Osteoporosis is a skeletal disease characterized by a decrease in bone density and quality, leading to increased fragility and a high risk of fractures—particularly in the wrist, hip, and vertebrae. It is often referred to as a «silent disease» because it progresses without symptoms for decades until a fracture occurs, sometimes following minimal trauma or even spontaneously. In North America, approximately one in three women and one in five men over the age of 50 will experience an osteoporosis-related fracture during their lifetime. Hip fractures, the most serious complication, are associated with a one-year mortality rate of 20 to 30 % and permanent loss of independence in 50 % of survivors.
The menopausal transition is a critical period for women’s bone health: the sharp drop in estrogen dramatically accelerates bone resorption, with bone loss reaching as much as 2 to 3 % of bone mass per year in the first few years following menopause. This window corresponds precisely to the time when prevention and screening are most effective—identifying women with accelerated bone loss at age 50 allows for intervention before bone density reaches the fragility threshold. Omicron Clinic includes osteoporosis risk assessment in its health screenings for women aged 50 and older at several of its locations in Quebec, enabling personalized preventive care.
Risk Factors for Osteoporosis: Who Should Be Screened First?
Osteoporosis Canada recommends a fracture risk assessment for all women aged 65 and older, and for women aged 50 to 64 who have clinical risk factors. Major risk factors—those that warrant bone densitometry screening before age 65—include: a fragility fracture after age 40 (a fracture resulting from minimal trauma that would not have fractured a normal bone), a history of hip fracture in a first-degree relative, systemic corticosteroid therapy lasting more than three months (prednisone ≥ 7.5 mg/day or equivalent), early menopause before age 45—whether spontaneous or surgical—and certain conditions associated with accelerated bone loss: rheumatoid arthritis, celiac disease, Crohn’s disease, hyperthyroidism, or hyperparathyroidism.
Secondary risk factors that contribute to the overall risk assessment include: active smoking, alcohol consumption of more than two drinks per day, a low body mass index (BMI) of less than 20 kg/m², vitamin D deficiency, a sedentary lifestyle, repeated falls, and prolonged use of bone-depleting medications—proton pump inhibitors, antiepileptic drugs, antiandrogens for prostate cancer, and aromatase inhibitors for breast cancer. The FRAX tool—Fracture Risk Assessment Tool, available online—incorporates these clinical factors to calculate the 10-year probability of a major fracture and a hip fracture, guiding the decision on whether to treat.
Bone Densitometry (DEXA): How to Interpret the Results
Dual-energy X-ray absorptiometry (DXA or DEXA) is the gold standard test for measuring bone mineral density and diagnosing osteoporosis. It measures bone density in the lumbar spine and the femoral neck, the two sites that provide the most information regarding the risk of vertebral and hip fractures, respectively. The result is expressed as a T-score—the standard deviation from the peak bone density of a young adult of the same sex used as a reference. A T-score greater than -1.0 is normal, a score between -1.0 and -2.5 corresponds to osteopenia (low bone mass that does not reach the osteoporotic threshold), and a score of -2.5 or lower defines osteoporosis according to WHO criteria. The presence of a fragility fracture associated with a T-score ≤ -2.5 defines severe or established osteoporosis.
The T-score must always be interpreted in a clinical context—a T-score of -2.0 in a healthy 50-year-old woman with no risk factors requires a different approach than the same score in a 70-year-old woman with a history of repeated falls. The FRAX tool combines the T-score with clinical factors to calculate the 10-year absolute risk of fracture, allowing for personalized treatment decisions. In Quebec, bone densitometry is covered by the RAMQ based on specific indications—a previous fragility fracture, prolonged corticosteroid therapy, early menopause, certain osteopenia-causing diseases—and is repeated every 2 to 5 years depending on the initial result and risk factors. Health screenings at Clinique Omicron include an assessment of osteoporosis risk and a referral for bone densitometry when clinically indicated.
