What risk factors are assessed?

Age, sex, BMI, previous fracture, parental hip fracture, smoking, glucocorticoids, rheumatoid arthritis, secondary osteoporosis, alcohol, and optional BMD T-score.

When is treatment recommended?

Treatment generally recommended when 10-year major fracture risk exceeds 20% or hip fracture risk exceeds 3%.

FRAX is the WHO fracture risk assessment tool that integrates clinical risk factors with or without BMD.

How accurate is this calculator?

This is a simplified FRAX-based model. For clinical decisions, use the official FRAX tool or consult a specialist.

What lifestyle changes help?

Calcium 1000-1200mg/day, vitamin D 800-1000 IU, weight-bearing exercise, fall prevention, smoking cessation.

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MEDICALGeriatric MedicineHealth Calculator

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Osteoporosis Fracture Risk

Estimate 10-year probability of major osteoporotic and hip fracture using FRAX-based clinical risk factors.

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Major risk ≥20%: consider treatment Hip risk ≥3%: consider treatment FRAX-based methodology

Ready to run the numbers?

Why: Fracture risk assessment guides treatment decisions. Treatment recommended when major risk exceeds 20% or hip risk exceeds 3%.

How: Enter age, sex, weight, height, and clinical risk factors. Optional BMD T-score refines the estimate.

Major risk ≥20%: consider treatmentHip risk ≥3%: consider treatment

Sources:WHO FRAX

Run the calculator when you are ready.

Calculate Fracture RiskUse the calculator below to check your health metrics

Low Risk (55F)

Post-menopausal woman with no risk factors

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Moderate Risk (65F)

Woman with family history and previous fracture

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High Risk (72F)

Elderly woman on steroids with multiple risk factors

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Male with Risk Factors (68M)

Man with smoking history and glucocorticoid use

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Very High Risk (80F)

Elderly woman with osteoporosis and multiple fractures

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Sample Scenarios

Low Risk (55F)

Post-menopausal woman with no risk factors

Moderate Risk (65F)

Woman with family history and previous fracture

High Risk (72F)

Elderly woman on steroids with multiple risk factors

Male with Risk Factors (68M)

Man with smoking history and glucocorticoid use

Very High Risk (80F)

Elderly woman with osteoporosis and multiple fractures

Patient Information

Age (40-90)

Sex

Weight (kg)

Height (cm)

Clinical Risk Factors

Previous Fragility Fracture

Parental Hip Fracture

Current Smoking

Glucocorticoids (≥5mg/day for ≥3mo)

Rheumatoid Arthritis

Secondary Osteoporosis

Alcohol (3+ units/day)

Bone Mineral Density (Optional)

Include BMD?

For informational purposes only — not medical advice. Consult a healthcare professional before acting on results.

🏥 Health Facts

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FRAX-based assessment

— WHO

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Guides treatment decisions

— Clinical

What is the Osteoporosis Risk Calculator?

The Osteoporosis Risk Calculator estimates the 10-year probability of major osteoporotic fracture (spine, forearm, hip, shoulder) and hip fracture. Based on the FRAX algorithm developed by WHO, it integrates clinical risk factors with or without bone mineral density (BMD) measurements.

This tool helps healthcare providers identify patients who may benefit from pharmacologic treatment and guides treatment decisions. Treatment is generally recommended when 10-year major osteoporotic fracture risk exceeds 20% or hip fracture risk exceeds 3%.

Risk Factors Assessed

Major Risk Factors

• Previous fragility fracture
• Parental hip fracture
• Glucocorticoid use
• Low BMD (T-score ≤-2.5)

Other Risk Factors

• Current smoking
• Rheumatoid arthritis
• Excessive alcohol
• Secondary osteoporosis

Treatment Thresholds

According to NOF guidelines, treatment is recommended when:

• 10-year major osteoporotic fracture risk ≥ 20%
• 10-year hip fracture risk ≥ 3%
• T-score ≤ -2.5 at femoral neck, total hip, or spine
• Previous hip or vertebral fracture

Detailed Risk Factor Analysis

Previous Fragility Fracture

A previous fragility fracture (occurring from low trauma, such as a fall from standing height) is the strongest predictor of future fracture. Risk is doubled compared to those without prior fracture. Include vertebral, hip, wrist, or other fragility fractures.

Increases fracture risk 2-4 fold

Parental Hip Fracture

Family history of hip fracture in a parent indicates genetic predisposition to low bone density and fracture. This risk factor is independent of the patient's own BMD and other risk factors.

Increases hip fracture risk 2-fold

Glucocorticoid Use

Glucocorticoid-induced osteoporosis (GIO) is the most common form of secondary osteoporosis. Risk begins within 3 months of starting steroids. Consider treatment for patients taking ≥5mg prednisone equivalent daily for ≥3 months.

