Osteoporosis doesn't hurt until something breaks. That's what makes it dangerous. You can lose 30-40% of your bone density without any symptoms. The first sign is often a fracture from something that shouldn't have caused one - stepping off a curb, bending to pick up a bag, or a minor fall that would have been nothing ten years ago.
Who Needs a Bone Density Scan
DEXA scans are recommended for:
- All women at age 65 and all men at age 70
- Postmenopausal women under 65 with risk factors
- Anyone who has had a fragility fracture (a fracture from a fall at standing height or less)
- People on long-term corticosteroids (prednisone), proton pump inhibitors, or certain cancer treatments
Risk factors that lower the screening age:
- Family history of hip fracture (especially a parent)
- Low body weight (under 127 lbs / 58 kg)
- Smoking
- More than 3 alcoholic drinks per day
- Early menopause (before age 45) or surgical menopause
- Rheumatoid arthritis
The scan takes about 15 minutes, involves minimal radiation (less than a chest X-ray), and gives you a T-score. A T-score of -1.0 to -2.5 is osteopenia (thinning bones). Below -2.5 is osteoporosis.
What Actually Builds Bone
Weight-bearing exercise. Walking counts but isn't optimal. The bone-building stimulus comes from impact and muscle pulling on bone. Better options: jogging, stair climbing, tennis, dancing, jumping. For people who can't do impact exercise, weighted walking (a vest or backpack) helps.
Resistance training. This matters more than most people realize. Heavy compound movements (squats, deadlifts, overhead press) stress the spine and hip - exactly where osteoporotic fractures occur. Two to three sessions per week. The load needs to be challenging. Light weights with high reps do less for bone density than heavy weights with fewer reps.
Calcium and Vitamin D. Target 1,000-1,200 mg of calcium daily (from food first, supplements if needed). Vitamin D: 1,000-2,000 IU daily, more if your blood level is low (ask your doctor to check 25-hydroxyvitamin D). Most adults in northern latitudes are deficient.
Protein intake. Bone is 50% protein by volume. Adequate protein (at least 0.8 g per kg body weight, ideally 1.0-1.2 g/kg for older adults) supports both bone and muscle health.
Falls Are the Enemy
The fracture equation has two parts: bone fragility and the force applied. You can strengthen bone (slowly, over years), but you can also reduce fall risk (immediately).
Balance training. Stand on one leg while brushing your teeth. Practice tandem stance (heel to toe). Do tai chi - the evidence for fall prevention is strong. Yoga helps too, but avoid extreme forward bending with osteoporosis (spinal flexion under load can cause vertebral compression fractures).
Home hazards. Remove loose rugs, install grab bars in bathrooms, keep hallways lit, secure electrical cords. Boring but effective. Most hip fractures happen at home.
Medications that cause dizziness. Blood pressure medications, sleep aids, antihistamines, and muscle relaxants all increase fall risk. Review your medication list with your doctor annually.
Vision. Updated glasses, cataract surgery if needed, and bifocal awareness (they distort depth perception on stairs).
When Medication Is Needed
If your T-score is below -2.5, or if you have osteopenia with high fracture risk (calculated by FRAX tool), your doctor will likely recommend medication.
Bisphosphonates (alendronate, risedronate, zoledronic acid) are the first-line treatment. They slow bone breakdown and reduce fracture risk by 40-70% at the spine and 20-40% at the hip. Common side effects: GI upset with oral forms, flu-like symptoms with IV form (first dose only).
Denosumab (Prolia) is an injection every 6 months. Effective for people who can't tolerate bisphosphonates. Important: stopping denosumab causes rapid bone loss. You must transition to a bisphosphonate after discontinuing.
Anabolic agents (teriparatide, romosozumab) actually build new bone rather than just slowing breakdown. Reserved for severe osteoporosis or patients who fracture despite other treatments. Expensive and time-limited (1-2 years).
After a Fracture
If you've already fractured, you're in a high-risk category for the next fracture. The re-fracture rate within 2 years is 10-20%. Treatment should start immediately, not "after the fracture heals." Bone density testing, medication initiation, fall prevention assessment, and physical therapy should all happen within weeks of the fracture, not months.
An orthopaedic surgeon treats the fracture. An endocrinologist or primary care physician manages the osteoporosis. Both are needed.