Preventing osteoporosis-related fractures in older women requires action on several fronts simultaneously: getting screened early, building and maintaining bone density through exercise and nutrition, reducing fall risk in daily environments, and — when bone loss is already significant — using medications proven to cut fracture rates nearly in half. A woman at 65 who has never had a bone density scan, avoids weight-bearing exercise, and takes a low-dose calcium supplement thinking that covers her bases is, statistically, in a much more vulnerable position than she realizes. This article covers screening guidelines, lifestyle interventions, pharmacological options, and the persistent gaps in who receives care. The stakes are high enough that they warrant plain language. White women face a one-in-six lifetime risk of hip fracture — higher than their one-in-nine lifetime risk of breast cancer, a disease that draws far more public attention and preventive screening effort.
Women aged 90 and older face a 20.9% five-year probability of hip fracture. Among those who do fracture a hip, roughly 40% cannot walk independently a year later, and about one-third end up in a nursing home. One-year mortality after hip fracture approaches 40% in women between 80 and 89. These are not edge-case outcomes. They are common, and many are preventable.
Table of Contents
- Why Are Older Women at Such High Risk for Osteoporosis Fractures?
- What Do Current Screening Guidelines Recommend for Women?
- Which Lifestyle Changes Most Effectively Reduce Fracture Risk?
- How Does Fall Prevention Fit Into Fracture Prevention?
- What Medications Are Available for Osteoporosis Treatment?
- How Do Health Disparities Affect Fracture Outcomes for Women of Color?
- What Does the Future of Fracture Prevention Look Like for Aging Women?
- Conclusion
- Frequently Asked Questions
Why Are Older Women at Such High Risk for Osteoporosis Fractures?
Osteoporosis disproportionately affects women because estrogen plays a central role in maintaining bone density, and its sharp decline at menopause accelerates bone loss dramatically. In the years immediately following menopause, some women lose bone density at a rate of 1–2% per year or more. By the time a woman reaches her mid-70s, decades of cumulative loss can leave bones porous enough that a minor stumble — or in some cases, no traumatic event at all — results in a fracture. The spine, hip, and wrist are the most common sites. The statistics on fracture burden are skewed heavily toward women. Approximately 75% of all hip fractures occur in women, and the risk compounds with age in a steep and largely underappreciated curve.
A woman aged 80–84 has a 7.1% five-year probability of hip fracture; by age 90, that figure climbs to nearly 21%. For context, that means one in five women who reach their 90s will fracture a hip within the next five years. Compare that to the attention — clinical and cultural — directed at other age-related health risks in older women, and it becomes clear that fracture prevention is chronically under-prioritized. Bone loss does not cause pain and is not visible, which is part of why it goes undetected for so long. Many women receive their first osteoporosis diagnosis only after a fracture has already occurred. This makes screening and proactive assessment essential, rather than reactive.
What Do Current Screening Guidelines Recommend for Women?
The U.S. Preventive Services Task Force updated its osteoporosis screening recommendation in 2025, reaffirming guidance that all women aged 65 and older should be screened for osteoporosis. The recommendation also extends to postmenopausal women under 65 who are at increased risk, based on clinical risk factors such as low body weight, family history of fracture, smoking, or long-term use of corticosteroids. The USPSTF assigns this recommendation moderate certainty of moderate net benefit, meaning the evidence base is solid but not without limits. The standard screening tool is dual-energy X-ray absorptiometry, or DEXA scan, which measures bone mineral density at the hip and spine. The FRAX tool — a 10-year fracture risk calculator developed by the World Health Organization — can also be used to assess fracture probability and help guide clinical decisions, though the USPSTF cautions that FRAX is not meant to be applied as a rigid threshold.
A woman’s clinical picture, history, and individual risk factors all matter. A FRAX score alone does not determine whether treatment is warranted. There is an important caveat here: screening rates remain uneven. Black and Hispanic women are significantly less likely to receive bone density testing, including after a hip fracture when testing would be most clearly indicated. According to data cited in the USPSTF’s 2025 recommendation statement published in JAMA, Hispanic and Black women are 60% less likely to receive bone density testing after a hip fracture compared to White women, and nearly 10% fewer Black women receive treatment following a diagnosis. These disparities are not explained by differences in fracture risk — they reflect structural gaps in how preventive care is delivered.
Which Lifestyle Changes Most Effectively Reduce Fracture Risk?
