Clinical manifestations, diagnosis, and

evaluation of osteoporosis in
postmenopausal women
Author: Harold N Rosen, MD
Section Editors: Clifford J Rosen, MD, Kenneth E Schmader, MD
Deputy Editor: Jean E Mulder, MD

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: May 2022. | This topic last updated: Apr 27, 2022.

INTRODUCTION

Osteoporosis is characterized by low bone mass, microarchitectural

disruption, and skeletal fragility, resulting in decreased bone strength and
an increased risk of fracture. Decreased bone strength is related to many
factors other than bone mineral density (BMD), including rates of bone
formation and resorption (turnover), bone geometry (size and shape of
bone), and microarchitecture (picture 1).

The World Health Organization (WHO) has defined diagnostic thresholds

for low bone mass and osteoporosis based upon BMD measurements
compared with a young adult reference population (T-score). The majority
of postmenopausal women with osteoporosis have bone loss related to
estrogen deficiency and/or age.

Early diagnosis and quantification of bone loss and fracture risk are
important because of the availability of therapies that can slow or even
reverse the progression of osteoporosis.
The clinical manifestations, diagnosis, and evaluation of osteoporosis in
postmenopausal women will be reviewed here. The evaluation of
osteoporosis in premenopausal women and men and the treatment of
osteoporosis are reviewed separately. (See "Evaluation and treatment of
premenopausal osteoporosis" and "Clinical manifestations, diagnosis, and
evaluation of osteoporosis in men" and "Overview of the management of
osteoporosis in postmenopausal women" and "Treatment of osteoporosis
in men".)

CLINICAL MANIFESTATIONS

Osteoporosis has no clinical manifestations until there is a fracture. This is

an important fact because many patients without symptoms incorrectly
assume that they must not have osteoporosis. On the other hand, many
patients with achy hips or feet assume that their complaints are due to
osteoporosis. This is unlikely true in the absence of fracture. In comparison,
pain is common in osteomalacia in the absence of fractures or other bone
deformities. (See "Epidemiology and etiology of osteomalacia".)

● Vertebral fracture – Vertebral fracture is the most common clinical

manifestation of osteoporosis. Most of these fractures (approximately
two-thirds) are asymptomatic; they are diagnosed as an incidental
finding on chest or abdominal radiograph (image 1). The clinical
manifestations of symptomatic vertebral fracture, including height
loss, are reviewed separately. (See "Osteoporotic thoracolumbar
vertebral compression fractures: Clinical manifestations and
treatment".)

● Other fractures – Hip fractures are relatively common in osteoporosis,

affecting up to 15 percent of women and 5 percent of men by 80 years
of age [1]. In addition, distal radius fractures (Colles fractures) may
occur. Colles fractures are more common in women shortly after
menopause, whereas the risk of hip fracture increases exponentially
 with age. (See "Overview of common hip fractures in adults" and
"Distal radius fractures in adults".)

DIAGNOSIS

Osteoporosis is characterized by low bone mass, microarchitectural

disruption, and increased skeletal fragility. A clinical diagnosis of
osteoporosis may be made in the presence of [2-4]:

● Fragility fracture, particularly at the spine, hip, wrist, humerus, rib, and
pelvis

or

● T-score ≤-2.5 standard deviations (SDs) at any site based upon bone
mineral density (BMD) measurement by dual-energy x-ray
absorptiometry (DXA) (see "Screening for osteoporosis in
postmenopausal women and men", section on 'Candidates for BMD
testing')

As another means for diagnosis of osteoporosis in postmenopausal

women, we agree with the National Bone Health Alliance suggestion that a
clinical diagnosis of osteoporosis may be made if there is a clear elevated
risk for fracture [3]. In the United States, for example, a clinical diagnosis of
osteoporosis may be made when the FRAX 10-year probability of major
osteoporotic fracture (hip, clinical spine, proximal humerus, or forearm) is
≥20 percent or the 10-year probability of hip fracture is ≥3 percent [2,3].
(See "Osteoporotic fracture risk assessment", section on 'Fracture risk
assessment tool' and "Overview of the management of osteoporosis in
postmenopausal women", section on 'Fracture risk assessment'.)

