Each year in the United States, approximately 2 million bone fractures are attributable to osteoporosis. Hip fractures in older women carry a one-year mortality rate approaching 20% — higher than many cancers we devote enormous resources to preventing. Vertebral fractures cause chronic pain, height loss, and disability. Wrist fractures herald future fracture risk that, if identified, could trigger interventions that prevent more serious injury.
We have the tools to identify who is at risk, when to screen, and how to treat. We are systematically failing to use them.
The Screening Gap
DEXA scanning — bone mineral density measurement — is recommended for all women over 65 and for younger postmenopausal women with risk factors. Uptake remains far below recommended levels. Preventive care is deprioritized in overwhelmed primary care settings. Insurance coverage for DEXA is inconsistent. Clinicians underestimate fracture risk in women who do not appear to fit the osteoporosis stereotype — thin, white, older — missing Black, Hispanic, and Asian women whose fracture risk tools were not calibrated on their populations.
The years immediately following menopause represent the fastest period of bone loss in a woman’s lifetime — up to 20% of bone mass in five to seven years. This window is both the period of greatest risk and the period of greatest opportunity for intervention. Most women in perimenopause are not having conversations with their clinicians about bone health.
From Break-and-Fix to Predict-and-Prevent
The dominant model for osteoporosis in the health care system is reactive: a woman fractures her hip, is treated for the fracture, and may or may not receive follow-up for the underlying bone disease. The fracture liaison service model — systematic follow-up of all fragility fracture patients for osteoporosis evaluation and treatment — has been shown to dramatically reduce secondary fracture rates. It is not widely implemented.
SWHR has advocated for a shift to a predict-and-prevent model: systematic risk assessment, bone density screening at recommended thresholds, and treatment initiation before the first fracture rather than after it.
The Equity Dimension
Fracture risk assessment tools perform less accurately in non-white populations. Black women have higher bone density on average than white women — but this does not make them immune to osteoporosis, and it has contributed to Black women being underscreened and underdiagnosed. When osteoporosis is diagnosed in Black women, it is more often at an advanced stage. The tools and clinical assumptions were designed for one population and applied broadly. That is a research gap with clinical consequences.