Exercise is the most effective modifiable lifestyle factor for preserving bone density and reducing fracture risk, and not all types of exercise are equally useful. Weight-bearing activity — walking, hiking, dancing, stair climbing — and resistance training are the most evidence-supported forms. They work by placing mechanical load on bones, which stimulates bone-forming cells. Moderate-to-high-impact exercise also improves balance and coordination, reducing the risk of falls that lead to fractures in the first place. Swimming and cycling, while valuable for cardiovascular health, do not provide the same bone-protective benefit because they are not weight-bearing. Calcium and vitamin D are standard recommendations, but the picture is more nuanced than supplement labels suggest.
The USPSTF advises against supplementing with 1,000 mg or less of calcium combined with 400 IU or less of vitamin D in postmenopausal women, citing insufficient evidence that low-dose supplementation reduces fracture risk and some evidence of potential harms including kidney stones. This does not mean calcium and vitamin D are irrelevant — adequate dietary intake matters — but it does mean that taking a low-dose supplement and considering the job done is not a sound strategy. Women who cannot meet calcium needs through diet should discuss appropriate supplementation doses and forms with their physician. Smoking and excessive alcohol consumption both accelerate bone loss and increase fracture risk and should be avoided. Smoking impairs estrogen metabolism and reduces calcium absorption. Alcohol in excess disrupts bone remodeling and also increases fall risk through its effects on balance and coordination. For a 70-year-old woman who smokes a half-pack a day and has a glass of wine with dinner most nights, addressing these habits is as clinically relevant as any supplement regimen.
How Does Fall Prevention Fit Into Fracture Prevention?
A fracture requires both fragile bone and a precipitating event, usually a fall. This is why fall prevention is treated as a core pillar of fracture prevention rather than a secondary concern. A woman can have significant osteoporosis and never fracture if she never falls. Conversely, even moderate bone loss combined with poor balance or a hazardous home environment can result in serious fracture. Addressing both sides of that equation is more effective than treating only one.
Fall prevention interventions that have demonstrated effectiveness include balance training programs such as Tai Chi, strength training targeting the legs and core, review and modification of medications that cause dizziness or drowsiness, and home hazard modification — removing loose rugs, improving lighting, installing grab bars in bathrooms, ensuring that walkways are clear. For a woman already taking several medications for hypertension or anxiety, a medication review by her physician or pharmacist can identify combinations that increase fall risk and may be adjusted. The tradeoff worth naming here is one of engagement. Balance training and home modification require active participation, which means they depend on the woman’s willingness and ability to follow through. For women with early cognitive decline — particularly relevant on a brain health platform — this is not a trivial barrier. Caregivers and family members may need to take the lead on identifying home hazards and supporting consistent exercise routines, rather than leaving that to the older adult alone.
What Medications Are Available for Osteoporosis Treatment?
For women diagnosed with osteoporosis or identified as high risk, pharmacological treatment significantly reduces fracture rates. Bisphosphonates — which include alendronate, risedronate, and zoledronic acid — are first-line therapy. The American College of Physicians gives bisphosphonates a strong recommendation backed by high-certainty evidence. The typical course is up to five years for oral bisphosphonates or three years for intravenous zoledronic acid. A 2025 randomized trial found that over ten years, fractures occurred in 11.1% of women in the placebo group compared to 6.3–6.6% in women treated with zoledronate in the 50–60 age group — a reduction of roughly 40%. Denosumab is an alternative for women who cannot tolerate or absorb oral bisphosphonates.
Administered by injection every six months, it improves bone mineral density more quickly than bisphosphonates in head-to-head comparisons. However, denosumab carries an important discontinuation warning: stopping it abruptly without transitioning to another therapy can lead to rapid bone loss and a significant rebound increase in fracture risk. Women on denosumab who plan to stop or whose physician discontinues the medication need a clear transition plan. A newer anabolic approach uses romosozumab — a monoclonal antibody that both stimulates bone formation and inhibits bone resorption — for one year, followed by one year of alendronate. This sequential strategy has been shown to reduce fracture risk more than two years of alendronate alone, and represents the most aggressive option for women at very high fracture risk. Romosozumab does carry a boxed warning about cardiovascular risk, making it unsuitable for women with a history of stroke or myocardial infarction. This is a critical tradeoff: the most effective fracture prevention option for very high-risk women may be contraindicated based on their cardiac history.
How Do Health Disparities Affect Fracture Outcomes for Women of Color?
