Osteoporosis Prevention, Screening, and Diagnosis

Publication Date: September 1, 2021
Last Updated: March 14, 2022

Common Risk Factors for Osteoporosis

  • Increasing age
  • Parental history of hip or spine fracture
  • BMI less than 20 kg/m2 or body weight less than 127 lb
  • Smoking
  • Excessive alcohol use (ie, more than three drinks per day)
  • Conditions, diseases, and medications associated with secondary osteoporosis:*
    • AIDS and HIV, anorexia nervosa, diabetes mellitus (type 1 and type 2), diminished ovarian reserve, gastric bypass, hyperparathyroidism, hypocalcemia, premature menopause (induced, surgical, or spontaneous), primary ovarian insufficiency, renal impairment, rheumatoid arthritis, Turner’s syndrome, vitamin D deficiency
    • Antiepileptic drugs (eg, phenytoin, carbamazepine, primidone, and phenobarbital), antiretroviral drugs, aromatase inhibitors, chemotherapy, DMPA, glucocorticoids, gonadotropin-releasing hormone agonists, gonadotropin-releasing hormone antagonists), heparin

Prevention Strategies

Physical Activity

ACOG recommends routine aerobic physical activity (moderate-to-high impact) and weight-bearing exercises (muscle strengthening or exercise against resistance) to maintain bone health and prevent bone loss. ( Moderate , Strong )

Vitamin D and Calcium

Counsel patients to consume the recommended daily allowance of dietary calcium and vitamin D for bone health and general health. ( Evidence Gap , No recommendation )

Screening and Diagnosis

Diagnostic Criteria for Postmenopausal Osteoporosis

Any one of the following criteria is consistent with a diagnosis of postmenopausal osteoporosis:
  • T-score −2.5 or lower by DXA of the femoral neck, total hip, lumbar spine, or distal 1/3 radius*
  • History of fragility fracture, including asymptomatic vertebral fracture
  • T-score between –1.0 and –2.5 and increased risk of fracture, as determined by a formal clinical risk assessment tool†
*Hip (femoral neck) and lumbar spine measurements by DXA provide the most accurate and precise measurements of BMD. When one or both these sites cannot be evaluated (eg, in the case of bilateral hip replacements, lumbar spine surgery, or both), BMD measurement at the forearm (distal one third of the radius) can be used for diagnosis.

†For example, using the U.S. Fracture Risk Assessment Tool (FRAX) tool, this would be a 10-year hip fracture probability of 3% or greater or a 10-year major osteoporotic fracture probability of 20% or greater

Bone Mineral Density Testing

ACOG recommends screening for osteoporosis in postmenopausal patients 65 years and older with BMD testing to prevent osteoporotic fractures. ( High , Strong )

ACOG recommends screening for osteoporosis with BMD testing to prevent osteoporotic fractures in postmenopausal patients younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. ( High , Strong )

ACOG suggests repeat osteoporosis screening in postmenopausal patients with initial BMD test results near treatment thresholds or with significant changes in risk factors; for most patients, repeat BMD testing should be performed no sooner than 2 years after initial screening. ( Low , Conditional (weak) )

Lifestyle and Environmental Modifications to Prevent Falls

Assess risk of falls in postmenopausal patients with low BMD or osteoporosis. Fall-prevention strategies for those at increased risk include weight-bearing and muscle-strengthening exercises as well as individualized multifactorial interventions (eg, vision assessment and treatment, balance training, and environmental assessment and modification). ( Evidence Gap , No recommendation )

Recommendation Grading




Osteoporosis Prevention, Screening, and Diagnosis

Authoring Organization

Publication Month/Year

September 1, 2021

Last Updated Month/Year

December 19, 2022

Document Type


Country of Publication


Inclusion Criteria

Female, Adult, Older adult

Health Care Settings


Intended Users

Nurse, nurse midwife, physician, nurse practitioner, physician assistant


Diagnosis, Assessment and screening, Prevention

Diseases/Conditions (MeSH)

D010024 - Osteoporosis


osteoporosis, screening

Source Citation

Osteoporosis Prevention, Screening, and Diagnosis: ACOG Clinical Practice Guideline No. 1. Obstet Gynecol. 2021 Sep 1;138(3):494-506. doi: 10.1097/AOG.0000000000004514. PMID: 34412075.


Number of Source Documents
Literature Search Start Date
February 1, 2020
Literature Search End Date
February 1, 2021