Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Epidemiology and etiology of premenopausal osteoporosis

Carolyn B Becker, MD
Adi Cohen, MD, MHS
Section Editor
Clifford J Rosen, MD
Deputy Editor
Jean E Mulder, MD


Osteoporosis is a skeletal condition characterized by low bone mass, which is associated with reduced bone strength and an increased risk of fractures. Osteoporosis occurs most commonly in postmenopausal women. Numerous guidelines and recommendations exist regarding the evaluation and management of osteoporosis in this population. Male osteoporosis has also gained attention as a growing public health concern. Postmenopausal osteoporosis and osteoporosis in men are reviewed separately. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women" and "Overview of the management of osteoporosis in postmenopausal women" and "Epidemiology and etiology of osteoporosis in men".)

Both fractures and low bone mass are less common in premenopausal women. Low bone mass, when present, may be related to either inadequate peak bone mass acquisition and/or ongoing bone loss. Bone loss and/or fractures can often be attributed to a secondary cause such as estrogen deficiency, glucocorticoid exposure, or hyperparathyroidism. The term idiopathic osteoporosis is reserved for the subset of women with no apparent etiology or known secondary cause.

The diagnosis of osteoporosis and guidelines for treatment of osteoporosis based upon bone mass in postmenopausal women do not generally apply to premenopausal women as the relationship between bone mass and fracture in premenopausal women is not the same as in postmenopausal women.

This topic reviews the definition, epidemiology, and etiology of premenopausal osteoporosis. Evaluation and management will be reviewed separately. (See "Evaluation and treatment of premenopausal osteoporosis".)


Low bone mass — The measurement of bone mineral density (BMD) by dual-energy x-ray absorptiometry (DXA) is used as an index of bone strength and fracture risk, and can be used to diagnose osteoporosis in some populations, such as postmenopausal women. The World Health Organization (WHO) defines osteoporosis in postmenopausal women as a BMD value at the spine, hip, or forearm of 2.5 or more standard deviations (SD) below the young adult mean (T-score ≤-2.5), with or without the presence of a fragility fracture [1]. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women" and "Overview of dual-energy x-ray absorptiometry".)


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: Jan 29, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Kanis JA, Melton LJ 3rd, Christiansen C, et al. The diagnosis of osteoporosis. J Bone Miner Res 1994; 9:1137.
  2. 2013 ISCE Official Positions - Adult http://www.iscd.org/official-positions/2013-iscd-official-positions-adult/ (Accessed on October 31, 2013).
  3. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int 2014; 25:2359.
  4. Peris P, Monegal A, Martínez MA, et al. Bone mineral density evolution in young premenopausal women with idiopathic osteoporosis. Clin Rheumatol 2007; 26:958.
  5. Cohen A, Liu XS, Stein EM, et al. Bone microarchitecture and stiffness in premenopausal women with idiopathic osteoporosis. J Clin Endocrinol Metab 2009; 94:4351.
  6. Cohen A, Dempster DW, Recker RR, et al. Abnormal bone microarchitecture and evidence of osteoblast dysfunction in premenopausal women with idiopathic osteoporosis. J Clin Endocrinol Metab 2011; 96:3095.
  7. Mora S, Gilsanz V. Establishment of peak bone mass. Endocrinol Metab Clin North Am 2003; 32:39.
  8. Theintz G, Buchs B, Rizzoli R, et al. Longitudinal monitoring of bone mass accumulation in healthy adolescents: evidence for a marked reduction after 16 years of age at the levels of lumbar spine and femoral neck in female subjects. J Clin Endocrinol Metab 1992; 75:1060.
  9. Bachrach LK, Hastie T, Wang MC, et al. Bone mineral acquisition in healthy Asian, Hispanic, black, and Caucasian youth: a longitudinal study. J Clin Endocrinol Metab 1999; 84:4702.
