The fracture risk assessment tool (FRAX ) was developed by the World Health Organization to predict the risk of osteoporotic fracture for a person over the next 10 years and the calculator can be found online at http://​www.​sheffield.​ac.​uk/​FRAX/​. The output is a 10-year probability of hip fracture and the 10-year probability of a major osteoporotic fracture (clinical spine, forearm, hip, or shoulder fracture).

A physical exam , looking for risk factors for falling, such as decreased mobility or strength (e.g., unable to rise from a chair without using hands), decreased proprioception, decreased visual acuity, signs of osteoporosis (i.e., evidence of vertebral compression fractures with loss of height, kyphosis, and overly protuberant abdomen) should be done. The physical exam should also rule out signs of other possible causes of metabolic disease (i.e., cushingoid features, goiter, jaundice, etc).

The information gathered from the history and physical will help identify patients for whom further diagnostic imaging is indicated.

The United States Preventative Services Task Force (USPSTF ) recommends screening for osteoporosis in women aged 65 years or older and in younger women whose fracture risk is equal to or greater than that of a 65-year-old white woman with no additional risk factures [5]. (SOR-B) Dual energy X-ray absorptiometry (DEXA) is currently considered the gold standard for measuring BMD [3]. The areal unit of measurement is grams per square centimeter (g/cm²), although it is usually reported as a T-score, which is a standard deviation without units of measurement. The World Health Organization (WHO) has defined osteoporosis on the basis of BMD as measured by DEXA. BMD that is greater than 2.5 standard deviations below the mean for a young, white, healthy female is defined as osteoporosis. BMD 1.0–2.5 standard deviations below the mean is defined as low bone mass (previously called osteopenia).

Other methods used to measure BMD include quantitative computed tomography (QCT) and quantitative ultrasound (QUS). However, DEXA of the hip is the best predictor of future hip fracture and the only imaging recommended for serial evaluations of patients being treated for osteoporosis .

Once the diagnosis of osteoporosis has been made, there are a number of pharmacological and nonpharmacological treatments available. Some of the treatments are also used for the prevention of osteoporosis in high-risk individuals. Non-pharmacological interventions for treatment and prevention of osteoporosis are listed in Table 8.2.

Pharmacological treatments used to prevent and treat osteoporosis include antiresorptive drugs such as the bisphosphonates (alendronate, risedronate, ibandronate), calcitonin, estrogen, and partial estrogen agonists and antagonists (previously known as selective estrogen receptor modulators or SERMs), such as raloxifene. The bisphosphonates reduce bone turnover and subsequently prevent bone loss. Calcitonin inhibits osteoclasts, and previous studies have shown a decrease in the incidence of vertebral fractures as well as an analgesic effect when administered after acute vertebral fractures [4]. Currently, there is no significant information on the effect of calcitonin on early menopausal BMD, so it is not recommended within the first 5 years of menopause. Estrogen also inhibits bone resorption, increases total hip BMD, and reduces the risk of fracture at the hip, spine, and wrist, and is currently approved for prevention, but not treatment for osteoporosis. Raloxifene is able to exert estrogen-like effects on the skeleton, although not as effectively as estrogen or the bisphosphonates [4]. Calcium and vitamin D supplementation is also important therapy and can be prescribed for prevention of osteoporosis, and should be prescribed for any patients taking bisphosphonates for prevention or treatment of osteoporosis. Not all medications used to treat osteoporosis have data supporting reduced fractures of all kinds (spine, hip, nonvertebral fractures). Specifically, ibandronate (Boniva) does not show reduced hip and nonvertebral fractures. Calcium carbonate and gluconate will require an acidic environment, so patients on PPIs will need calcium citrate supplementation, which is effective in acidic or alkaline environment [6].

The fundamental goal of managing patients at high risk for osteoporosis is to prevent fractures and loss of function, and also to prevent or decrease pain. While there is evidence of increased bone density and decreased risk of fracture with pharmacologic intervention, there are still remaining questions about the effectiveness of interventions in asymptomatic populations [4, 7].

While there is general consensus that women over the age of 65 should have a BMD test, for women under age 65, BMD testing is generally reserved for those considered to be “at risk” for osteoporosis [4, 7]. What defines “at risk” is not universally agreed upon, and any data on using medications to prevent bone loss in perimenopausal women with normal BMD are extremely limited. Also, the risk factors, testing, and treatment of osteoporosis in populations other than postmenopausal white women need to be further investigated.