The racial and ethnic disparities in osteoporosis screening and treatment are well-documented and not closing at a meaningful pace. Black women are less likely to be screened, less likely to receive treatment after a diagnosis, and less likely to receive follow-up bone density testing after a fracture — even though hip fractures in Black women carry the same serious consequences. The USPSTF’s 2025 recommendation explicitly addresses these gaps, noting that clinical risk assessment tools like FRAX may underestimate fracture risk in Black women, partly because they were developed and validated predominantly in White populations.
This matters practically: a Black woman at elevated risk may receive a FRAX score that doesn’t reflect her actual vulnerability, and her physician may not screen or treat accordingly. Clinicians working with diverse populations should treat FRAX as one input among many, and should not rely on race-specific risk thresholds that have not been well-validated across populations. For women and caregivers navigating this system, asking directly about bone density testing — regardless of what screening tools suggest — is a reasonable and appropriate step.
What Does the Future of Fracture Prevention Look Like for Aging Women?
The global burden of hip fractures is expected to nearly double between 2018 and 2050, driven by aging populations across North America, Europe, and Asia. This projection reflects the scale of the problem if current prevention and treatment rates stay constant. The tools to reduce that burden already exist — screening guidelines are clear, effective medications are available, exercise and fall prevention programs have strong evidence behind them — but uptake remains incomplete, particularly among underserved populations.
The integration of fracture prevention into broader geriatric and cognitive health care is an important frontier. Women with dementia or mild cognitive impairment are at elevated fall and fracture risk, yet they are often excluded from trials of pharmacological interventions and may have difficulty adhering to exercise programs or oral bisphosphonate regimens. Intravenous or injectable therapies, caregiver-facilitated fall prevention, and coordinated care models that connect neurology and bone health are likely to become increasingly important as the population ages.
Conclusion
Osteoporosis-related fractures in older women are not an inevitable consequence of aging. They are a predictable outcome of modifiable risk factors — bone density loss, fall risk, inadequate screening, and undertreated disease — that can be addressed at multiple points.
The evidence base for prevention is strong: weight-bearing exercise preserves bone and reduces falls, screening at 65 (or earlier in high-risk women) identifies disease before fracture occurs, and bisphosphonates, denosumab, and newer anabolic therapies cut fracture rates substantially for women who qualify. The practical next step for any older woman or her caregiver is a conversation with a physician that includes three questions: Has she been screened for osteoporosis? If she has osteoporosis, has treatment been offered or discussed? And what is her current fall risk, and what can be done about it? These are not specialized questions requiring a specialist — they are part of standard preventive care, and asking them directly is often the step that gets the conversation started.
Frequently Asked Questions
At what age should women start getting screened for osteoporosis?
The USPSTF recommends routine screening for all women at age 65. Postmenopausal women under 65 should be screened earlier if they have risk factors such as low body weight, a family history of hip fracture, smoking history, or long-term use of corticosteroids.
Are calcium and vitamin D supplements enough to prevent fractures?
No. Low-dose supplementation — specifically, 1,000 mg or less of calcium combined with 400 IU or less of vitamin D — has not been shown to reduce fracture risk in postmenopausal women, and the USPSTF recommends against it for that purpose. Adequate dietary calcium intake matters, but supplementation alone is not a substitute for exercise, fall prevention, or medication when bone loss is significant.
How long does someone need to take bisphosphonates?
The typical recommended course is up to five years for oral bisphosphonates such as alendronate or risedronate, or up to three years for intravenous zoledronic acid. After that, a reassessment is recommended to determine whether continuing, pausing, or switching therapy is appropriate based on fracture risk.
Is osteoporosis treatment safe for women with dementia?
Women with dementia are at increased fall and fracture risk, which makes treatment particularly important. However, oral bisphosphonates require specific administration instructions that can be difficult to follow with cognitive impairment. Injectable or intravenous options such as denosumab or zoledronic acid may be better suited in these cases. A physician familiar with both conditions should guide the decision.
Can fractures be prevented by fall prevention alone, without treating the underlying bone loss?
Fall prevention significantly reduces fracture risk and should always be part of a prevention strategy. However, it addresses only one side of the equation. Treating underlying bone loss reduces the severity of fractures when falls do occur and provides protection that fall prevention alone cannot. The two approaches are complementary, not interchangeable.
Why are Black and Hispanic women less likely to be screened or treated for osteoporosis?
Research documents persistent racial disparities in screening and treatment rates that are not explained by differences in fracture risk. Structural factors including access to care, implicit bias in clinical decision-making, and limitations of risk assessment tools validated primarily in White populations all contribute. Hispanic and Black women are 60% less likely to receive bone density testing after a hip fracture compared to White women, according to data cited in the USPSTF’s 2025 recommendation.