  10. Baxter-Jones AD, Faulkner RA, Forwood MR, et al. Bone mineral accrual from 8 to 30 years of age: an estimation of peak bone mass. J Bone Miner Res 2011; 26:1729.
  11. Recker RR, Davies KM, Hinders SM, et al. Bone gain in young adult women. JAMA 1992; 268:2403.
  12. Tenenhouse A, Joseph L, Kreiger N, et al. Estimation of the prevalence of low bone density in Canadian women and men using a population-specific DXA reference standard: the Canadian Multicentre Osteoporosis Study (CaMos). Osteoporos Int 2000; 11:897.
  13. Löfman O, Larsson L, Toss G. Bone mineral density in diagnosis of osteoporosis: reference population, definition of peak bone mass, and measured site determine prevalence. J Clin Densitom 2000; 3:177.
  14. Walker MD, Babbar R, Opotowsky AR, et al. A referent bone mineral density database for Chinese American women. Osteoporos Int 2006; 17:878.
  15. Mein AL, Briffa NK, Dhaliwal SS, Price RI. Lifestyle influences on 9-year changes in BMD in young women. J Bone Miner Res 2004; 19:1092.
  16. Sowers MR, Jannausch M, McConnell D, et al. Hormone predictors of bone mineral density changes during the menopausal transition. J Clin Endocrinol Metab 2006; 91:1261.
  17. Bainbridge KE, Sowers MF, Crutchfield M, et al. Natural history of bone loss over 6 years among premenopausal and early postmenopausal women. Am J Epidemiol 2002; 156:410.
  18. Melton LJ 3rd, Atkinson EJ, O'Connor MK, et al. Determinants of bone loss from the femoral neck in women of different ages. J Bone Miner Res 2000; 15:24.
  19. Chapurlat RD, Garnero P, Sornay-Rendu E, et al. Longitudinal study of bone loss in pre- and perimenopausal women: evidence for bone loss in perimenopausal women. Osteoporos Int 2000; 11:493.
  20. Sowers M, Crutchfield M, Bandekar R, et al. Bone mineral density and its change in pre-and perimenopausal white women: the Michigan Bone Health Study. J Bone Miner Res 1998; 13:1134.
  21. Slemenda C, Longcope C, Peacock M, et al. Sex steroids, bone mass, and bone loss. A prospective study of pre-, peri-, and postmenopausal women. J Clin Invest 1996; 97:14.
  22. Berger C, Langsetmo L, Joseph L, et al. Change in bone mineral density as a function of age in women and men and association with the use of antiresorptive agents. CMAJ 2008; 178:1660.
  23. Finkelstein JS, Brockwell SE, Mehta V, et al. Bone mineral density changes during the menopause transition in a multiethnic cohort of women. J Clin Endocrinol Metab 2008; 93:861.
  24. Sowers MR, Zheng H, Jannausch ML, et al. Amount of bone loss in relation to time around the final menstrual period and follicle-stimulating hormone staging of the transmenopause. J Clin Endocrinol Metab 2010; 95:2155.
  25. Iki M, Morita A, Ikeda Y, et al. Biochemical markers of bone turnover predict bone loss in perimenopausal women but not in postmenopausal women-the Japanese Population-based Osteoporosis (JPOS) Cohort Study. Osteoporos Int 2006; 17:1086.
  26. Seifert-Klauss V, Link T, Heumann C, et al. Influence of pattern of menopausal transition on the amount of trabecular bone loss. Results from a 6-year prospective longitudinal study. Maturitas 2006; 55:317.
  27. Greendale GA, Sowers M, Han W, et al. Bone mineral density loss in relation to the final menstrual period in a multiethnic cohort: results from the Study of Women's Health Across the Nation (SWAN). J Bone Miner Res 2012; 27:111.
  28. Macdonald HM, New SA, Campbell MK, Reid DM. Influence of weight and weight change on bone loss in perimenopausal and early postmenopausal Scottish women. Osteoporos Int 2005; 16:163.