All postmenopausal women with osteoporosis should have an evaluation to

exclude causes of low bone mass other than age and estrogen deficiency.
(See 'Evaluation' below.)
Fragility fracture — A clinical diagnosis of osteoporosis may be made in
the presence of a fragility fracture, particularly at the spine, hip, wrist,
humerus, rib, and pelvis, without measurement of BMD. Fragility fractures
are those occurring spontaneously or from minor trauma, such as a fall
from a standing height or less. Fragility fractures result from mechanical
forces that would not ordinarily result in fracture. Reduced bone density is
a major risk factor for fragility fractures.

The most common sites of fragility fracture are the spine (vertebral
compression fractures), hip, and wrist. Fragility fractures also occur at the
humerus, rib, and pelvis. Certain skeletal locations, including the skull,
cervical spine, hands, feet, and ankles, are not associated with fragility
fractures. Stress fractures are also not considered fragility fractures, as they
are due to repetitive injury. (See "Overview of stress fractures".)

Bone mineral density — In the absence of a fragility fracture, BMD

assessment by DXA is the standard test to diagnose osteoporosis,
according to the classification of the World Health Organization (WHO)
[2,5].

T-score — The WHO established diagnostic thresholds for BMD (by DXA)

according to the SD difference between a patient's BMD and that of a
young adult reference population (T-score) (table 1) [5].

● ≤-2.5 SD – A BMD T-score that is 2.5 SD or more below the young adult
mean BMD is defined as osteoporosis, provided that other causes of
low BMD have been ruled out (such as osteomalacia)

● -1 to -2.5 SD – A T-score that is 1 to 2.5 SD below the young adult mean

is termed low bone mass (osteopenia)

● ≥-1 SD – Normal bone density is defined as a value within 1 SD of the

mean value in the young adult reference population
Individuals with T-scores of ≤-2.5 have the highest risk of fracture. However,
collectively there are more fractures in patients with a T-score between -1
and -2.5 because there are so many more patients in this category [6]. (See
"Overview of dual-energy x-ray absorptiometry".)

Z-score — The Z-score is a comparison of the patient's BMD to an age-

matched population. A Z-score of -2 or lower is considered below the
expected range for age [7]. Thus, the presence of Z-score values more than
2 SD below the mean should prompt careful scrutiny for coexisting
problems (eg, glucocorticoid therapy or alcoholism) that can contribute to
osteoporosis. (See 'Additional evaluation' below.)

Applicability of WHO criteria — The World Health Organization (WHO)

thresholds were chosen based upon fracture risk in postmenopausal White
women. Similar diagnostic threshold values for men are less well defined,
although for any given BMD, the age-adjusted fracture risk is similar in
men and women [8]. We agree with the International Society for Clinical
Densitometry (ISCD) recommendations for the application of the WHO
classification in clinical practice [7]:

● Postmenopausal women and men ≥50 years – The ISCD advises that
the WHO criteria be used in postmenopausal women and in men age
50 years and older.

● Premenopausal women and men <50 years – The ISCD advises that
the WHO criteria not be used in premenopausal women or men under
age 50 years, because the relationship between BMD and fracture risk
is not the same in younger women and men.

● Children – The WHO classification should not be used in children (male

or female under age 20 years), and a diagnosis of osteoporosis cannot
be made in a child based on densitometric criteria alone. Z-scores, not
T-scores, should be used, since it is not appropriate to compare the
BMD of someone who has not yet achieved peak bone mass with that
 of an adult who has. Osteoporosis can be diagnosed in children based
on the presence of a vertebral compression fracture, or a Z-score <-2 in
combination with a significant fracture history (eg, two long bone
fractures before age 10 years or three long bone fractures before 19
years) [9].

Method of BMD measurement — Several different methods are available

to measure bone mineral density (BMD). DXA is the best available clinical
tool for the diagnosis of osteoporosis and monitoring changes in BMD over
time. Detailed information about DXA is found elsewhere (see "Overview of
dual-energy x-ray absorptiometry"). Other methods of measuring BMD for
fracture risk assessment are reviewed separately. (See "Osteoporotic
fracture risk assessment", section on 'Methods of measurement of BMD'.)

