Until recently, the management of osteoporosis was centred around the use of diagnostic thresholds based on bone mineral density (BMD) measured at the spine or hip by dual x-ray absorptiometry (DXA). This was reflected in UK guidance for the identification of individuals at high fracture risk from the Royal College of Physicians (RCP).The guidance was based on an opportunistic case-finding strategy where physicians were alerted to the possibility of osteoporosis and high fracture risk by the presence of clinical risk factors associated with fracture. This provided a trigger for the measurement of BMD, and treatment was considered in those with a BMD value that lay in the range of osteoporosis as defined by the WHO. Treatment was, however, also recommended for women with a prior fragility fracture without necessarily measuring BMD. Since the development of these guidelines, it has become apparent that the presence of several of the risk factors used to trigger a BMD test is associated with a fracture risk greater than can be accounted for by BMD alone. [With external links to the evidence base]