  29. Thompson PW, Taylor J, Dawson A. The annual incidence and seasonal variation of fractures of the distal radius in men and women over 25 years in Dorset, UK. Injury 2004; 35:462.
  30. Melton LJ 3rd, Amadio PC, Crowson CS, O'Fallon WM. Long-term trends in the incidence of distal forearm fractures. Osteoporos Int 1998; 8:341.
  31. Hosmer WD, Genant HK, Browner WS. Fractures before menopause: a red flag for physicians. Osteoporos Int 2002; 13:337.
  32. Wu F, Mason B, Horne A, et al. Fractures between the ages of 20 and 50 years increase women's risk of subsequent fractures. Arch Intern Med 2002; 162:33.
  33. Hsu YH, Venners SA, Terwedow HA, et al. Relation of body composition, fat mass, and serum lipids to osteoporotic fractures and bone mineral density in Chinese men and women. Am J Clin Nutr 2006; 83:146.
  34. Goulding A, Gold E, Walker R, Lewis-Barned N. Women with past history of bone fracture have low spinal bone density before menopause. N Z Med J 1997; 110:232.
  35. Fiorano-Charlier C, Ostertag A, Aquino JP, et al. Reduced bone mineral density in postmenopausal women self-reporting premenopausal wrist fractures. Bone 2002; 31:102.
  36. Lauder TD, Dixit S, Pezzin LE, et al. The relation between stress fractures and bone mineral density: evidence from active-duty Army women. Arch Phys Med Rehabil 2000; 81:73.
  37. Wigderowitz CA, Cunningham T, Rowley DI, et al. Peripheral bone mineral density in patients with distal radial fractures. J Bone Joint Surg Br 2003; 85:423.
  38. Hung LK, Wu HT, Leung PC, Qin L. Low BMD is a risk factor for low-energy Colles' fractures in women before and after menopause. Clin Orthop Relat Res 2005; :219.
  39. Rozental TD, Deschamps LN, Taylor A, et al. Premenopausal women with a distal radial fracture have deteriorated trabecular bone density and morphology compared with controls without a fracture. J Bone Joint Surg Am 2013; 95:633.
  40. Valentino R, Savastano S, Tommaselli AP, et al. The influence of intense ballet training on trabecular bone mass, hormone status, and gonadotropin structure in young women. J Clin Endocrinol Metab 2001; 86:4674.
  41. Warren MP, Brooks-Gunn J, Hamilton LH, et al. Scoliosis and fractures in young ballet dancers. Relation to delayed menarche and secondary amenorrhea. N Engl J Med 1986; 314:1348.
  42. Warren MP, Brooks-Gunn J, Fox RP, et al. Osteopenia in exercise-associated amenorrhea using ballet dancers as a model: a longitudinal study. J Clin Endocrinol Metab 2002; 87:3162.
  43. Kadel NJ, Teitz CC, Kronmal RA. Stress fractures in ballet dancers. Am J Sports Med 1992; 20:445.
  44. Gam A, Goldstein L, Karmon Y, et al. Comparison of stress fractures of male and female recruits during basic training in the Israeli anti-aircraft forces. Mil Med 2005; 170:710.
  45. Shaffer RA, Rauh MJ, Brodine SK, et al. Predictors of stress fracture susceptibility in young female recruits. Am J Sports Med 2006; 34:108.
  46. Lappe J, Davies K, Recker R, Heaney R. Quantitative ultrasound: use in screening for susceptibility to stress fractures in female army recruits. J Bone Miner Res 2005; 20:571.
  47. Joy EA, Campbell D. Stress fractures in the female athlete. Curr Sports Med Rep 2005; 4:323.
  48. Korpelainen R, Orava S, Karpakka J, et al. Risk factors for recurrent stress fractures in athletes. Am J Sports Med 2001; 29:304.
  49. Kumagai S, Kawano S, Atsumi T, et al. Vertebral fracture and bone mineral density in women receiving high dose glucocorticoids for treatment of autoimmune diseases. J Rheumatol 2005; 32:863.
