Low bone mass and microarchitectural deterioration leading to increased fracture risk. The diagnosis may be made clinically, or on bone densitometry scanning.

General examination

To diagnose osteoporosis a detailed and full general examination is mandatory in the initial assessment of all patients.

Body habitus, height, arm span and body mass index

Patients with Cushing’s tend to have central adiposity with relative sparing of the limbs.

Low BMI should also be documented.

Height and arm span should also be documented. Loss of height indicates probable loss of height in the vertebral bodies.

Blood pressure

Blood pressure may be elevated in patients with Cushing’s syndrome and low in hypopituitarism.

Skin and mucous membranes

Extensive bruising, for example from venepuncture, thinning and redness of the skin, acne, livid striae, and acanthosis nigricans, may all be seen with Cushing’s syndrome and adrenal cancers.

Body hair should be staged, with loss of hair occurring in hypogonadism. Inceased fine vellus hair may be seen with extreme low body mass.


Blue colouration of the sclera is seen in many sub types of osteogenesis imperfecta, which may be confused with osteoporosis.

Musculoskeletal system

Bone and joint deformities may be obvious in rheumatoid arthritis.

Previous fractures and disuse atrophy should also be noted.

Proximal myopathy is a sensitive sign in Cushing’s syndrome, though this may also occur with rheumatoid arthritis.


Gynaecomastia may occur with thyroid dysfunction, Cushing’s or hypogonadism.

Galactorrhoea indicates elevated prolactin, which if long standing also predisposes to osteoporosis.

Thyroid status

Thyrotoxicosis or sub-clinical hyperthyroidism both increase bone turnover and increase the risk of osteoporosis.

Pituitary status

Any signs of anterior pituitary failure, hypogonadism, or of Cushing’s syndrome should prompt appropriate investigation.