American Health & Medical Research Association
Evidence review

The real odds after a broken hip, when few people get bone medicine

In 2015, only about 3 in 100 hip fracture patients in a large U.S. study started an osteoporosis drug. Below, we cover how to gauge your risk and weigh the medicines' real benefits and harms.

By the Health Research USA editorial team

Published Last updated October 2026

Written from the sources listed below; links checked October 2026. It touches on medicines, doses or health conditions and has not yet been reviewed by a licensed clinician, so use it to prepare for a conversation with yours. How we research and review

Sources11, listed below Reading time15 minutes

Where the evidence stands

  • Strong evidence Bisphosphonates cut hip and spine fractures in women with osteoporosisDenosumab cuts fractures in women with osteoporosisRomosozumab prevents spine fractures, more than alendronate does
  • Promising but early Bisphosphonates help men with osteoporosis
  • Not enough evidence Treating low bone mass in women 65+ prevents hip fractures
  • Evidence says no, or unsafe Rare harms outweigh the fractures preventedStopping denosumab without a follow-on drug is safe

Each use is rated separately, from the scorecard in this guide. Safety cautions are spelled out in the guide itself. How we grade

On this page
  1. A first broken bone is a warning about the next one
  2. Your bone density score is only part of your risk
  3. Some medicines and illnesses quietly thin bone
  4. What the medicines do, counted per 1,000 people
  5. The rare harms, in real numbers
  6. Your bone-risk conversation guide
  7. How strong is the evidence?
  8. Loading, food and fall-proofing work alongside medicine
  9. Questions readers ask
  10. The bottom line

Key takeaways

  • In a study of more than 97,000 U.S. hip fracture patients who had never taken an osteoporosis drug, the share who started one after the break fell from 9.8% in 2004 to 3.3% in 20152.
  • A bone density score doesn’t decide treatment by itself: the Bone Health & Osteoporosis Foundation also uses FRAX, a 10-year fracture risk calculator, and advises treating anyone who has broken a hip or spine bone, whatever the score45.
  • In trials reviewed by the American College of Physicians, bisphosphonates meant about 6 fewer hip fractures and 18 fewer spine fractures that caused symptoms for every 1,000 women treated7.
  • Jaw bone damage affected 0.01% to 0.3% of bisphosphonate users, and a 2020 study estimated that for every 10,000 White women treated for three years, about 149 hip fractures were prevented and 2 drug-related thigh-bone fractures occurred710.
  • After denosumab stops, the risk of several spine fractures at once rises, so the FDA label says to move to another bone drug; that switch is a plan to make with your clinician8.

In a study published in 2018, researchers sifted through insurance records for more than 97,000 Americans 50 and older who had broken a hip and had never taken an osteoporosis medicine2. Under bone guidelines, a broken hip alone is usually reason enough to consider treatment4.

Year after year, fewer of those patients started treatment. In 2004, 9.8% began an osteoporosis drug after the fracture. By 2015, just 3.3% did2.

In an editorial, Douglas Bauer called the results “a shocking failure to provide adequate care” to people at high risk2.

An earlier study found the same slide from a different angle. Among 96,887 hip fracture patients, the share using any osteoporosis medicine in the year after the break fell from 40.2% in 2002 to 20.5% in 20111. Men and older patients were less likely to be treated1.

Lifting, jumping and good food matter, as our bone strength and calcium articles show. This guide covers the other half: knowing your fracture risk and weighing the medicines’ benefits against their rare side effects.

A first broken bone is a warning about the next one

A fracture after 50 from a minor fall is more than bad luck. The Bone Health & Osteoporosis Foundation (BHOF), a nonprofit advocacy group, calls any adult fracture a red flag that should prompt a bone evaluation4.

The 2018 study’s authors noted that 15% to 25% of hip fracture patients break another bone within 10 years2. Their analysis also suggested that starting treatment after the hip fracture was tied to about 4 fewer later fractures for every 100 patients treated for a year2. That estimate came from insurance data, not a trial, though the researchers used a statistical method meant to reduce bias2.

The gap isn’t only an American problem. In the year after a fragility fracture, a break from a minor injury, fewer than 20% of patients get a fracture-reducing medicine, according to a 2019 review by European bone researchers3.

One fix is a fracture liaison service, or FLS. It’s a program, run by a coordinator under a doctor’s direction, that finds people over 50 who’ve had a fracture6. The coordinator checks their risk, arranges tests, helps them start and stay on treatment, and teaches fall prevention6. The 2019 review said the most successful prevention systems usually center on such a service, staffed by a mix of doctors and specialist nurses3.

If you’ve broken a bone after 50, ask whether your health system has one, or ask your primary care clinician for a bone evaluation.