  50. Borba VZ, Matos PG, da Silva Viana PR, et al. High prevalence of vertebral deformity in premenopausal systemic lupus erythematosus patients. Lupus 2005; 14:529.
  51. Honkanen R, Tuppurainen M, Kroger H, et al. Associations of early premenopausal fractures with subsequent fractures vary by sites and mechanisms of fractures. Calcif Tissue Int 1997; 60:327.
  52. Rothberg AD, Matshidze PK. Perimenopausal wrist fracture--an opportunity for prevention and management of osteoporosis. S Afr Med J 2000; 90:1121.
  53. Bainbridge KE, Sowers M, Lin X, Harlow SD. Risk factors for low bone mineral density and the 6-year rate of bone loss among premenopausal and perimenopausal women. Osteoporos Int 2004; 15:439.
  54. Adami S, Giannini S, Giorgino R, et al. Effect of age, weight and lifestyle factors on calcaneal quantitative ultrasound in premenopausal women: the ESOPO study. Calcif Tissue Int 2004; 74:317.
  55. Uusi-Rasi K, Sievänen H, Pasanen M, et al. Association of physical activity and calcium intake with the maintenance of bone mass in premenopausal women. Osteoporos Int 2002; 13:211.
  56. Sun L, Peng Y, Sharrow AC, et al. FSH directly regulates bone mass. Cell 2006; 125:247.
  57. Peris P, Guañabens N, Martínez de Osaba MJ, et al. Clinical characteristics and etiologic factors of premenopausal osteoporosis in a group of Spanish women. Semin Arthritis Rheum 2002; 32:64.
  58. Eskandari F, Martinez PE, Torvik S, et al. Low bone mass in premenopausal women with depression. Arch Intern Med 2007; 167:2329.
  59. Petronijević M, Petronijević N, Ivković M, et al. Low bone mineral density and high bone metabolism turnover in premenopausal women with unipolar depression. Bone 2008; 42:582.
  60. Altindag O, Altindag A, Asoglu M, et al. Relation of cortisol levels and bone mineral density among premenopausal women with major depression. Int J Clin Pract 2007; 61:416.
  61. Black AJ, Topping J, Durham B, et al. A detailed assessment of alterations in bone turnover, calcium homeostasis, and bone density in normal pregnancy. J Bone Miner Res 2000; 15:557.
  62. Naylor KE, Iqbal P, Fledelius C, et al. The effect of pregnancy on bone density and bone turnover. J Bone Miner Res 2000; 15:129.
  63. Karlsson MK, Ahlborg HG, Karlsson C. Maternity and bone mineral density. Acta Orthop 2005; 76:2.
  64. Sowers M, Crutchfield M, Jannausch M, et al. A prospective evaluation of bone mineral change in pregnancy. Obstet Gynecol 1991; 77:841.
  65. Kaur M, Pearson D, Godber I, et al. Longitudinal changes in bone mineral density during normal pregnancy. Bone 2003; 32:449.
  66. Holmberg-Marttila D, Leino A, Sievänen H. Bone turnover markers during lactation, postpartum amenorrhea and resumption of menses. Osteoporos Int 2003; 14:103.
  67. Sowers M, Corton G, Shapiro B, et al. Changes in bone density with lactation. JAMA 1993; 269:3130.
  68. Kolthoff N, Eiken P, Kristensen B, Nielsen SP. Bone mineral changes during pregnancy and lactation: a longitudinal cohort study. Clin Sci (Lond) 1998; 94:405.
  69. Kalkwarf HJ, Specker BL, Bianchi DC, et al. The effect of calcium supplementation on bone density during lactation and after weaning. N Engl J Med 1997; 337:523.
  70. Sowers MF, Hollis BW, Shapiro B, et al. Elevated parathyroid hormone-related peptide associated with lactation and bone density loss. JAMA 1996; 276:549.
