot take oral bisphosphonates; NICE approved

3. Other NHS-Approved Treatments

  • Denosumab (Prolia) — 6-monthly subcutaneous injection; highly effective; preferred for those with kidney disease where bisphosphonates are contraindicated; NICE TA204
  • Romosozumab (Evenity) — monthly injection; anabolic (builds bone) and anti-resorptive; NICE approved 2020 for postmenopausal women with high fracture risk
  • Teriparatide (Forsteo) — daily injection for 24 months; anabolic (builds new bone); reserved for severe osteoporosis; NICE TA161
  • HRT — highly effective at maintaining bone density in postmenopausal women; see our menopause guide
  • Raloxifene (Evista) — SERM; reduces vertebral fracture risk; second-line option

Preventing Falls: A Critical Part of Fracture Prevention

Osteoporosis treatment alone is insufficient — preventing the falls that cause fractures is equally important. NICE recommends:

  • Strength and balance exercises (Otago programme, tai chi) — NHS physiotherapy referral available
  • Home hazard assessment — grab rails, non-slip mats, adequate lighting
  • Medication review — especially sedatives, antihypertensives, and psychotropics that increase fall risk
  • Vision checks — correcting poor vision reduces falls
  • Hip protectors — padded underwear that absorbs impact; evidence-based in nursing home settings

UK Support and Resources

  • Royal Osteoporosis Society (ROS) — theros.org.uk | Helpline: 0808 800 0035 | UK’s national charity dedicated to bone health
  • Strong and Steady — NHS fall prevention programme; available through your local community health service
  • NICE TA464 — Bisphosphonates for treating osteoporosis — nice.org.uk
  • FRAX Calculator — shef.ac.uk/FRAX — calculate your personal 10-year fracture risk

What Major Health Sites Often Miss About Osteoporosis

1. Bisphosphonate Drug Holidays — A UK Clinical Decision

After 3–5 years of bisphosphonate therapy, NICE and the Royal Osteoporosis Society recommend reassessment for a “drug holiday” in lower-risk patients — pausing treatment while residual anti-fracture effect continues. In higher-risk patients, treatment continues. This concept is under-discussed in US health content, yet is standard NHS practice. If you’ve been on alendronic acid for 5+ years without review, ask your GP to reassess your ongoing need.

2. The Fracture Liaison Service (FLS) — A UK Innovation

The NHS Fracture Liaison Service (FLS) — available in many UK hospitals — identifies and treats patients who have had fragility fractures but have not yet been assessed for osteoporosis. Studies show FLS reduces subsequent fracture rates by up to 40%. If you or an elderly relative has had a wrist, hip, or vertebral fracture, you are entitled to be referred to your local FLS for assessment and treatment. Ask your GP if your area has one.

Related Health Guides on YourHealthXpert