Osteopenia

Osteopenia is defined as a reduction in bone density (1,2,3).

The term is often used radiologically when it describes a qualitative appearance of bone on a radiograph.

Increasingly however the term refers to a quantitative loss of bone mineral density (BMD) usually measured either at the hip or spine with dual energy X ray aborptiometry.

Osteopaenia is defined when bone density at the spine or hip between 1.0 and 2.5 standard deviations below the average for healthy young adults (T-score between -1 and -2.5).

Osteoporosis is defined if the T-score is more than 2.5 standard deviations below the average.

Normal bone mineral density is : T-score of -1 standard deviations or above.

Decreasing BMD values are reflective of an underlying disruption in the microarchitecture of bone and osteopenia, and osteoporosis is considered quantitative, not qualitative, disorders of bone mineralization (1).

Management:

Use validated risk estimation tools to determine the fracture risk and then decide if the patient should be advised on general lifestyle measures only, offered pharmacological treatment, or referred to a specialist (3)

• lifestyle advice includes:
  • balanced diet including adequate calcium and vitamin D
    • National Osteoporosis Foundation (NOF) recommends 1,200 to 1500 mg of calcium per day and 800 to 1,000 IUs of daily vitamin D for adults over the age of 50 (1)
  • regular weight-bearing exercise e.g. walking, dancing, skipping, gym
  • stop smoking
  • reduce alcohol intake
    
    
• zoledronic acid may be considered to reduce risk of clinical fractures in women over 65 years of age who have osteopenia at hip or femoral neck on DXA (2)
  • note that while the recommendations for pharmacologic intervention in patients diagnosed with osteoporosis are universally accepted, the pharmacologic treatment of osteopenic patients is much more controversial secondary to the much higher number needed to treat (NNT) threshold reported in the literature (1)
    • compared to osteoporosis (NNT = 10 to 20 patients), the NNT for osteopenia exceeds 100 patients
      
      
• patients with osteopenia (t score -1 to -2.5) should be re- scanned in 3 years

A review suggests (3)

• refer patients in the “very high risk” category to a specialist for consideration of parenteral or anabolic therapies
  • very high risk category includes patients with a fracture within the past two years (particularly of the hip or spine), more than one vertebral fracture, or a FRAX 10 year risk of >30% for major osteoporotic fracture or >4.5% for hip fracture

Notes

• a presumptive diagnosis of osteoporosis can be made in postmenopausal women and men older than 50 years of age with a prior fragility fracture (3)

Reference:

1. Varacallo MA, Seaman TJ, Jandu JS, et al. Osteopenia. [Updated 2023 Aug 4]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-.
2. SIGN (June 2020). Management of osteoporosis and the prevention of fragility fractures.
3. Suresh E, Suresh N, Low R, Tng E L. 10-Minute Consultation: Osteopenia.BMJ 2025; 391 :e085622.