In June 2026, bone specialist Dr Susan Ott published an opinion piece in JAMA arguing that we treat too few people for osteoporosis, that some recent changes to how drugs are approved may be heading the wrong way, and that one underused option — oestrogen around the menopause — deserves a fresh look. This is one expert’s view, not a new trial, but it raises points worth discussing with your doctor.
The starting point isn’t controversial: many people at high risk of fracture aren’t getting preventive treatment. Even after breaking a bone, fewer than 15% are prescribed osteoporosis medication. The disagreement is about how to fix that.
US regulators have begun allowing new bone drugs to be approved on the basis of bone density (a measurement) rather than actual fractures (what patients care about), using shorter, smaller trials. Dr Ott warns this is risky: density and fracture protection don’t always go together. Her key example is an old fluoride treatment that raised bone density dramatically yet led to more fractures, not fewer — a reminder that a better scan number doesn’t always mean stronger bone.
Bone slowly repairs its own micro-damage, and this takes years. Some drugs that switch off bone turnover work well early but, used for a very long time, can let micro-damage build up — which is the rare risk behind “atypical” thigh-bone fractures with long-term bisphosphonates or denosumab. Several newer drugs also lose their benefit once stopped. The message: treatment duration needs care, in both directions.
Dr Ott argues the best moment to prevent fractures is to prevent the rapid bone loss that happens in the year before and after the last period. She makes a case that oestrogen, especially newer skin-patch forms (which appear safer for blood clots), is effective, underused and widely misunderstood — and that waiting until age 65 to screen is too late to use it. She also notes a single yearly infusion of zoledronate showed promise in women aged 50–60.
| If you are… | What this viewpoint suggests discussing |
|---|---|
| At high risk, or have already fractured | You may be undertreated. It’s worth actively asking whether preventive medication is right for you. |
| Worried about drug side-effects | Serious effects are real but rare; fear of them shouldn’t automatically rule out treatment. Ask for the actual numbers. |
| On long-term bone medication | Ask how long you should stay on it — duration matters, and “indefinitely” isn’t always right. |
| Around the menopause (roughly 45–60) | This is the window the author highlights. Worth discussing bone health, screening, and whether HRT/oestrogen fits your situation. |
| Considering oestrogen/HRT | Benefits and risks depend heavily on your age and how it’s taken (patches may be safer). A personal conversation is essential. |
This is a respected specialist’s argument, not settled guidance — but its themes are sound: we treat too few people for osteoporosis, a good bone-density number isn’t the same as a strong bone, treatment length needs thought, and the menopause is a powerful and often-missed window to protect bones. Oestrogen in particular, the author argues, is underused and poorly understood.
None of this is a reason to start, stop, or change any treatment on your own. It’s a reason to have a fuller, more personalised conversation with your doctor — especially if you’re approaching or going through the menopause.
This piece is an appraisal for educational and communication purposes produced by the Education Directorate of IIMHE. It is not a substitute for individual clinical advice. The underlying study is: Ott SM. Controversies About Osteoporotic Fracture Prevention Strategies. JAMA, published online 3 June 2026. doi:10.1001/jama.2026.7878
2nd February 2026 @ 20:00 GMT
Nutrition and musculoskeletal health
Given by: Dr Kimberley Zambito, Orthopaedic Consultant
Hosted by: Dr Nick Birch
Throughout 2026 and beyond, IIMHE (the International Institute of Musculoskeletal Health Education), in partnership with OsteoscanUK, will host a series of engaging educational webinars, open to anyone interested in bone and musculoskeletal health.
