By Dr. Susan E. Brown, PhD

Some clients come to me wondering about the difference between osteopenia and osteoporosis. Often, individuals receive the news that their “osteopenia diagnosis” necessitates bone drugs to avert life-altering fractures. Woman thinking about the difference between osteoporosis and osteopenia.

Their confusion doesn’t surprise me, as most physicians share the same level of confusion regarding fracture risk. But the evidence is clear: osteoporosis and osteopenia are not the same things, and their risk of fractures is not the same either. Here is the difference between osteopenia and osteoporosis, in a nutshell:

Osteoporosis suggests a disease process; osteopenia is a description of lowered bone density. 

When diagnosed with osteoporosis, it indicates the presence of a tangible disorder observable under a microscope. The word “osteoporosis” means “porous bone,” and a close look at the bones of someone with osteoporosis shows the bones are more like Swiss cheese than the spongy appearance of healthy bone.

Osteoporosis is not a normal response to aging but is indicative of long-term imbalances which culminate in a bone-weakening disease process.

Osteopenia, on the other hand, is not a diagnosis. It’s a description. This is a key difference between osteopenia and osteoporosis. The word “osteopenia” means “low bone mass”—and all it’s really doing is stating an observation that your bone mass is lower than that of a woman in her late 20s—someone at the peak of their bone-building and strength.

I’m often tempted to roll my eyes and exclaim, “Well, no surprise there!” After all, it’s only natural for a 55-year-old woman to have grayer hair and less bone density compared to a 25-year-old.

Osteoporosis warrants an extensive work-up looking for causes of excessive bone loss. Osteopenia may or may not be an early warning sign of bone weakening and generally does not trigger the need for a work-up or conventional medical treatment — with some exceptions.

Since osteoporosis is a disease process with a lot of potential factors, a diagnosis of osteoporosis should initiate a full workup.

Osteopenia, however, is not a diagnosis nor a disease and often, in fact, is the result of statistics.  Because bone density testing “T scores” represent a statistical calculation — by statistical definition, 15% of healthy young people will be told they have osteopenia. Most often these are small-boned, lightweight individuals. In these cases having “osteopenia” is simply a product of an individual’s general body type and more a statistical artifact testing bias than anything to do with their actual bone health.

When is osteopenia something to take seriously?

Since women’s peak bone mass occurs in their late 20s, it stands to reason that some amount of bone loss takes place throughout the subsequent decades. Whether or not slipping into the “osteopenic” bone density range is a serious concern depends on the individual case. This is where we find the proverbial devil hiding in the details. Here’s how this goes…

Through continuous clinical research at the Center for Better Bones, we have identified various “types” of osteopenia, varying in levels of concern. Let me highlight key factors differentiating harmless osteopenia from potentially significant bone weakening.

  • Finding “osteopenia” in a bone scan becomes concerning if subsequent scans reveal rapid and excessive bone loss, such as more than 2% a year loss during the menopause transition, and more than .05 to 1 % a year loss from 5 years after menopause and onwards.  On-going excessive bone loss signals that one is on the road to osteoporosis.
  • Osteopenia is found in those whose parent(s) have fractured a hip. A hip fracture could be an early red flag of future bone fragility. It warrants follow-up to find out whether this individual herself is losing bone, and if so, how rapid is the loss.
  • Entering menopause with osteopenia is a concern as the average woman loses 10% of her bone mass between the first few years before and the first five years after her last period. Some women lose up to 20% in this transition. Starting the menopause transition with lower-than-normal bone mass signals the need for a life-supporting, bone-preserving program.
  • Anyone with osteopenia who has experienced a low-trauma fracture has documented bone weakness and would do well to take their “osteopenia” seriously by implementing a bone-building lifestyle and nutrition program.

To conclude, let me say that the limitations of bone density testing are now clear. Amongst other things, it is now obvious you cannot foretell fracture by bone density alone.

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