My DEXA only says osteopenia but my doctor wants me on a bone medication anyway because of a FRAX number. Is that normal?

Long time reader, first post. I'm 67, had my second ever DEXA in August, and the word on the report is osteopenia. Lowest T-score is -2.1 at the left hip. I read everything on this site about osteopenia vs osteoporosis and I came away thinking, OK, osteopenia, that's the "keep an eye on it" one. Calcium, walking, rescan in a couple of years.

Then I go in for the follow up and my doctor pulls up something called a FRAX score and says my ten year hip fracture risk is high enough that she'd like me to start a bisphosphonate. I sort of nodded along because I was surprised, and now I'm home and confused. How can the scan say I don't have osteoporosis and the doctor still want to treat it like I do? Is this a normal thing or is this one of those "everybody gets a prescription" situations?

Background in case it matters: my mother broke her hip at 80, I broke my wrist slipping on ice four winters ago, and I was on prednisone for a long stretch for my lungs about ten years back. I'm small, always have been.

Deb, I'm the resident portal panic person here so I know the feeling of a word not matching a plan. What I learned at my own appointment is the T-score is only one of the inputs. The doctor's question isn't "what does your hip look like" it's "how likely are you to break something," and your mom's hip, your wrist, and the prednisone all go into that pot. Reading your list, I'm honestly not surprised your number came out high.

Osteopenia here too, spine -1.9, hip -1.6, and my doctor ran the same calculator and told me I was under the line, so no medication, rescan in two years. So it cuts both ways. Same label, different plan, because my history is pretty boring compared to yours. That made me trust the calculator more, not less, if that makes sense.

Ask her to show you the actual numbers on the screen. Mine printed it for me.

Deb in Naperville said:

How can the scan say I don't have osteoporosis and the doctor still want to treat it like I do?

This is a normal and widely used approach, and Linda has the logic exactly right. The bone density category and the decision to treat are related but not the same thing. The T-score tells you how dense the measured bone is compared with a young adult reference. What treatment decisions are really about is the chance of a fracture, and density is only one of the things that predicts that.

FRAX is a calculator that estimates your probability of a hip fracture, and of a major osteoporotic fracture (hip, spine, forearm, or shoulder), over the next 10 years. It combines age, sex, height and weight, a previous fragility fracture, a parent who broke a hip, current smoking, long-term steroid tablets, rheumatoid arthritis, other causes of bone loss, alcohol intake, and, if available, the bone density at the hip. Several of those are on your list. A wrist broken in a fall from standing height counts as a fragility fracture in most assessments, a parental hip fracture is one of the stronger inputs, and a long course of prednisone is a recognised cause of bone loss in its own right. It is entirely possible for a woman in the osteopenia range with that history to have a higher fracture probability than a woman with a lower T-score and none of it.

The thresholds at which treatment is offered are set by national guidelines and differ between countries, which is why two women with the same label can get two different plans, as Sue's experience shows. That is not inconsistency; it is the calculator working as intended.

I would not try to second-guess the number from here. What is worth doing is going back with the questions that make the plan yours: which risk factors drove my result, what my 10-year probabilities are, how much the medication is expected to reduce that, and how long the course would run before it is reviewed. The site's guide to osteoporosis medication covers what starting a bisphosphonate involves, the dosing rules, and the side effects people worry about, so the conversation starts from information rather than surprise.

Wrist on ice. Deb, I think half the women in northern Illinois have that fracture in their file and none of us called it anything but bad luck. Mine was the thing that got me scanned in the first place.

On the weekly pill a good while now. Sit up straight for the half hour, full glass of water, Monday mornings. That's the whole drama.

Closing the loop. Went back with the questions written down. She showed me the screen: my 10 year hip number was over the line where she treats, the other number was close to it, and when she took the prednisone out of the calculator just to show me, it dropped noticeably. So it really was my history doing the talking, not the scan.

Started the weekly tablet last Monday, sitting bolt upright with my coffee waiting like Carol said. Rescan planned for two years. Thank you all, I came here thinking I was being oversold and I'm leaving feeling like somebody actually did the math.