Bone Health · Collection 05

She was told it was only osteopenia.
Then she broke her wrist.

Why fracture risk is more than a T-score.

The clinical education

Osteopenia is a T-score range. It is not a promise that a fracture will not happen.

A DXA scan measures bone mineral density. Fracture risk also reflects bone quality, age, prior fractures, falls, menopause timing, medications, family history, medical conditions, and how quickly bone is changing.

Bone is living tissue. It is continuously broken down and rebuilt. Estrogen helps restrain bone breakdown, so the menopause transition can accelerate bone loss, particularly around the final menstrual period and early postmenopause. Premature or early menopause, surgical menopause, ovarian suppression, aromatase inhibitors, prolonged glucocorticoid exposure, low body weight, smoking, heavy alcohol use, malabsorption, and several endocrine disorders can move the timeline forward.

A DXA T-score compares bone density with that of a healthy young adult. A T-score from minus 1.0 to above minus 2.5 is categorized as low bone mass, commonly called osteopenia. A T-score of minus 2.5 or lower at an accepted skeletal site meets the bone-density definition of osteoporosis. Those categories are useful, but they are not complete risk assessments.

The scan measures density. The woman’s history gives that density its meaning.

Why a fracture can happen before the T-score reaches minus 2.5

The individual fracture rate is highest among people with osteoporosis-range bone density. Yet many fractures occur in people whose T-scores are in the osteopenia range because that group is much larger and because factors beyond density influence bone strength and falls.

A low-trauma fracture, usually from standing height or less, is a clinical alarm. A hip or vertebral fracture can establish osteoporosis regardless of the T-score. Fractures of the wrist, pelvis, or upper arm in a person with osteopenia may also support pharmacologic treatment after the full risk picture is evaluated. A fracture should trigger assessment for osteoporosis and secondary causes, not simply repair of the broken bone.

What FRAX adds, and what it may miss

FRAX estimates the 10-year probability of hip fracture and major osteoporotic fracture using age, sex, weight, height, selected clinical risks, and sometimes femoral-neck bone density. In the United States, commonly used treatment thresholds for osteopenia include a 10-year hip-fracture probability of at least 3 percent or a major osteoporotic-fracture probability of at least 20 percent.

Those thresholds guide discussion; they are not a substitute for judgment. FRAX does not fully capture fall frequency, lumbar-spine density that is much lower than hip density, recency or number of fractures, dose and duration of glucocorticoids, rapid bone loss, frailty, or every cancer-treatment effect. A number below a threshold does not erase a clinically important pattern.

Screening should follow risk, not birthdays alone

The 2025 U.S. Preventive Services Task Force recommendation supports screening women age 65 and older and screening younger postmenopausal women who are at increased risk based on clinical assessment. Women with premature menopause, a fragility fracture, aromatase-inhibitor treatment, long-term steroid exposure, or another high-risk condition may need evaluation well before routine age-based screening.

The StrongHer truth

“Only osteopenia” can be falsely reassuring. Low bone mass is a signal to calculate risk, examine the history, look for correctable causes, and decide whether prevention alone is enough.

A composite experience

“She exercised. She took calcium. She had never broken a bone.”

This educational vignette combines experiences commonly described by women. It is not the story of one identifiable patient.

Her first bone-density report said osteopenia. The word sounded mild, almost ordinary. She was told to take calcium, continue walking, and repeat the scan later. She left relieved that it was not osteoporosis.

She did what she had been told. She bought a supplement. She walked most mornings. She did not smoke, rarely drank, and had never broken a bone. Bone health moved to the bottom of a long list of things competing for attention.

No one connected the scan to menopause at 44, years of intermittent steroid treatment, her mother’s hip fracture, or the acid-suppressing medication she had taken for a long time. No one reviewed whether the spine and hip told the same story or whether the change from her earlier scan exceeded the machine’s expected measurement variation.

Then she tripped on the edge of a rug and caught herself with one hand. The fall was small. The wrist fracture was not.

What shook her was not only the broken bone. It was realizing that “not osteoporosis” had sounded like “not at risk.”