Bone loss most rapid in first 6-12 months

Current Smoking

Smoking has direct toxic effects on bone cells and impairs intestinal calcium absorption. It also affects estrogen metabolism. Risk diminishes after cessation but may never fully normalize.

Increases fracture risk 1.3-1.8 fold

Alcohol Consumption

Excessive alcohol intake (≥3 units/day) increases fracture risk through direct effects on bone cells and increased fall risk. Moderate alcohol consumption may have neutral or slightly protective effects.

1 unit = 10ml pure alcohol

Pharmacologic Treatment Options

Bisphosphonates (First-Line)

Alendronate (Fosamax)

70mg weekly oral; reduces spine and hip fractures 50%

Risedronate (Actonel)

35mg weekly or 150mg monthly oral

Ibandronate (Boniva)

150mg monthly oral or 3mg IV quarterly

Zoledronic Acid (Reclast)

5mg IV annually; most potent bisphosphonate

Non-Bisphosphonate Options

Denosumab (Prolia)

60mg SQ every 6 months; RANK-ligand inhibitor

Teriparatide (Forteo)

20mcg SQ daily; anabolic, builds new bone

Romosozumab (Evenity)

210mg SQ monthly × 12 months; newest anabolic

Raloxifene (Evista)

60mg daily; SERM, postmenopausal women only

Non-Pharmacologic Management

Calcium & Vitamin D

Calcium: 1000-1200mg/day (diet + supplements)
Vitamin D: 800-1000 IU/day (target 25(OH)D ≥30ng/mL)
• Split calcium doses (≤500mg per dose for absorption)
• Take calcium carbonate with food
• Calcium citrate if achlorhydric or on PPI

Exercise Recommendations

• Weight-bearing: walking, jogging, dancing, stair climbing
• Resistance training: 2-3 times/week, major muscle groups
• Balance training: reduces fall risk 20-40%
• Avoid high-impact activities if severe osteoporosis
• Physical therapy referral for individual program

Lifestyle Modifications

• Smoking cessation (critical for bone health)
• Limit alcohol to ≤2 drinks/day
• Adequate protein intake (1g/kg/day)
• Fall prevention measures
• Regular vision and hearing checks

Fall Prevention

• Remove home hazards (rugs, cords, clutter)
• Install grab bars and handrails
• Ensure adequate lighting
• Review medications for fall risk
• Consider hip protectors for high-risk

Understanding DXA Results

T-Score	Classification	Recommendations
-1.0 or above	Normal	Lifestyle measures, repeat DXA per guidelines
-1.0 to -2.5	Osteopenia (Low Bone Mass)	Calculate FRAX; treat if high risk or fragility fracture
-2.5 or below	Osteoporosis	Pharmacologic treatment recommended
Any T-score + fracture	Severe Osteoporosis	Consider anabolic therapy (teriparatide, romosozumab)

Note: T-scores compare BMD to young healthy adults. Z-scores (comparison to age-matched peers) should be used in premenopausal women, men under 50, and children.

Research Evidence

FRAX Development (Kanis et al., 2008)

The FRAX algorithm was developed using data from population-based cohorts with nearly 250,000 patient-years of follow-up. It predicts 10-year fracture probability and has been validated in independent cohorts worldwide.

Osteoporosis International, 19(4), 385-397.

Bisphosphonate Efficacy (Black et al., 1996)

The Fracture Intervention Trial demonstrated that alendronate reduces vertebral fractures by 47% and hip fractures by 51% in women with osteoporosis.

Lancet, 348(9041), 1535-1541.

Denosumab (FREEDOM Trial, 2009)

Denosumab reduced new vertebral fractures by 68%, hip fractures by 40%, and nonvertebral fractures by 20% compared to placebo in postmenopausal women.

New England Journal of Medicine, 361(8), 756-765.

Frequently Asked Questions

How often should I get a DXA scan?

For most people on treatment, repeat DXA every 2 years. Those with normal BMD may wait 5-10 years between scans. Your provider will recommend timing based on your individual situation.

How long should I take osteoporosis medication?

Bisphosphonates are typically taken for 3-5 years, then a "drug holiday" may be considered for low-risk patients. High-risk patients may need to continue longer. Denosumab should not be stopped without a plan for follow-up therapy.

Can men get osteoporosis?

Yes. While less common than in women, 1 in 4 men over 50 will have an osteoporosis-related fracture. Men with low testosterone, on glucocorticoids, or with other risk factors should be screened.

Osteoporosis Treatment Options

First-Line Therapies: Bisphosphonates

Oral Options

• Alendronate (Fosamax) - weekly
• Risedronate (Actonel) - weekly/monthly
• Ibandronate (Boniva) - monthly

IV Options

• Zoledronic acid (Reclast) - yearly
• Ibandronate (Boniva) - quarterly

RANK Ligand Inhibitor

Denosumab (Prolia)

Subcutaneous injection every 6 months

Key considerations:

Must not discontinue without transition therapy due to rebound bone loss and vertebral fracture risk.