Your bone density score is only part of your risk

A bone density scan, called a DXA scan, gives you a T-score. A score of −2.5 or lower at the hip or spine is in the osteoporosis range. Scores between −1.0 and −2.5 are low bone mass, often called osteopenia4.

BHOF’s 2022 guide for clinicians doesn’t rely on the score alone. It advises treatment in three situations4:

  • A T-score of −2.5 or lower at the hip or spine.
  • A hip or spine fracture, whatever your T-score.
  • Low bone mass plus a high FRAX score: a 10-year chance of 3% or more for a hip fracture, or 20% or more for any major osteoporotic fracture.

FRAX is a calculator developed at the University of Sheffield in England, at a World Health Organization collaborating center for bone disease5. It combines your bone density with other risk factors to estimate your chance of breaking a hip, or a spine, hip, forearm or shoulder bone, in the next 10 years5. Drinking three or more alcoholic drinks a day is one of the factors it counts4.

Picture a 68-year-old woman whose hip T-score is −2.1. That’s low bone mass, not osteoporosis. If her FRAX hip number comes back at 3% or higher, BHOF’s guide says she has reason to consider treatment anyway4.

Who should get a scan? BHOF advises testing women 65 and older and men 70 and older, plus younger adults past 50 with risk factors, anyone who breaks a bone after 50, and people taking certain bone-thinning drugs4. The U.S. Preventive Services Task Force makes a narrower call, which our bone strength article explains.

BHOF also advises a spine X-ray or similar image to look for spine fractures if you’ve lost 1.5 inches or more of your adult height4.

Some medicines and illnesses quietly thin bone

BHOF’s guide lists medicines that can cause bone loss4:

  • Steroid pills such as prednisone, at 5 milligrams a day or more for three months or longer.
  • Hormone-blocking cancer drugs, including aromatase inhibitors for breast cancer and androgen deprivation therapy for prostate cancer.
  • Acid reducers called proton pump inhibitors, and a class of antidepressants called SSRIs.
  • Some diabetes drugs (thiazolidinediones), some seizure medicines, and too much thyroid hormone.

Conditions on the list include an overactive parathyroid gland, chronic kidney disease, diabetes, rheumatoid arthritis, celiac disease, inflammatory bowel disease, and weight-loss or other stomach surgery4.

Many of these medicines are essential. Talk with your clinician before changing any of them, and ask whether your bones need checking.

What the medicines do, counted per 1,000 people

In 2023, the American College of Physicians (ACP) updated its guideline on osteoporosis drugs7. For women past menopause with osteoporosis, it strongly recommends bisphosphonates first, a group that includes alendronate, risedronate and zoledronic acid7. Denosumab comes second, for people who can’t take a bisphosphonate7.

For women at very high risk, ACP suggests starting with romosozumab or teriparatide, drugs that build new bone, then following with a bisphosphonate7. For men, it suggests the same first two steps but calls the evidence low in certainty, because most trials enrolled women7.

This is what the main options do, in absolute numbers. The bisphosphonate figures are ACP’s; the others are the FDA labels’ trial results or our arithmetic from them.

Medicine Fewer fractures per 1,000 treated Main warnings Source
Bisphosphonates (pills or an IV infusion) About 6 fewer hip fractures and 18 fewer spine fractures with symptoms, in pooled trials Rare jaw damage and thigh-bone fractures; both rise with years of use 710
Denosumab (a shot every 6 months) In the main 3-year trial of 7,808 women: about 48 fewer new spine fractures, 15 fewer other fractures and 3 fewer hip fractures Spine fractures can surge after stopping; boxed warning for severe low calcium in advanced kidney disease 8
Romosozumab (monthly shots for 12 months) About 13 fewer new spine fractures in one year compared with placebo; about 39 fewer over two years compared with alendronate Boxed warning for heart attack, stroke and heart-related death; about 9 more serious heart and stroke events per 1,000 than alendronate in one trial 9

Two caveats. For women 65 and older with low bone mass but not osteoporosis, ACP calls treatment an individual decision, and no drug clearly cut hip fractures in that group7. And taking a bisphosphonate beyond five years kept preventing spine fractures but not other breaks, while long-term harms rose7.

Hormone therapy is changing, too. In November 2025, the FDA began removing warnings about heart disease, breast cancer and dementia from the boxed warning on menopause hormone therapy11. In February 2026, it approved the first six revised labels and noted that women who start within 10 years of menopause, generally before 60, had fewer fractures in randomized studies11. If hot flashes and bone loss are both on your mind, it’s a fair topic to raise with your clinician.

