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Tests to Determine Secondary Causes of Bone Loss

Primary osteoporosis is associated with the normal loss of estrogen following the menopause as well as age.  The average older woman with normal bone density loses about 13% of her bone density in 10 years or about 1.3% per year.  However, there are a number of medical conditions and medications that can cause more rapid bone loss — the most common conditions are hyperparathyroidism, hyperthyroidism, vitamin D deficiency and celiac disease, and the most common medications are steroids and aromatase inhibitors.  If you have low bone density, there may be other tests that your doctor will consider to determine if active bone loss is occurring. It is important to correct underlying causes before taking a treatment for osteoporosis.

What tests to expect

Your doctor will ask questions about your medical history and may prescribe blood or urine tests. This is especially important if you have had any broken bones.  There are also tests that your doctor might request before determining what osteoporosis medicine to prescribe. 

Standard blood panel

  • Complete blood count (CBC)
  • Chemistry levels (Calcium, renal function, phosphorus, and magnesium)
  • Liver function tests
  • Thyroid-stimulating hormone (TSH) level
  • Serum 25(OH)D level
  • Parathyroid hormone (PTH)
  • Total testosterone and gonadotropin levels in younger men

Blood tests for certain situations

  • Serum protein electrophoresis (SPEP), serum immunofixation, serum free light chains
  • Tissue transglutaminase antibodies
  • Iron and ferritin levels
  • Homocysteine
  • Tryptase
  • Bone-specific Alkaline Phosphatase

Urine tests

  • 24-hour urinary calcium
  • Urine NTx (N-linked peptide of type 1 collagen)

Urine tests for certain situations

  • Protein electrophoresis (UPEP)
  • Urinary free cortisol level
  • Urinary histamine

Factors and medical conditions that cause bone loss and increase fracture risk

Lifestyle factors

Alcohol > 3 drinks/day

High salt intake

Smoking (active or passive)

Low calcium intake

Not enough physical activity


Vitamin D insufficiency


Weight < 127 lbs

Excess vitamin A




Low sex hormone


Cystic fibrosis

Androgen insensitivity

Celiac disease


Anorexia nervosa and bulimia

Gastric bypass

Gaucher’s disease


GI surgery

Glycogen storage diseases

Premature menopause

Inflammatory bowel disease


Premature ovarian failure



Athletic amenorrhea

Pancreatic disease



Primary biliary cirrhosis

Idiopathic hypercalciuria



Marfan syndrome

Adrenal insufficiency

Central nervous system

Menkes steely hair syndrome

Diabetes mellitus (Type 2)


Osteogenesis imperfecta

Cushing’s syndrome

Multiple sclerosis

Parent history of hip fracture


Parkinson’s disease


Central Adiposity

Spinal cord injury

Riley-Day syndrome






Rheumatologic and autoimmune diseases


Multiple myeloma

Ankylosing spondylitis





Leukemia and lymphomas

Rheumatoid arthritis

Chronic metabolic acidosis

Systemic mastocytosis


Chronic obstructive lung disease



Congestive heart failure

Monoclonal gammopathies



Sickle cell disease


End-stage renal disease






Idiopathic Scoliosis


Muscular dystrophy


Chronic metabolic acidosis


Post-transplant bone disease




Weight loss


Reviewed: 10/31/19.
As a service to our readers, American Bone Health provides access to our library of archived content. Please note the date of the last review on all articles. No content on this site, regardless of date, should ever be used as a substitute for direct medical advice from your doctor or other qualified clinician.

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What to know about bone health
and fracture prevention during COVID-19

  • Remove fall dangers in your home.
  • Stay physically active, and at least 6 feet away from others.
  • Eat for proper nutrition, and take a supplement if needed to get enough calcium and vitamin D.
  • Stick with your osteoporosis medicines and ask your doctor for extra if you’re unable to go to the pharmacy.
  • If you are due for Reclast, there is little concern about delaying for a few weeks or months.
  • If you take Prolia or Evenity injections, don’t miss your appointment.  Some facilities offer “drive-through” injections. Check with your doctor.
  • Bone density testing can be postponed, if necessary.
  • Speak with your doctor about the possibility of telephone and video visits.

The Centers for Disease Control and Prevention has a page with steps you can take to reduce your risk of catching the virus if you have a chronic illness.

Be well. We are here for you if you have any questions.