Anabolic Agents (For Severe Osteoporosis)

Options

• Teriparatide (Forteo) - daily injection, 24 months max
• Abaloparatide (Tymlos) - daily injection, 24 months max
• Romosozumab (Evenity) - monthly injection, 12 months

Indications

• Very high fracture risk
• Multiple vertebral fractures
• Failed bisphosphonate therapy
• T-score < -3.0

Hormone Therapy

Estrogen therapy (women)

May be considered in postmenopausal women with vasomotor symptoms. Not first-line for osteoporosis alone due to cardiovascular risks.

Testosterone (men)

For men with documented hypogonadism. Does not replace need for osteoporosis-specific therapy in severe cases.

Screening Guidelines Summary

Women

• Age ≥65: Screen with DXA
• Postmenopausal <65 with risk factors: Screen
• Postmenopausal with fragility fracture: Screen and treat
• Premenopausal with risk factors: Consider screening

Men

• Age ≥70: Screen with DXA
• Age 50-69 with risk factors: Screen
• Any age with fragility fracture: Screen and treat
• On glucocorticoids or androgen deprivation: Screen

Risk Factors Warranting Earlier Screening

• Prior fragility fracture• Parental hip fracture• Low body weight (<58 kg)• Smoking• Excess alcohol• Glucocorticoid use• Rheumatoid arthritis• Secondary osteoporosis

Calcium and Vitamin D Requirements

Population	Calcium (mg/day)	Vitamin D (IU/day)	Notes
Women 19-50	1,000	600-800	Dietary sources preferred
Women 51+	1,200	800-1,000	May need supplement
Men 19-70	1,000	600-800	Dietary sources preferred
Men 71+	1,200	800-1,000	May need supplement
On osteoporosis therapy	1,200	800-2,000	Target 25(OH)D >30 ng/mL

Note: Recent guidelines emphasize getting calcium from dietary sources when possible, as high-dose calcium supplements may be associated with cardiovascular risk. Vitamin D supplements are often necessary, especially in those with limited sun exposure.

Lifestyle Interventions for Bone Health

Weight-Bearing Exercise

• Walking (30+ min most days)
• Jogging/running
• Dancing
• Stair climbing
• Tennis/racquet sports
• Tai Chi for balance

Resistance Training

• 2-3 sessions per week
• Focus on major muscle groups
• Progressive resistance
• Consider PT supervision initially
• Include core strengthening
• Avoid excessive spinal flexion

Things to Avoid

• Smoking (quit smoking)
• Excessive alcohol (>2 drinks/day)
• High-impact activities if fragile
• Excessive forward bending
• Heavy lifting improperly
• Fall-risk activities

Treatment Monitoring & Follow-up

DXA Monitoring Schedule

• On treatment: Repeat DXA every 2 years
• Stable/improving: May extend to every 3-5 years
• Declining BMD: Reassess treatment
• After treatment change: Repeat in 1-2 years

Bone Turnover Markers

• CTX (resorption marker) - baseline and 3-6 months
• P1NP (formation marker) - for anabolic agents
• Useful to confirm medication adherence
• Not routinely recommended for monitoring

Secondary Causes of Osteoporosis

Endocrine

• Hyperthyroidism
• Cushing's syndrome
• Hyperparathyroidism
• Hypogonadism
• Diabetes mellitus (Type 1)
• Growth hormone deficiency

Gastrointestinal

• Celiac disease
• Inflammatory bowel disease
• Malabsorption syndromes
• Chronic liver disease
• Bariatric surgery
• Primary biliary cholangitis

Medications

• Glucocorticoids
• Anticonvulsants
• Aromatase inhibitors
• Androgen deprivation therapy
• PPIs (long-term)
• Excess thyroid hormone

Clinical Pearl: Always evaluate for secondary causes in patients with unexpected osteoporosis (e.g., premenopausal women, men under 70). Initial workup may include: CBC, CMP, TSH, 25(OH)D, PTH, and celiac screen.

