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Osteoporosis Initial Assessment

Last updated: 29 September 2025
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Clinical Presentation

Osteoporosis is often asymptomatic until the patient presents with a fragility fracture. Osteoporotic or fragility fractures are caused by low-level trauma or mechanical forces that do not usually result in fracture. Vertebral fracture can cause back pain, height loss, and increasing kyphosis.

History

The medical history should include childhood illness, family history of fractures (fragility fractures), family history of osteoporosis or parental hip fractures, menstrual history, presence of underlying conditions (eg endocrine and gastrointestinal disorders) medications, physical activity, diet, smoking, caffeine and alcohol consumption.

Physical Examination

Osteoporosis_Initial AssesmentOsteoporosis_Initial Assesment




Measure the patient’s height and weight. Osteoporosis may present as a decrease in patient’s height ≥4 cm (≥1.5 in) and low BMI (<18.5 kg/m2). Evaluate the patient’s muscle strength and balance and for the presence of kyphosis. Assess for signs of undiagnosed vertebral fracture. Tenderness over the anterior tibia or thoracic vertebrae may indicate focal bone disease or osteomalacia. The presence of blue sclerae or joint laxity may indicate osteogenesis imperfecta.

Diagnosis or Diagnostic Criteria

Diagnosis of Postmenopausal Osteoporosis

To diagnose postmenopausal osteoporosis, the following should be present:

  • A T-score of ≤-2.5 in the femoral neck, lumbar spine, total proximal femur, and/or 33% radius
  • Low-trauma fracture of the hip or spine (regardless of bone mineral density)
  • Osteopenia, or low bone mass, with a fragility fracture of the pelvis, proximal humerus, or distal forearm, or with multiple fractures at other sites
  • Osteopenia or low bone mass and high probability of FRAX™ fracture based on country-specific cutoffs

Screening

Indications for Bone Mineral Density (BMD) Measurements

Screening for osteoporosis is recommended for all postmenopausal women, men ≥50 years old, and adults with risk factors.

Based on the 2025 US Preventive Services Task Force (USPSTF), screening should be done in:

  • Women ≥65 years old
  • Postmenopausal women <65 years old considered at increased risk for osteoporosis based on a formal clinical risk assessment tool

Based on the 2022 Bone Health and Osteoporosis Foundation, screening should be done in:

  • Women ≥65 years old
  • Postmenopausal women ≥50 years old with risk factors for or a history of adult-age fracture
  • Men ≥70 years old, or ≥50 years old with risk factors for or a history of adult-age fracture

Based on the 2023 International Society for Clinical Densitometry (ISCD), screening should be done in:

  • Women ≥65 years old
  • Postmenopausal women <65 years old with a risk factor for low bone mass
  • Women during menopausal transition with risk factors for fracture
  • Men ≥70 years old, or <70 years old with a risk factor for low bone mass
  • Adults:
    • With a fragility fracture
    • With a condition or who are taking medications associated with low bone mass or bone loss
    • Being considered for pharmacological therapy
    • Receiving treatment to monitor effect
    • Not on treatment in whom evidence of bone loss would require treatment

Some authorities recommend that patients >65 years old with multiple risk factors or prevalent osteoporotic fracture be started on treatment for osteoporosis without BMD measurements.

Osteoporosis Self-Assessment Tool for Asians (OSTA)

The formula combines the patient’s age and body weight. This is useful for identifying young postmenopausal women for BMD testing and can support detecting a postmenopausal woman’s risk for osteoporosis.

WHO Fracture Risk Assessment Model (FRAX™)

The WHO Fracture Risk Assessment Model (FRAX™) was developed to calculate the 10-year risk of osteoporosis fracture, with or without bone mineral density values, based on individual factors (eg sex, age, ethnicity, family history, previous fracture, glucocorticoid treatment, smoking status, alcohol consumption, rheumatoid arthritis, and BMI). The level of fracture probability will vary between countries. This is useful in identifying among the group of patients with osteopenia those at higher risk of fracture. If BMD is not available, FRAX™ can be used to diagnose osteoporosis among at-risk postmenopausal women without fracture. The limitations of FRAX™ include lack of detail on some risk factors (eg smoking, prior fracture, effects of glucocorticoids) and non-inclusion of other known risk factors (eg biochemical markers, falls).