Osteopenia: what it means, symptoms and treatment

Osteopenia is a term used when a bone density scan shows lower density than the average for your age, but not low enough to be classed as osteoporosis. It is a measurement category rather than a disease that causes problems by itself.

The NHS explains that bones are thickest and strongest in early adult life, until the late 20s, and that everyone gradually starts losing bone from around the age of 35. Some people lose bone much faster than normal, which puts them at greater risk of a fracture. Osteopenia sits on that curve, between normal bone and osteoporosis.

The NHS says osteopenia does not always lead to osteoporosis. What matters is the wider picture of your fracture risk, not the label alone.

Treatment for osteopenia is mainly about keeping bone as strong as possible and lowering the chance of a fracture. For many people that means lifestyle measures only. The NHS says that if you have osteopenia your doctor may also prescribe one of the bone-strengthening treatments given to people with osteoporosis, depending on how weak your bones are and your risk of breaking a bone.

NICE Clinical Knowledge Summaries (CKS) sets out how doctors decide. A 10-year fracture risk score is calculated first, using QFracture (preferred) or FRAX. People at low risk are not offered a scan or treatment and are given lifestyle advice. A bisphosphonate should be offered to people with a T-score of -2.5 or lower, if appropriate. A result in the osteopenia range, on its own, therefore sits above the usual bisphosphonate threshold, which is why individual risk factors carry so much weight.

The NHS lists the medicines used for osteoporosis, which are sometimes used in osteopenia as well. Bisphosphonates slow the rate that bone is broken down. They are taken as a tablet, liquid or injection, always on an empty stomach with a full glass of water, standing or sitting upright for 30 minutes afterwards. The NHS says they usually take 6 to 12 months to work and you may need them for 5 years or longer. Other options exist for people who cannot take them or have more severe disease.

For women at or after the menopause, the NHS says HRT has been shown to keep bones strong and reduce the risk of osteoporosis. If periods stop before the age of 45, the NHS says you will usually be advised to take HRT or a hormonal contraceptive until at least age 51.

No. The NHS says osteoporosis is not usually painful until a bone is broken, and NICE CKS describes osteoporosis as asymptomatic and often undiagnosed until a fragility fracture occurs. Osteopenia is earlier and milder than that, so it does not cause symptoms either.

That is why most people hear the word osteopenia after a scan arranged for another reason, such as a previous broken bone, a long course of steroid tablets, an early menopause or concern about family history.

If a broken bone does happen, the NHS says the most common injuries in osteoporosis are a broken wrist, hip or spinal bones, and that sometimes a cough or sneeze can cause a broken rib or partial collapse of a spinal bone. Sudden back pain or any suspected broken bone needs prompt medical assessment.

The NHS says that genes affect the strength of your skeleton, but lifestyle factors such as diet and exercise influence how healthy your bones are.

• Calcium: the NHS says adults need 700mg a day, which you should be able to get from your daily diet. It lists leafy green vegetables, dried fruit, tofu and dairy products such as milk, cheese and yoghurt.

• Vitamin D: all adults should consume 10 micrograms a day. The NHS lists oily fish, red meat, liver, egg yolks and fortified foods such as most fat spreads and some breakfast cereals, and says to consider a daily supplement because it is difficult to get enough from food alone.

• Sunlight: from late March or early April to the end of September, sunlight triggers vitamin D production. In autumn and winter you need to get it from diet or a supplement.

• Aerobic exercise: adults aged 19 to 64 should do at least 2 hours 30 minutes of moderate-intensity aerobic activity a week, plus muscle-strengthening activities on 2 or more days a week.

• Weight-bearing exercise, where your feet and legs support your weight, such as running, skipping, dancing and aerobics, and resistance exercise such as press-ups and weights, are particularly important for bone density.

• Smoking and alcohol: the NHS says smoking is associated with an increased risk of osteoporosis, and it recommends not drinking more than 14 units of alcohol a week and avoiding binge drinking.

Losing bone is a normal part of ageing. The NHS says women lose bone rapidly in the first few years after the menopause, and are more at risk if the menopause begins early (before 45) or they have had their ovaries removed. Men can be affected too, and the NHS links risk to low testosterone, which can be caused by some medicines such as steroid tablets, alcohol misuse or hypogonadism.

Other factors the NHS lists include taking high-dose steroid tablets for more than 3 months, inflammatory or hormone-related conditions, malabsorption problems such as coeliac disease and Crohn's disease, a family history of osteoporosis (particularly a hip fracture in a parent), some medicines used for breast and prostate cancer, an eating disorder, a low body mass index, not exercising regularly, heavy drinking and smoking, and long periods of inactivity.

A bone density (DEXA) scan uses low dose X-rays. The NHS says it is quick, painless and more effective than normal X-rays at identifying low bone density, and takes 10 to 20 minutes depending on the area scanned. Your bone density is compared with that of a healthy young adult, and the difference is the T-score.

The NHS says you may need a scan if you are over 50 with a risk of developing osteoporosis, or under 50 with other risk factors such as smoking or a previous broken bone. Results are usually used alongside a fracture risk assessment. Scans are not recommended in pregnancy.

NICE CKS says a risk score should normally be calculated before a scan, except in people over 50 with a history of fragility fractures, and people under 40 with a major risk factor, who should be offered a scan. It also says other causes of low bone density, such as an overactive thyroid, should be looked for where appropriate.

The two terms describe points on the same scale. The table summarises the differences described by the NHS.

See a GP if you have had a fracture from a minor fall or sudden impact, especially if you are over 50, if you have risk factors such as long-term steroid use or an early menopause, or if you are worried about your bone health. The NHS says a diagnosis is often only made when a fall or sudden impact causes a bone to break.

Seek prompt medical help for a suspected broken bone, or sudden severe back pain after minor strain. Osteopenia itself is not an emergency.

In the NHS pathway a GP usually reviews your risk factors, calculates a fracture risk score and decides whether a scan, blood tests or referral are appropriate. People who have broken a bone may be seen through local fracture prevention services.

Some people choose to arrange a bone density scan or a specialist opinion privately. The scan is the same technology the NHS uses, so the value is mainly in interpretation, a fracture risk assessment and a check for underlying causes. Whatever route you use, it helps to share the result with your GP so it sits in your records.