Site of measurement — In women who are candidates for BMD testing,

we suggest DXA measurements of the spine and hip because fractures at
these sites have the greatest impact on patients' health. Measurement of
hip BMD also has the highest predictive value for hip fracture. In addition, if
pharmacologic therapy is planned, measurement of spine BMD is useful as
it shows less variability and can detect responses to therapy earlier than
hip BMD. We make the diagnosis according to the lowest T-score
measured.

Interference from osteophytes and vascular calcifications on the spine

measurement are common in aging women and interfere with the
assessment of BMD at this site. In this setting, measurement of hip BMD
alone or hip and one-third radial site is sufficient.

In all studies, the risk for most fractures is inversely proportional to bone
density [10-18]. Some studies suggest that the risk for fracture at a
particular site is best estimated by measuring bone density at that site [19-
22]. Other studies, however, have found that measurement of BMD at any
site predicts fracture risk at all sites equally well [23]. The preferred site for
measurement of bone density and the number of sites to measure are
debatable, and it may vary according to the clinical situation. The Fracture
Risk Assessment Tool (FRAX) can improve the prediction of fractures above
that achieved by BMD. (See "Osteoporotic fracture risk assessment",
section on 'Fracture risk assessment tool' and "Screening for osteoporosis
in postmenopausal women and men", section on 'Skeletal site to measure'.)

DIFFERENTIAL DIAGNOSIS

Decreased bone mass can occur because peak bone mass is low, bone
resorption is excessive, or bone formation during remodeling is decreased.
All three processes are likely to contribute, in varying degrees, to
osteoporosis in individual patients. Most postmenopausal women with
osteoporosis, however, have either age- or estrogen deficiency-related
bone loss due primarily to excessive bone resorption.

Other causes of bone fractures and reduced bone mineral density (BMD)
include osteomalacia, malignancy (eg, multiple myeloma), Paget disease,
and hyperparathyroidism. Most of these diagnoses can be distinguished
from estrogen deficiency-related osteoporosis by the clinical history,
physical examination, and laboratory testing. (See 'Evaluation' below.)

Physical abuse should always be considered a possibility in a patient with

fractures, particularly when the fracture burden exceeds what one would
expect based on BMD, or when location of fractures is atypical. (See "Elder
abuse, self-neglect, and related phenomena", section on 'Warning signs'.)

Low BMD may also be seen in conjunction with renal osteodystrophy in

patients with decreased kidney function [24-26]. It is difficult to distinguish
low bone density due to osteoporosis from low bone density due to any of
the components of chronic kidney disease-metabolic bone disease. The
distinction may be made biochemically in most cases, but may sometimes
require bone biopsy. The diagnosis, evaluation, and management of
osteoporosis in patients with chronic kidney disease and the diagnosis and
management of renal osteodystrophy and secondary hyperparathyroidism
are discussed in detail elsewhere. (See "Osteoporosis in patients with
chronic kidney disease: Diagnosis and evaluation" and "Bone biopsy and
the diagnosis of renal osteodystrophy" and "Management of secondary
hyperparathyroidism in adult nondialysis patients with chronic kidney
disease" and "Management of secondary hyperparathyroidism in adult
dialysis patients".)

EVALUATION

The goal of the evaluation is to exclude causes of low bone mass other than
age and estrogen deficiency, such as osteomalacia, hyperthyroidism, and
hyperparathyroidism, and to detect potentially remediable causes or other
contributing factors to osteoporosis (table 2) [27-31].

Initial evaluation — The initial evaluation includes a history to assess for

clinical risk factors for fracture and to evaluate for other conditions that
contribute to bone loss, a physical examination, and basic laboratory tests.

● History and physical examination – Most of the conditions causing

osteoporosis can be excluded with a careful history and physical
examination (table 2). Lifestyle factors that contribute to bone loss,
including smoking, excessive alcohol, physical inactivity, and poor
nutrition, should be addressed. Height and weight should be
measured.