The fracture changed the conversation. Her clinician reviewed the actual DXA images and site-specific T-scores, calculated fracture probability, measured her height, and asked about back pain, falls, medications, menstrual history, nutrition, and family history. Laboratory testing identified vitamin D insufficiency and ruled out several secondary contributors.

Her new plan included progressive resistance and balance training, enough protein and calcium from food with supplementation only for the gap, correction of vitamin D, home fall prevention, and medication selected for her fracture risk and medical history. The plan also explained how treatment would be monitored and what would happen when it was time to change or stop therapy.

Where women see themselves

A diagnosis does not have to sound severe to deserve a serious plan. Asking what your result means for your actual fracture risk is not overreacting. It is prevention.

Dr. Rhaney’s perspective

I do not treat a bone-density number. I treat fracture risk.

The T-score matters. So does everything that can make the same T-score mean something different in two different women.

I review the lowest valid T-score, but I do not stop there. I look at the individual sites, scan quality, machine used, prior studies, and whether the apparent change exceeds the facility’s least significant change. Arthritis, scoliosis, compression fractures, positioning, and other artifacts can make the lumbar spine look better or worse than the bone truly is.

I ask about every fracture after age 50 and how it happened. I ask about height loss, back pain, falls, balance, vision, footwear, muscle strength, family history, menopause timing, nutrition, gastrointestinal disease, kidney stones, cancer treatment, steroids, thyroid medication, antiseizure drugs, and other exposures that affect bone or falling.

A bone-density report is data. The clinical task is deciding how close this woman is to the fracture we still have time to prevent.

The evaluation before treatment

Appropriate laboratory testing is guided by the history and may include calcium, albumin, kidney and liver function, phosphorus, alkaline phosphatase, blood count, 25-hydroxyvitamin D, and thyroid testing. Parathyroid hormone, celiac testing, urine calcium, protein electrophoresis, and other studies are selected when the clinical picture supports them. Treatment should not cover up an unrecognized secondary cause.

I also determine whether risk is high or very high. A recent fracture, multiple fractures, a fracture while on therapy, a very low T-score, high fall risk, or very high calculated probability may justify a more aggressive or anabolic-first strategy. The sequence matters because gains from anabolic therapy need to be maintained with an antiresorptive medication.

Medication decisions require an end plan at the beginning

Bisphosphonates remain appropriate first-line therapy for many women. Oral treatment requires correct administration and may not fit significant esophageal or gastrointestinal disease. Intravenous zoledronic acid avoids the upper gastrointestinal tract but requires kidney assessment and counseling about the temporary flu-like reaction that can follow an infusion.

Denosumab can be highly effective and may be useful when bisphosphonates are not tolerated or are not the best fit. But it is not a medication to delay casually or stop without a transition plan. Its effect reverses after dosing stops, and unprotected discontinuation can cause rapid bone loss and multiple vertebral fractures. Another antiresorptive therapy is generally needed when denosumab is discontinued.

Rare complications such as osteonecrosis of the jaw and atypical femur fracture deserve honest counseling without losing perspective about the far more common fractures treatment is intended to prevent. Dental health, kidney function, calcium and vitamin D status, adherence, cost, route, and patient preference all belong in the choice.

The clinical standard

The right plan identifies the risk, treats correctable contributors, selects therapy proportionate to that risk, and explains monitoring and transition before the first dose is given.

Felicia L. Rhaney, MD, FACOG, MSCP
Double board-certified OB-GYN and urogynecologist

The bone-health guide

Before you are told to take calcium and return in two years, ask these questions.

Calcium and exercise matter. They do not replace a complete risk assessment when bone density is low, a fracture has occurred, or menopause and medical treatment have changed the timeline.

Read the full DXA report

Ask for the T-scores at each valid site, the comparison with prior scans, and whether any change is statistically meaningful. A single summary word can hide important differences between the spine and hip.

Build the complete risk profile

Include prior fractures, falls, family history, menopause age, body weight, smoking, alcohol, cancer therapy, steroids, medical conditions, and medications. Use FRAX when appropriate, but ask what it may not capture.