Treatment Thresholds by Risk Level

Risk Category	FRAX Hip	FRAX MOF	Recommendation
Low Risk	<3%	<10%	Lifestyle measures, reassess in 5-10 years
Moderate Risk	-	10-20%	Consider DXA, individualize decision
High Risk	≥3%	≥20%	Pharmacologic treatment recommended
Very High Risk	≥3% + VF	≥30%	Consider anabolic therapy first

MOF = Major Osteoporotic Fracture (hip, spine, forearm, humerus); VF = Vertebral Fracture

Patient Education Points

Understanding Your Risk

• Osteoporosis is often called a "silent disease"
• You can have weak bones without symptoms
• The first sign may be a fracture
• Risk increases with age but is preventable
• Treatment can reduce fracture risk by 50-70%

Medication Adherence

• Take bisphosphonates correctly for best absorption
• Stay upright for 30 min after oral bisphosphonates
• Don't skip doses - bone protection requires consistency
• Report any unusual side effects promptly
• Continue calcium/vitamin D as directed

Key References

1. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology Clinical Practice Guidelines for the Diagnosis and Treatment of Postmenopausal Osteoporosis. Endocr Pract. 2020;26(Suppl 1):1-46.
2. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int. 2014;25(10):2359-2381.
3. Kanis JA, Harvey NC, McCloskey E, et al. Algorithm for the management of patients at low, high and very high risk of osteoporotic fractures. Osteoporos Int. 2020;31(1):1-12.
4. US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521-2531.
5. Shoback D, Rosen CJ, Black DM, Cheung AM, Murad MH, Eastell R. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update. J Clin Endocrinol Metab. 2020;105(3):dgaa048.
6. Kanis JA, Cooper C, Rizzoli R, Reginster JY. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int. 2019;30(1):3-44.
7. Compston J, Cooper A, Cooper C, et al. UK clinical guideline for the prevention and treatment of osteoporosis. Arch Osteoporos. 2017;12(1):43.
8. Black DM, Rosen CJ. Clinical Practice. Postmenopausal Osteoporosis. N Engl J Med. 2016;374(3):254-262.
9. Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2019;104(5):1595-1622.
10. LeBoff MS, Greenspan SL, Insogna KL, et al. The clinician's guide to prevention and treatment of osteoporosis. Osteoporos Int. 2022;33(10):2049-2102.

Understanding the FRAX Algorithm

What FRAX Considers

• Age (40-90 years)
• Sex
• Weight and height (BMI calculation)
• Previous fragility fracture
• Parental history of hip fracture
• Current smoking
• Glucocorticoid use
• Rheumatoid arthritis
• Secondary osteoporosis causes
• Alcohol consumption (3+ units/day)
• Femoral neck BMD (optional)

FRAX Limitations

• Does not account for dose-response of glucocorticoids
• Number of prior fractures not considered
• Lumbar spine BMD not included
• Fall risk not directly assessed
• May underestimate risk in diabetics
• Country-specific calibration needed

Major Osteoporotic Fractures

Hip Fracture

Most serious; 20% mortality within 1 year

Vertebral Fracture

Often asymptomatic; chronic pain, kyphosis

Wrist Fracture

Common early sign; good outcomes

Humerus Fracture

Proximal; fall on outstretched arm

Clinical Pearls for Osteoporosis Management

• T-score vs Z-score: T-score compares to young adult; Z-score compares to age-matched controls. Use T-score for treatment decisions in postmenopausal women and men ≥50.
• Vertebral fracture assessment: Consider lateral spine imaging with DXA or X-ray in patients with height loss >1.5 inches, unexplained back pain, or T-score in osteopenia range.
• Treatment goals: Primary goal is fracture prevention, not just BMD improvement. Some patients may need treatment even with "normal" BMD if other risk factors are high.
• Drug holidays: For bisphosphonates, consider a "drug holiday" after 3-5 years in low-risk patients. High-risk patients may need continued or alternative therapy.
• Denosumab discontinuation: Never stop denosumab without a transition plan. Rebound vertebral fractures can occur within months of last dose.
• Anabolic-first approach: For very high-risk patients (multiple fractures, T-score < -3.0), consider starting with anabolic therapy before antiresorptive.
• Fracture liaison services: Coordinated care programs after fracture can improve treatment rates from <20% to >80% and reduce re-fracture risk.
• Secondary prevention: Any patient with a fragility fracture should be evaluated and treated for osteoporosis regardless of BMD results.
• Monitor for atypical fractures: With long-term bisphosphonate use, watch for prodromal thigh pain that may indicate atypical femur fracture.
• Optimize fall prevention: Even with excellent BMD treatment, fall prevention remains critical to reduce fracture risk.
• Reassess regularly: Monitor treatment response with DXA every 2 years and consider bone turnover markers if poor response.
• Address adherence: Half of patients stop osteoporosis medications within one year. Address barriers and simplify regimens when possible.
• Multidisciplinary approach: Best outcomes involve endocrinologists, rheumatologists, orthopedists, primary care, physical therapy, and nutrition working together.
• Patient empowerment: Educate patients about their role in bone health - exercise, nutrition, medication adherence, and fall prevention are all essential.
• Goal-oriented care: Set realistic, measurable goals with patients and track progress to maintain engagement in long-term treatment.
• Consider comorbidities: Modify treatment approach based on renal function, GI intolerance, and cardiovascular status.

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