A history of a fragility fracture is an important risk factor for a

subsequent fracture [10,32,33]. In women who have a vertebral
fracture, approximately 19 percent will have another fracture in the
next year [32]. A meta-analysis of 11 cohorts (15,259 men and 44,902
women) showed that a previous fracture was associated with an
increased risk of any fracture compared with those without a prior
fracture (relative risk [RR] 1.86, 95% CI 1.75-1.98) [34]. Thus, individuals
with a history of a fragility fracture are a high-risk group that requires
evaluation and treatment. (See "Osteoporotic fracture risk assessment"
 and "Overview of the management of osteoporosis in postmenopausal
women" and "Osteoporotic thoracolumbar vertebral compression
fractures: Clinical manifestations and treatment".)

● Laboratory evaluation – We suggest that postmenopausal women

with low BMD (T-score below -2.5) and/or fragility fracture have the
following basic tests (table 3) [27,28,31,35]:

• Biochemistry profile (especially calcium, phosphorous, albumin, total

protein, creatinine, liver enzymes including alkaline phosphatase,
electrolytes)

• 25-hydroxyvitamin D (25[OH]D)

• Complete blood count (CBC)

• If the diagnosis of osteoporosis is based upon the presence of a

fragility fracture, we also obtain a BMD measurement (dual-energy
x-ray absorptiometry [DXA]), performed on a nonurgent basis, for
quantitative assessment of bone density and to monitor response to
therapy

Additional evaluation — The need for additional laboratory evaluation

depends upon the initial evaluation and Z-score (table 3). Women who have
abnormalities on initial laboratory testing, suspicious findings on history
and physical examination suggesting a secondary cause of osteoporosis, or
Z-scores ≤-2 may require additional evaluation to detect these secondary
causes (table 2).

As examples:

● 24-hour urine for calcium and creatinine measurement is useful to

assess for adequate calcium intake and absorption in women with
gastrointestinal disorders, such as inflammatory bowel disease and
celiac disease, or after gastrointestinal surgery, such as gastrectomy or
bariatric surgery. Assessment of urinary calcium is also necessary in
 women with kidney stones, and it may be helpful in women with
osteoporosis and no risk factors beyond age to identify idiopathic
hypercalciuria [36]. (See "Metabolic bone disease in inflammatory
bowel disease" and "Kidney stones in adults: Epidemiology and risk
factors", section on 'High urine calcium'.)

● A woman with unexplained anemia, vitamin D deficiency, and/or low

urinary calcium excretion should be tested for celiac disease. (See
"Vitamin D deficiency in adults: Definition, clinical manifestations, and
treatment", section on 'Defining vitamin D sufficiency' and "Diagnosis
of celiac disease in adults" and "Epidemiology, pathogenesis, and
clinical manifestations of celiac disease in adults", section on
'Metabolic bone disorders'.)

● Cancer or multiple myeloma should be considered in patients who also

have hypercalcemia, otherwise unexplained anemia, weight loss, or
proteinuria. Measurement of serum and urine protein electrophoresis
would be indicated in this case. (See "Multiple myeloma: Clinical
features, laboratory manifestations, and diagnosis".)

● Serum parathyroid hormone (PTH) should be measured in patients

with hypercalcemia, hypercalciuria, a history of renal stones, or
osteopenia. (See "Primary hyperparathyroidism: Diagnosis, differential
diagnosis, and evaluation".)