  71. VanHouten JN, Dann P, Stewart AF, et al. Mammary-specific deletion of parathyroid hormone-related protein preserves bone mass during lactation. J Clin Invest 2003; 112:1429.
  72. Woodrow JP, Sharpe CJ, Fudge NJ, et al. Calcitonin plays a critical role in regulating skeletal mineral metabolism during lactation. Endocrinology 2006; 147:4010.
  73. Wysolmerski JJ. Interactions between breast, bone, and brain regulate mineral and skeletal metabolism during lactation. Ann N Y Acad Sci 2010; 1192:161.
  74. Sowers M, Eyre D, Hollis BW, et al. Biochemical markers of bone turnover in lactating and nonlactating postpartum women. J Clin Endocrinol Metab 1995; 80:2210.
  75. Vajda EG, Bowman BM, Miller SC. Cancellous and cortical bone mechanical properties and tissue dynamics during pregnancy, lactation, and postlactation in the rat. Biol Reprod 2001; 65:689.
  76. Michaëlsson K, Baron JA, Farahmand BY, Ljunghall S. Influence of parity and lactation on hip fracture risk. Am J Epidemiol 2001; 153:1166.
  77. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 1995; 332:767.
  78. Alderman BW, Weiss NS, Daling JR, et al. Reproductive history and postmenopausal risk of hip and forearm fracture. Am J Epidemiol 1986; 124:262.
  79. Smith R, Athanasou NA, Ostlere SJ, Vipond SE. Pregnancy-associated osteoporosis. QJM 1995; 88:865.
  80. Heshmati HM, Khosla S. Idiopathic osteoporosis: a heterogeneous entity. Ann Med Interne (Paris) 1998; 149:77.
  81. Rizzoli R, Bonjour JP. Pregnancy-associated osteoporosis. Lancet 1996; 347:1274.
  82. Peris P, Guañabens N, Monegal A, et al. Pregnancy associated osteoporosis: the familial effect. Clin Exp Rheumatol 2002; 20:697.
  83. Phillips AJ, Ostlere SJ, Smith R. Pregnancy-associated osteoporosis: does the skeleton recover? Osteoporos Int 2000; 11:449.
  84. Malizos KN, Zibis AH, Dailiana Z, et al. MR imaging findings in transient osteoporosis of the hip. Eur J Radiol 2004; 50:238.
  85. Sweeney AT, Blake M, Holick MF. Transient osteoporosis of hip in pregnancy. J Clin Densitom 2000; 3:291.
  86. Samdani A, Lachmann E, Nagler W. Transient osteoporosis of the hip during pregnancy: a case report. Am J Phys Med Rehabil 1998; 77:153.
  87. Khosla S, Lufkin EG, Hodgson SF, et al. Epidemiology and clinical features of osteoporosis in young individuals. Bone 1994; 15:551.
  88. Reed BY, Zerwekh JE, Sakhaee K, et al. Serum IGF 1 is low and correlated with osteoblastic surface in idiopathic osteoporosis. J Bone Miner Res 1995; 10:1218.
  89. Pepene CE, Seck T, Diel I, et al. Concentration of insulin-like growth factor (IGF)-I in iliac crest bone matrix in premenopausal women with idiopathic osteoporosis. Exp Clin Endocrinol Diabetes 2004; 112:38.
  90. Rubin MR, Schussheim DH, Kulak CA, et al. Idiopathic osteoporosis in premenopausal women. Osteoporos Int 2005; 16:526.
  91. Peris P, Ruiz-Esquide V, Monegal A, et al. Idiopathic osteoporosis in premenopausal women. Clinical characteristics and bone remodelling abnormalities. Clin Exp Rheumatol 2008; 26:986.
  92. Donovan MA, Dempster D, Zhou H, et al. Low bone formation in premenopausal women with idiopathic osteoporosis. J Clin Endocrinol Metab 2005; 90:3331.