About This Page
This is a clinician-written, evidence-based summary aligned to the 2026 MLA Content Map. It is intended for medical students and junior doctors preparing for the UKMLA. Always cross-reference with NICE guidance, local protocols, and clinical judgement.
The Bottom Line
- Defined by DXA T-score ≤ −2.5 (osteopenia: T-score −1.0 to −2.5)
- Assess fracture risk using FRAX or QFracture in patients with risk factors (NICE CG146)
- Fragility fracture = fracture from standing height or less — ANY fragility fracture warrants treatment
- First-line treatment: oral bisphosphonate (alendronate 70 mg weekly or risedronate 35 mg weekly)
- All patients: calcium (diet or supplement), vitamin D (800–1000 IU/day), weight-bearing exercise, fall prevention
Overview
Osteoporosis is a systemic skeletal disorder characterised by low bone mass and microarchitectural deterioration of bone tissue, resulting in increased bone fragility and fracture risk. It is defined by the WHO as a DXA T-score of ≤ −2.5 at the hip or lumbar spine. The clinical significance of osteoporosis lies entirely in the fractures it causes (fragility fractures), most commonly of the vertebral body, proximal femur (hip), and distal radius (wrist). Osteoporosis is classified as primary (postmenopausal or age-related) or secondary (glucocorticoids, hyperparathyroidism, hyperthyroidism, coeliac disease, hypogonadism, chronic liver/kidney disease).
Epidemiology
Osteoporosis affects approximately 3 million people in the UK, with over 500,000 fragility fractures annually. It is much more common in women — 1 in 2 women over 50 will have an osteoporotic fracture in their lifetime (compared to 1 in 5 men). Risk factors include female sex, postmenopausal status (oestrogen withdrawal), advanced age, family history (parental hip fracture), low BMI (<18.5), glucocorticoid use (≥7.5 mg prednisolone for ≥3 months), smoking, excessive alcohol, previous fragility fracture, rheumatoid arthritis, and secondary causes.
Clinical Features
Symptoms
Often ASYMPTOMATIC until fracture occurs — "silent disease"
Back pain: may indicate vertebral crush fracture (acute or chronic)
Height loss: progressive height reduction from vertebral compression fractures
Kyphosis: thoracic curvature ("dowager's hump") from anterior wedge vertebral fractures
Fragility fracture: fracture from minimal trauma (standing height or less)
Signs
Thoracic kyphosis from multiple vertebral fractures
Height loss (>4 cm historically or >2 cm from previous measurement)
Localised spinal tenderness (acute vertebral fracture)
Often no specific signs — identified through screening or after fracture
Investigations
First-line
FRAX or QFracture risk assessmentCalculate 10-year fracture probability in patients with risk factors. FRAX includes age, sex, BMI, previous fracture, parental hip fracture, steroids, smoking, alcohol, RA, secondary causes. Guides DXA referral and treatment decisions
DXA scan (dual-energy X-ray absorptiometry)Gold standard for measuring bone mineral density. T-score: ≤ −2.5 = osteoporosis, −1.0 to −2.5 = osteopenia. Measured at hip and lumbar spine
Second-line
BloodsExclude secondary causes: calcium, phosphate, ALP, TFTs, 25-OH vitamin D, U&Es, LFTs, coeliac screen (tTG), testosterone (men), FBC, ESR, protein electrophoresis (myeloma)
Lateral spine X-ray or VFA (vertebral fracture assessment)If height loss >4 cm, back pain, or kyphosis — identify vertebral fractures (which independently increase future fracture risk)
Specialist
Bone turnover markersCTX (resorption), P1NP (formation) — used to monitor treatment response, not for diagnosis
Management
NICE CG146 (Osteoporosis: fragility fracture risk), 2012/2017 + NOGG Clinical Guideline 20221
Lifestyle and general measures (ALL patients)
- Calcium: 700–1200 mg/day (diet preferred; supplement 500–1000 mg if dietary intake insufficient)
- Vitamin D: 800–1000 IU/day supplementation
- Weight-bearing and resistance exercise — reduces falls and improves bone strength
- Fall prevention: home hazard assessment, vision check, medication review (reduce sedatives)
- Smoking cessation and moderate alcohol
2
First-line pharmacological (oral bisphosphonate)
- Alendronate 70 mg WEEKLY: first-line. Take on empty stomach, with full glass of water, remain upright for 30 min
- Risedronate 35 mg weekly: alternative if alendronate not tolerated
- Side effects: GI intolerance (oesophagitis, dyspepsia), atypical femoral fractures (rare, long-term), osteonecrosis of jaw (rare, mainly with IV bisphosphonates)
- Review treatment after 5 years of oral bisphosphonate — consider drug holiday if appropriate (reassess risk)
3
If oral bisphosphonate not tolerated or contraindicated
- Denosumab 60 mg SC every 6 months (anti-RANKL antibody). Effective but must not be stopped abruptly (rebound vertebral fractures)
- IV zoledronate 5 mg annually
- Raloxifene (SERM) — for postmenopausal women at vertebral fracture risk (but no hip fracture benefit)
- Teriparatide (PTH analogue): for severe osteoporosis (≥2 vertebral fractures) — anabolic agent, 24-month course
- Romosozumab (anti-sclerostin): newer anabolic agent for severe osteoporosis
4
Glucocorticoid-induced osteoporosis
- Assess fracture risk in anyone starting oral glucocorticoids ≥7.5 mg prednisolone for ≥3 months
- Start bone protection (usually bisphosphonate) at time of starting steroids — do NOT wait for DXA
Complications
- Fragility fractures: Hip fracture (30-day mortality ~10%), vertebral fractures (pain, kyphosis, height loss), Colles fracture (wrist)
- Chronic pain: From vertebral fractures — significant morbidity
- Loss of independence: ~50% of hip fracture patients lose the ability to live independently
- Bisphosphonate-related complications: Osteonecrosis of the jaw (rare), atypical femoral fractures (rare, with prolonged use), oesophageal irritation
- Denosumab discontinuation: Rebound vertebral fractures if stopped — must transition to bisphosphonate
UKMLA Exam Tips
- 1T-score ≤ −2.5 = osteoporosis. T-score −1.0 to −2.5 = osteopenia. T-score > −1.0 = normal
- 2ANY fragility fracture warrants assessment and usually treatment — do not ignore
- 3FRAX: 10-year fracture risk calculation. Use to guide DXA referral and treatment decisions
- 4Alendronate 70 mg WEEKLY is first-line. Take fasting, upright for 30 minutes, with water
- 5Glucocorticoid-induced: start bone protection when starting steroids (≥7.5 mg pred for ≥3 months) — do NOT wait for DXA
- 6Denosumab: must NOT be stopped abruptly (rebound vertebral fractures) — transition to bisphosphonate
- 7Secondary osteoporosis causes: steroids, hyperthyroidism, hyperparathyroidism, coeliac, hypogonadism, myeloma
practicetest your knowledge on osteoporosisApply what you've learnt with UKMLA-style questions from the iatroX Q-Bank — musculoskeletal and beyond.
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