Prevention and Treatment: Calcium, Vitamin D, and Medications
Osteoporosis prevention relies on measures that can be taken throughout one’s life but are particularly important starting in one’s 50s. Adequate calcium intake—1,200 mg per day for women over 50, preferably from dietary sources—is the foundation of bone health: dairy products, leafy green vegetables, firm tofu, legumes, and fortified foods. Calcium supplementation is recommended only when dietary intake is insufficient, as recent meta-analyses suggest a possible association between excessive calcium supplementation and a slightly increased cardiovascular risk. Vitamin D is essential for the intestinal absorption of calcium—a daily intake of 800 to 2,000 IU is recommended for women over 50 in Quebec, given the insufficient sun exposure for most of the year. Weight-bearing physical activity—such as walking, hiking, strength training, and dancing—stimulates bone formation and improves muscle strength and balance, reducing the risk of falls.
Pharmacological treatment is recommended for women with established osteoporosis (T-score ≤ -2.5) or a high 10-year fracture risk according to FRAX. Bisphosphonates—alendronate, risedronate, zoledronic acid—remain the first-line class of therapy: they inhibit bone resorption, increase bone density, and reduce the risk of vertebral fractures by 40 to 70 % and hip fractures by 30 to 50 %. Denosumab—a semiannual subcutaneous injection—is an effective alternative, particularly useful in cases of contraindication or intolerance to bisphosphonates. Strontium ranelate, teriparatide (recombinant parathyroid hormone), and romosozumab are options for severe or refractory osteoporosis and are prescribed as specialty drugs. Hormone therapy for menopause—estrogen alone or in combination with a progestin—effectively prevents postmenopausal bone loss, but its use is guided by the individual benefit-risk ratio, taking into account other menopausal symptoms.
Frequently Asked Questions About Osteoporosis
Does osteoporosis affect men as well? When should they be screened?
Yes, osteoporosis also affects men, although less frequently and at a later age than in women because men do not experience a male equivalent of menopause—bone loss associated with aging is more gradual in men. About one in five men over the age of 50 will suffer an osteoporosis-related fracture during their lifetime. Hip fractures in men are associated with an even higher mortality rate than in women—up to 37 % at one year in some studies. Men are underdiagnosed and undertreated for osteoporosis compared to women. Osteoporosis Canada recommends assessing fracture risk in all men aged 65 and older, and in men aged 50 to 64 with risk factors—such as a previous fragility fracture, prolonged corticosteroid therapy, hypogonadism, antiandrogen therapy for prostate cancer, or osteopenia-inducing diseases. The diagnostic approach and treatment options are similar to those for women.
Is it possible to improve bone density naturally, without medication?
To a certain extent, yes—but the possibilities depend on the stage of the disease. During the prevention phase—mild to moderate osteopenia without fractures—lifestyle changes can stabilize or modestly improve bone density: regular weight-bearing physical activity and muscle-strengthening exercises two to three times a week, adequate dietary calcium intake of around 1,200 mg per day, vitamin D supplementation to maintain serum levels at 75 nmol/L or higher, smoking cessation, reducing alcohol consumption, and maintaining a healthy body weight. These measures are important and must be maintained for life, including in conjunction with pharmacological treatment. However, in a woman with established osteoporosis—T-score ≤ -2.5—or following a fragility fracture, lifestyle and dietary measures alone are insufficient to significantly reduce the risk of fracture—pharmacological treatment is therefore recommended by clinical guidelines.
Are calcium supplements sold at pharmacies helpful or dangerous?
The nuanced answer is that calcium supplements are useful when they compensate for an insufficient dietary intake, but unnecessary and potentially problematic when taken in addition to an already adequate dietary intake. Priority should always be given to dietary sources of calcium—they provide calcium along with other beneficial nutrients and without the potential risks associated with isolated supplemental doses. Recent meta-analyses have raised the question of a possible association between high-dose calcium supplementation—more than 1,000 mg per day—and a slightly increased risk of cardiovascular events and kidney stones, although this association remains a subject of debate in the literature. The current recommendation is to assess actual dietary calcium intake before prescribing a supplement: if intake is close to 1,200 mg per day, a supplement of 200 to 500 mg is sufficient; if intake is very low, a higher dose of supplementation is warranted. Calcium carbonate is best absorbed with a meal, while calcium citrate can be taken with or without meals and is preferred in cases of achlorhydria or when taking proton pump inhibitors.
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