Osteoporosis is a prevalent systemic metabolic disorder characterized by a reduction in bone mass and bone density, damage in microstructure of bone tissue, and raised bone fragility causing of fracture susceptibility. This study included 189 Iraqi adults aged 45–75 years, evaluating serum levels TGF-β3 and WNT5A across three groups: healthy individuals (n = 31) as control, those with primary osteoporosis/osteopenia (n = 61), and with comorbidity-related osteoporosis (linked to β-thalassemia, parathyroid disorders or diabetes; n = 97). Among those, β-thalassemia-associated osteoporosis patients showed the most distinct decrease in bone mineral density (0.57 ± 0.078 g/cm², p < 0.0001) along with marked increases in WNT5A (0.89 ± 0.68). Based on disease context, the level of TGF-β3 varied, peaking in thalassemia cases (0.28 ± 0.18 ng/mL). Significant disease-specific correlations were noticed, comprising moderate positive relationships between TGF-β3 and WNT5A (r = 0.433, p = 0.017) in diabetes patients, as well as a negative correlation between HbA1c and TGF-β3 in diabetes (r = −0.503, p = 0.047). Receiver Operating Characteristic (ROC) analysis highlighted WNT5A (AUC ≤ 0.882, sensitivity ≤ 81%) and TGF-β3 (AUC ≤ 0.891) as effective biomarkers for distinguishing thalassemia-related osteoporosis. These results underscore the role of comorbidities in altering stress response and signaling pathways, and support the use of WNT5A and TGF-β3 as promising diagnostic markers for targeted osteoporosis management in high-risk populations.