Look for correctable causes

Review nutrition, protein, calcium, vitamin D, kidney function, thyroid and parathyroid disease, malabsorption, medication exposure, and other secondary causes before assuming menopause and age explain everything.

Choose the treatment and the transition

Match medication strength, route, duration, monitoring, and sequence to the risk level. Ask what happens if the medicine is delayed, stopped, or not tolerated. Denosumab requires a specific transition plan.

Questions to bring to the visit

What are my actual T-scores at the spine, total hip, and femoral neck, and have they changed significantly?
Does my fracture history change the diagnosis or treatment recommendation even if my T-score is above minus 2.5?
What is my estimated fracture risk, and what important risks might the calculator miss?
Could early menopause, cancer treatment, medication exposure, or another medical condition be accelerating bone loss?
What laboratory evaluation is appropriate before we choose treatment?
Which medication fits my risk level, kidney function, gastrointestinal history, preferences, and ability to stay on schedule?
What is the monitoring plan, expected duration, and safe transition or stopping plan?

The foundation of the plan

Movement: Walking supports general health and provides weight-bearing activity, but walking alone is not a complete bone program. Include progressive resistance training, weight-bearing activity, balance work, and posture or spine-safe movement appropriate to your ability and fracture history. A physical therapist can help when falls, weakness, pain, or vertebral fracture change what is safe.

Nutrition: Aim to meet calcium needs primarily through food, using supplements to fill a measured gap rather than assuming more is better. Vitamin D needs vary with age, sun exposure, absorption, kidney and liver health, body size, and medications. Adequate protein and overall nutrition support bone and the muscle that helps prevent falls.

Fall prevention: Review vision, hearing, blood pressure, sedating medications, footwear, balance, home lighting, loose rugs, stairs, and bathroom safety. Preventing a fall can be as important as increasing bone density.

How medication pathways differ

Bisphosphonates slow bone breakdown and include oral and intravenous options. They remain first-line treatment for many women. Kidney function, gastrointestinal history, adherence, dental health, treatment duration, and reassessment for a possible holiday all matter.

Denosumab is an injection given every six months. It is not managed with a drug holiday. Doses should stay on schedule, and stopping requires follow-on therapy to reduce rebound bone loss and vertebral-fracture risk.

Anabolic or bone-building therapies such as teriparatide or abaloparatide may be used for women at very high fracture risk. Romosozumab both increases bone formation and decreases resorption and requires cardiovascular risk consideration. These therapies are time-limited and should be followed by antiresorptive treatment to preserve gains.

Other options may fit selected circumstances. Raloxifene primarily reduces vertebral-fracture risk and has effects on breast-cancer risk but can increase venous-thromboembolism risk. Menopausal hormone therapy can prevent bone loss in appropriately selected symptomatic women, but it is not appropriate for every woman and is not generally used solely as chronic osteoporosis treatment.

The denosumab question every woman should ask

“If I ever need to stop this medicine, what will I receive next, and when?” The exit plan is part of the treatment, not a conversation to postpone until the final injection.

Changes that deserve prompt review

A new fracture after a fall from standing height or less
Sudden or persistent back pain, height loss, or a new stooped posture
A denosumab injection that is approaching or has passed its scheduled date
New thigh or groin pain during long-term antiresorptive therapy
Poor healing, exposed jaw bone, or significant dental symptoms during treatment
Symptoms of very high or very low calcium, including severe weakness, confusion, muscle spasms, or an abnormal heart rhythm

Important: This guide is educational. Fracture risk and osteoporosis treatment require individualized evaluation. Do not begin, delay, or stop a prescription bone medication without a safe plan from a qualified clinician.

Publication and clinical review

Published September 26, 2026. Educational content reviewed September 26, 2026 by Felicia L. Rhaney, MD, FACOG, MSCP. This material is educational and is not a diagnosis or a substitute for individualized medical care.

Selected guidance and evidence

The complete StrongHer framework

Protect the bone.
Preserve the woman’s independence.

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