● Urinary cortisol excretion should be measured if Cushing's syndrome is

suspected and in patients with unexplained osteoporosis and vertebral
fracture since patients with subclinical hypercortisolism (mild
hypercortisolism without clinical manifestations of Cushing's
syndrome) are also at risk for low BMD and fractures. (See "Evaluation
and management of the adrenal incidentaloma", section on 'Subclinical
Cushing's syndrome' and "Establishing the diagnosis of Cushing's
syndrome" and "Epidemiology and clinical manifestations of Cushing's
syndrome", section on 'Bone loss'.)
Bone turnover markers — We do not routinely measure markers of bone
turnover (BTMs) in postmenopausal women with osteoporosis. While the
use of BTMs in clinical trials has been helpful in understanding the
mechanism of action of therapeutic agents, their role in the care of
individual patients is not well established. Potential roles of BTMs in clinical
practice include prediction of fracture risk, monitoring response to therapy,
and improving compliance with therapy. Biologic and laboratory variability
in BTM values have confounded their widespread use in clinical practice.
This topic is reviewed separately. (See "Use of biochemical markers of bone
turnover in osteoporosis".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected

countries and regions around the world are provided separately. (See
"Society guideline links: Osteoporosis".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in
plain language, at the 5th to 6th grade reading level, and they answer the
four or five key questions a patient might have about a given condition.
These articles are best for patients who want a general overview and who
prefer short, easy-to-read materials. Beyond the Basics patient education
pieces are longer, more sophisticated, and more detailed. These articles are
written at the 10th to 12th grade reading level and are best for patients who
want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can
also locate patient education articles on a variety of subjects by searching
on "patient info" and the keyword(s) of interest.)
 ● Basics topics (see "Patient education: Osteoporosis (The Basics)" and
"Patient education: Calcium and vitamin D for bone health (The
Basics)")

● Beyond the Basics topics (see "Patient education: Osteoporosis

prevention and treatment (Beyond the Basics)" and "Patient education:
Calcium and vitamin D for bone health (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

● Osteoporosis definition – Osteoporosis is characterized by low bone
mass, microarchitectural disruption, and skeletal fragility, resulting in
decreased bone strength and an increased risk of fracture. Decreased
bone strength is related to many factors in addition to bone mineral
density (BMD), including rates of bone formation and resorption
(turnover), bone geometry (size and shape of bone), and
microarchitecture (picture 1). (See 'Introduction' above.)

● Clinical manifestations – Osteoporosis has no clinical manifestations

until there is a fracture. Complications of fractures include pain,
deformity, disability, and loss of height. (See 'Clinical manifestations'
above.)

● Diagnosis

• Fragility fracture – A clinical diagnosis of osteoporosis may be

made in the presence of a fragility fracture, particularly at the spine,
hip, wrist, humerus, rib, and pelvis, without measurement of BMD.

• DXA – In the absence of a fragility fracture, BMD assessment by

dual-energy x-ray absorptiometry (DXA) is the standard test to
diagnose osteoporosis, according to the classification of the World
Health Organization (WHO) (table 1). A DXA T-score ≤-2.5 is
consistent with osteoporosis, whereas a T-score between -1 and -2.5
is low bone mass (osteopenia). (See 'Diagnosis' above.)
 • High fracture risk – For patients without a history of fragility
fracture and without a DXA T-score ≤-2.5, a clinical diagnosis of
osteoporosis may also be made if there is a clear elevated risk for
fracture. In the United States, for example, a clinical diagnosis of
osteoporosis may be made when the Fracture Risk Assessment Tool
(FRAX) 10-year probability of major osteoporotic fracture is ≥20
percent or the 10-year probability of hip fracture is ≥3 percent. (See
'Diagnosis' above.)

● Evaluation – All postmenopausal women with osteoporosis should

have a history, physical examination, and basic laboratory evaluation.
Initial laboratory studies should include a complete blood count (CBC),
biochemistry profile, and 25-hydroxyvitamin D (25[OH]D). (See
'Evaluation' above.)

The need for additional laboratory evaluation depends upon the initial
evaluation and Z-score (table 3). Women who have abnormalities on
initial laboratory testing, suspicious findings on history and physical
examination suggesting a secondary cause of osteoporosis, or Z-scores
≤-2 may require additional evaluation for these secondary causes (
table 2). (See 'Additional evaluation' above.)

● Treatment – The treatment of osteoporosis in postmenopausal

women is reviewed separately. (See "Overview of the management of
osteoporosis in postmenopausal women".)

ACKNOWLEDGMENT

The UpToDate editorial staff acknowledges Marc K Drezner, MD, who

contributed to an earlier version of this topic review.

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