Osteoporosis and bone health

Osteoporosis and osteopenia

Bone is living tissue that is constantly broken down and rebuilt. When more is lost than replaced, bones become less dense and more fragile, and break more easily.

Osteopenia and osteoporosis are not different diseases. They are two points on the same scale, defined by the same measurement — osteopenia means bone density is lower than normal, osteoporosis means it is lower still. Around 77 per cent of Australians over 50 with poor bone health have osteopenia rather than osteoporosis, which makes it the larger group by some margin.

The fracture that changes the diagnosis

A minimal trauma fracture is a break that follows little or no trauma — typically a fall from standing height or less, a minor trip, or in the spine sometimes no identifiable event at all.

This is the single most important concept on the page. Anyone over 50 who breaks a bone after minimal trauma should be considered to have osteoporosis until proven otherwise, whatever a bone density scan later shows. A wrist broken in a trip at 62 is not bad luck; it is information.

Spinal fractures are particularly easy to miss because they can occur without pain. Gradual height loss and increasing curvature of the upper back are often the only signs, and they are frequently attributed to ageing rather than investigated.

What raises your risk

Age and sex matter most — risk rises after 50 and is higher in women, particularly after menopause. But up to a quarter of cases occur in men, which is a group in whom the diagnosis is regularly missed.

• A previous fracture after minimal trauma at 50 or older
• A parent or sibling with osteoporosis, or with fractures from minor falls, or with unexplained height loss
• Long-term corticosteroid treatment, and some treatments for epilepsy, breast cancer and prostate cancer
• Early menopause, or low testosterone in men
• Coeliac disease, inflammatory bowel disease and other causes of malabsorption
• Rheumatoid arthritis, thyroid or parathyroid disorders, diabetes, chronic liver or kidney disease
• Smoking, excessive alcohol, low physical activity, low calcium intake and low vitamin D
• A thin build, or a history of significantly restricted eating

Measuring bone density

Bone density is measured with a DXA scan — a quick, painless, low-radiation scan of the lower spine and hip. The result is reported as a T-score, comparing your bone density with that of a healthy young adult.

A T-score of −1.0 or above is normal. Between −1.0 and −2.5 is osteopenia. A score of −2.5 or below meets the definition of osteoporosis.

Medicare subsidises DXA scanning in a number of circumstances, including after a minimal trauma fracture, with long-term corticosteroid use, with several specific medical conditions, and — the one most people do not know about — for everyone aged 70 and over, regardless of any other risk factor.

There is no population screening program for osteoporosis in Australia. The approach is case finding: identifying people whose history suggests they should be assessed, rather than scanning everyone.

Risk is more than a scan result

Bone density is only part of the picture. Fracture risk calculators combine density with age, previous fractures, family history, smoking, corticosteroid use, rheumatoid arthritis and alcohol intake to estimate the ten-year probability of fracture. Treatment decisions often rest on that combined estimate rather than the T-score alone — which is why two people with identical scan results can receive different advice.

Know Your Bones, developed by Healthy Bones Australia and the Garvan Institute, is a free self-assessment that produces a report you can bring to an appointment. It is a genuinely useful starting point, particularly for people who are not sure whether they need a scan at all.

What helps, beyond medication

Calcium is best obtained from food. Adults generally need around 1,000 mg a day, rising to about 1,300 mg for women over 50 and men over 70, because absorption falls with age. Supplements are useful where intake is genuinely inadequate, but routine supplementation in people who are not deficient is not recommended — calcium and vitamin D reduce fracture risk mainly in those who are actually short of them.

Vitamin D levels should sit above 50 nmol/L year round, and over 30 per cent of Australian adults are deficient. Sensible sun exposure is the main source, with sun protection still required whenever the UV index is 3 or above — which in Sydney is most of the year.

Exercise is specific rather than general. Resistance training at least twice a week, progressive and moderate to vigorous. Weight-bearing impact activity on most days — around 50 moderate impacts, such as jumping, jogging, skipping or stair climbing. And balance training, which addresses falls rather than bone density but prevents just as many fractures. Anyone who already has osteoporosis should have their programme designed by a physiotherapist or exercise physiologist rather than improvised.

Medicines, and the concerns people bring

Several classes of medicine reduce fracture risk. Bisphosphonates are taken as weekly or monthly tablets, or given as an annual infusion. Denosumab is a six-monthly injection. Other options exist for people at very high risk.

The rare side effects people have usually heard of — jaw problems and unusual thigh fractures — are worth discussing honestly. They are genuinely rare, and the comparison that matters is with the risk of the fractures the treatment prevents, which for someone who has already broken a bone is not a close call. That conversation belongs in an appointment, with the individual numbers.

One thing about denosumab that matters more than the rest

Denosumab is not a treatment that can simply be stopped, and this is the most important safety message in the whole topic.

When it is discontinued or a dose is significantly delayed, bone loss rebounds rapidly and bone density can return to pre-treatment levels within about twelve months. Multiple painful spinal fractures can follow. New spinal fractures have been reported as early as seven months after a last dose, and Australian product warnings were strengthened in February 2026 because of this.

In practice that means the six-monthly dose is a deadline rather than a suggestion. If it does need to stop — for a side effect, dental work, moving house, going overseas — a bisphosphonate should be started straight away and continued for at least twelve months. Anyone taking it should tell their dentist and pharmacist, and should not let a dose quietly lapse.

Monitoring

Repeat bone density scans are generally done no more often than every two years, because changes over a single year are usually too small to distinguish from measurement error. For people at low risk, considerably longer intervals are appropriate. More frequent scanning is reserved for situations where rapid bone loss is expected, such as ongoing corticosteroid treatment or certain cancer therapies.

When to seek assessment

Any fracture from a minor fall after the age of 50 warrants assessment, even if the bone has healed. So does unexplained height loss, a new stooped posture, or new mid-back pain in an older adult — which can represent a spinal fracture.

Sudden severe back pain after a minor movement, or back pain with numbness, weakness, or loss of bladder or bowel control, needs urgent assessment.