The rare harms, in real numbers

Jaw bone damage. Called osteonecrosis of the jaw, it means an area of jawbone that’s exposed and slow to heal. ACP’s review found it in 0.01% to 0.3% of bisphosphonate users after three years or more7. That’s between 1 in 10,000 and 3 in 1,000. The denosumab and romosozumab labels advise a routine mouth exam before starting89.

Unusual thigh-bone fractures. These atypical femur fractures break the long shaft of the thigh bone with little or no force. In 2020, researchers reported in the New England Journal of Medicine on 196,129 women taking bisphosphonates at Kaiser Permanente Southern California10. They found 277 such fractures10.

The risk climbed with time. Compared with women who had taken the drugs for less than three months, the risk was about 9 times higher after three to five years and about 44 times higher after eight years or more10. Those multiples start from a tiny base, and the authors called the absolute risk very low10.

Two other findings matter. Asian women had about five times the risk of White women10. And the risk fell by about half 3 to 15 months after stopping, and by roughly three-quarters in later years10.

The trade-off still favored treatment. The team modeled 10,000 women with osteoporosis treated for three years. Among White women, it estimated 149 hip fractures prevented and 2 drug-related thigh fractures; among Asian women, 91 prevented and 8 caused10. Kaiser Permanente and the University of California, San Francisco mainly paid for the study; a pilot grant from drugmaker Merck Sharp & Dohme helped start it, with no role in running it10.

Drug holidays. Since these harms rise with time7, BHOF’s guide says clinicians can consider a break after five years of bisphosphonate pills or three years of the IV form, but only if your risk is no longer high and you haven’t had a recent spine fracture4.

Denosumab is the exception. Its FDA label says fracture risk rises after stopping, including several spine fractures at once8. New spine fractures appeared as early as 7 months after the last shot, at 19 months on average, and a past spine fracture raised the odds8.

The label says to move to another drug that slows bone breakdown if denosumab stops, not to interrupt it without talking to your doctor, and to give a missed dose as soon as convenient8. BHOF advises the same follow-up drug after romosozumab, teriparatide or abaloparatide4. If you’re on one of these and thinking of stopping, plan the next step with your clinician before your next dose is due.

Your bone-risk conversation guide

We built this guide from the BHOF, ACP and FDA sources above. Fill in part 1 before your visit.

Part 1: Risk factors to bring (check any that apply)
– A broken bone after age 50 from a minor fall4
– Height loss of 1.5 inches or more4
– Any medicine on the bone-loss list above, with dose and how long you’ve taken it4
– A condition on the list above, such as rheumatoid arthritis or celiac disease4
– Three or more alcoholic drinks a day, or smoking4
– Falls in the past year, sedating medicines or vision trouble4

Part 2: Tests to ask about

Test When BHOF suggests it Ask
DXA bone density scan Women 65+, men 70+, younger adults with risk factors, anyone with a fracture after 504 “What are my T-scores at the hip and spine?”
FRAX calculation Adults 50+ with low bone mass who aren’t on treatment45 “What’s my 10-year risk of a hip fracture and of a major fracture?”
Spine imaging Height loss, long-term steroid use, or low scores at older ages4 “Could I have a spine fracture I don’t know about?”
Blood tests for hidden causes Part of a fracture liaison workup6 “Has anyone looked for a medical reason my bones are thin?”

Part 3: Questions about treatment
1. Based on my numbers, how many fractures per 1,000 people like me would this drug prevent7?
2. What are my chances of jaw damage or a thigh-bone fracture, and how do they change with time710?
3. How long would I take it, and when would we reconsider47?
4. Do I need a dental checkup first89?
5. If this drug ever stops, what comes next489?
6. What can I do with exercise, food and fall-proofing at the same time?

How strong is the evidence?

Claim Evidence rating What it rests on
Bisphosphonates cut hip and spine fractures in women with osteoporosis Strong evidence Pooled trials, high certainty7
Denosumab cuts fractures in women with osteoporosis Strong evidence A 7,808-woman trial and pooled review78
Romosozumab prevents spine fractures, more than alendronate does Strong evidence, with a heart warning Two randomized trials described in the FDA label9
Bisphosphonates help men with osteoporosis Promising but early Few trials in men; low certainty7
Treating low bone mass in women 65+ prevents hip fractures Not enough evidence No clear hip fracture benefit in trials7
Rare harms outweigh the fractures prevented Evidence says no, or unsafe Per 10,000 women over three years, an estimated 149 hip fractures prevented per 2 thigh fractures in White women; 91 per 8 in Asian women10
Stopping denosumab without a follow-on drug is safe Evidence says no, or unsafe FDA label warning on rebound spine fractures8

Loading, food and fall-proofing work alongside medicine

Natural health starts with prevention, and bone rewards it. Heavy lifting and jumping can build bone, as our bone strength article shows. Food is the best first source of calcium, as our calcium article explains.

