It develops when the natural process of bone renewal becomes imbalanced, with more bone being broken down than is replaced. This leads to a progressive reduction in bone mass and a deterioration of bone structure over time. The condition is often called a silent disease because bone loss occurs gradually without symptoms until a fracture happens. Fractures caused by osteoporosis most commonly affect the spine, hip and wrist and can have serious consequences for independence and quality of life. Without appropriate assessment and management, osteoporosis can lead to recurrent fractures, chronic pain, loss of height and reduced mobility.
What is osteoporosis?
Osteoporosis is a metabolic bone condition characterised by low bone mineral density and a deterioration in the microarchitecture of bone tissue. This makes bones weaker and significantly increases the risk of fracture, even following minor falls or, in severe cases, everyday activities such as bending or coughing.
Bone is a living tissue that is constantly being remodelled:
- Throughout life, old bone is broken down by cells called osteoclasts and new bone is built by cells called osteoblasts.
- In osteoporosis this balance is disrupted, and bone is lost faster than it can be replaced.
Peak bone mass is typically reached in early adulthood. After this, bone density naturally declines with age, and the rate of loss accelerates in women following the menopause due to falling oestrogen levels.
What are the causes of osteoporosis?
Osteoporosis develops when bone remodelling becomes imbalanced and bone density declines to a level where fractures can occur with minimal force. A combination of genetic, hormonal, nutritional and lifestyle factors contributes to this process.
Risk factors for osteoporosis include:
- Female sex, particularly after the menopause
- Increasing age
- A family history of osteoporosis or hip fracture
- Low body weight or low body mass index
Hormonal and medication factors
- Early menopause (before the age of 45) or premature ovarian insufficiency
- Long-term use of corticosteroid medications
- Some medications, including aromatase inhibitors, anti-epileptic drugs and proton pump inhibitors used long term
Lifestyle and medical conditions
- Low calcium or vitamin D intake
- Smoking and excessive alcohol consumption
- Physical inactivity or prolonged immobility
- Certain medical conditions, including inflammatory arthritis, coeliac disease, hyperthyroidism and chronic kidney or liver disease
What are the symptoms of osteoporosis?
Osteoporosis itself does not usually cause symptoms in its early stages. Many people are unaware they have the condition until they sustain a fracture. Signs and consequences of osteoporosis may include:
- A fracture following a minor fall or low-impact injury, particularly of the wrist, hip or spine
- Back pain caused by a fractured or collapsed vertebra
- A gradual loss of height over time
- A stooped or hunched posture (kyphosis)
- Bones that fracture more easily than expected
Because osteoporosis is often asymptomatic until a fracture occurs, early identification in people at increased risk is particularly important.
When to Seek Medical Advice?
You should seek specialist assessment if you have:
- Risk factors for osteoporosis
- Experienced a fracture following a minor injury
- Noticed a loss of height or change in posture
- Been advised that you may have low bone density
Early assessment allows treatment to begin before fractures occur, significantly reducing the risk of serious injury and long-term complications.
How osteoporosis is diagnosed?
Diagnosis is based on a combination of clinical assessment, fracture risk evaluation and bone density measurement. There is no single test that covers all aspects of assessment, and results need to be interpreted alongside your individual risk profile. Dr Nuttall will begin with a detailed review of your symptoms, medical history, medication history, diet, lifestyle and family history, together with a physical examination.
Investigations for osteoporosis may include:
- DEXA scan (dual-energy X-ray absorptiometry), which measures bone mineral density at the hip and spine and is the standard method for diagnosing osteoporosis
- Advanced risk profiling and imaging:
- FRAX or QFracture assessment, which are validated tools used to calculate your ten-year probability of sustaining a fragility fracture based on clinical risk factors
- Blood tests to identify secondary causes and assess bone metabolism, including calcium, vitamin D, parathyroid hormone, thyroid function, and markers of bone turnover
- Spine X-ray or vertebral fracture assessment, to identify existing vertebral fractures that may not have caused symptoms
- Further imaging or specialist investigations if a secondary cause is suspected
How to treat osteoporosis?
Treatment is aimed at reducing fracture risk, maintaining or improving bone density, and addressing any underlying causes or contributing factors. The approach is tailored to your individual risk level, bone density results and overall health.
Treatment options may include:
Medical management
- Calcium and vitamin D supplementation to support bone health, particularly where dietary intake or sun exposure is insufficient
- Bisphosphonates: oral agents such as alendronic acid or risedronate, which are the most commonly prescribed medications for osteoporosis and work by reducing bone breakdown; or intravenous zolendronic acid given yearly for 3 years
- Denosumab, an injectable medication that inhibits bone resorption and is used when bisphosphonates are not suitable or have not been effective
- Hormone replacement therapy (HRT), which can help preserve bone density in postmenopausal women and may be particularly appropriate when osteoporosis coexists with menopausal symptoms
- Romosozumab, Abaloparatide or Teriparatide, which stimulate new bone formation and are reserved for people with severe osteoporosis or a high fracture risk (osteoanabolic agents)
Lifestyle and rehabilitation
- Falls prevention advice and physiotherapy to improve balance, strength and mobility
- Lifestyle modifications, including weight-bearing exercise, smoking cessation, reducing alcohol intake and ensuring adequate nutrition
- Review and modification of medications that contribute to bone loss where possible
Dr Nuttall will tailor treatment to reduce fracture risk, improve bone strength, and support your long-term bone health and independence.