BHOF’s guide adds habits that matter whether or not you take a drug. It counts smoking and three or more drinks a day as risk factors. It also advises balance and strength training, a home check for trip hazards, and a review of sedating medicines and outdated glasses to prevent falls4.

Later articles in this series cover fall prevention, alcohol and tobacco.

Natural-health readers often worry about putting a drug into a body that can heal itself. That instinct deserves respect. But bone that has already broken is telling you something. A medicine, when your risk is high, can work with exercise and food rather than replace them.

Questions readers ask

Can exercise and diet replace osteoporosis drugs?

For people at low risk, they may be enough. For people with osteoporosis or a past hip or spine fracture, the drugs have trial evidence that they prevent fractures7. Exercise trials have mostly measured bone density instead, as our bone strength article explains, and BHOF’s guide pairs the two4.

Can I take a break from my bone drug?

With bisphosphonates, sometimes, if your risk has dropped4. Denosumab is different, because stopping without a follow-on drug can trigger spine fractures8. Make either choice with your clinician.

Do men need bone tests?

BHOF advises a scan for men 70 and older, and for men 50 to 69 with risk factors4. Men who break a hip are less likely than women to get treatment, so it’s worth asking1.

The bottom line

After a hip or spine fracture, the next break is a real risk, yet most patients never start medicine to prevent it. Your risk is more than a T-score, so ask about FRAX, the medicines and conditions that thin bone, and a fracture liaison service.

The bone drugs prevent many more fractures than they cause problems, and their rare harms can be managed with dental care, time limits and planned switches. Pair any medicine with lifting, good food and a safer home.

About this article

This article was researched using FDA drug labels and announcements, guidelines from the American College of Physicians and the Bone Health & Osteoporosis Foundation, and peer-reviewed studies and reviews, all listed below. It was reviewed in October 2026. It is general education and not medical, legal or financial advice.

Sources

  1. Solomon DH, et al. “Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011.” Journal of Bone and Mineral Research, 2014;29(9) (Weill Cornell Medicine record). pubmed.ncbi.nlm.nih.gov
  2. AJMC. “Rate of Osteoporosis Drug Treatment to Prevent Recurrent Fractures Dropping” (on Desai RJ, Mahesri M, Abdia Y, et al., JAMA Network Open, 2018;1(3):e180826, and an editorial by Bauer DC, e180844). July 20, 2018. ajmc.com
  3. Harvey NCW, McCloskey EV, Rizzoli R, Kanis JA, Cooper C, Reginster J-Y. “Osteoporosis: Treatment Gaps and Health Economics.” Encyclopedia of Endocrine Diseases, 2nd ed., Elsevier, 2019 (ESCEO copy). esceo.org
  4. LeBoff MS, Greenspan SL, Insogna KL, et al. “The clinician’s guide to prevention and treatment of osteoporosis.” Osteoporosis International, 2022;33(10):2049–2102 (PubMed Central). pmc.ncbi.nlm.nih.gov ; publication notice: Bone Health & Osteoporosis Foundation, June 6, 2022, bonehealthandosteoporosis.org
  5. Bone Health & Osteoporosis Foundation. “Risk Assessment: FRAX.” Accessed October 2026. bonehealthandosteoporosis.org
  6. Bone Health & Osteoporosis Foundation. “Fracture Liaison Service (FLS).” Accessed October 2026. bonehealthandosteoporosis.org
  7. Crandall C. “Latest ACP clinical guideline for the management of osteoporosis assesses benefits and harms of treatments” (on Qaseem A, Hicks LA, et al., Annals of Internal Medicine, 2023;176:224–238). Cleveland Clinic Journal of Medicine, April 28, 2023. ccjm.org ; see also American College of Physicians guideline summary, acponline.org
  8. U.S. Food and Drug Administration. “Prolia (denosumab) injection: Prescribing Information.” Revised June 2026. accessdata.fda.gov
  9. Amgen. “Evenity (romosozumab-aqqg) injection: Prescribing Information” (FDA-approved labeling). Revised January 2026. pi.amgen.com
  10. Black DM, Geiger EJ, Eastell R, et al. “Atypical Femur Fracture Risk versus Fragility Fracture Prevention with Bisphosphonates.” New England Journal of Medicine, August 20, 2020, doi:10.1056/NEJMoa1916525 (published version deposited by the University of Sheffield in White Rose Research Online). eprints.whiterose.ac.uk
  11. U.S. Food and Drug Administration. “FDA Approves Labeling Changes to Menopausal Hormone Therapy Products” (press release, via BioSpace). February 12, 2026. biospace.com