Beyond the T-Score: Individualized Fracture Prevention in Osteopenia

There is growing recognition that osteopenia is not a benign stage in bone health. The article by Mun et al. [1] clarifies this point. It offers a practical and clinical approach to individualized fracture prevention for postmenopausal women. Its publication is timely, as Korean clinicians are caring for a rapidly aging population and a growing number of fragility fractures. Its message is straightforward: early risk recognition and tailored intervention must begin before osteoporosis develops.

Epidemiologic data consistently show that fractures often occur outside the osteoporosis range. In the National Osteoporosis Risk Assessment (NORA) study, most fractures happened in women with osteopenia rather than osteoporosis [2]. The Rotterdam Study reported similar findings, demonstrating that major osteoporotic fractures frequently occur in women whose T-scores did not meet diagnostic thresholds [3]. The review builds on these observations and translates them into practical clinical guidance.

Korean data highlight the urgency even more. Among 271,197 Korean women aged 66, the 10-year fracture incidence was 37.5% in those with osteopenia [4]. Low body weight, rapid aging, and high baseline susceptibility contribute to this pattern. The review appropriately shifts attention from T-scores alone to individualized risk factors that reflect Korea’s clinical realities.

Some argue that osteopenia is too heterogeneous to guide targeted intervention. However, evidence suggests otherwise. Trials demonstrate that bisphosphonates, selective estrogen receptor modulators (SERMs), and other medications reduce fractures in high-risk osteopenic women, such as those with a recent history of fracture or higher fracture risk as determined by the fracture risk assessment tool (FRAX) [5]. Given the potential adverse effects of pharmacologic treatment, including gastrointestinal complications and osteonecrosis of the jaw, non-pharmacologic measures also play a role. Virtual reality–based balance and strength training has been shown to improve bone mineral density (BMD) and reduce FRAX-estimated fracture risk [6]. A recent Spanish multidisciplinary consensus similarly recommends structured risk stratification and lifestyle modification for osteopenia [7]. The authors’ review brings these findings together in a unified and practical model.

For Korean clinicians, the implications are clear. Fracture prevention could begin at the osteopenia stage. The review encourages clinicians to look beyond T-scores and consider age, previous fractures, FRAX probability, body weight, glucocorticoid exposure, and lumbar–hip discordance—factors that more accurately identify women who stand to benefit from early intervention.

Policy adjustments are also needed. Many fractures occur in women who do not meet the current osteoporosis-based reimbursement threshold, which in Korea is set at a T-score of –2.5 or below. A risk-based system, built on FRAX scores and clinical history, would better reflect contemporary evidence. Future studies should define Korean-specific risk cutoffs, validate non-BMD markers such as bone turnover markers and fall-risk assessment, and expand interventional trials for women with osteopenia.

Osteopenia represents a pivotal point in the fracture-risk continuum. This review reinforces that understanding and offers a practical path forward. Korean clinicians should adopt risk-based assessment, intervene when appropriate, and advocate for policies that reflect the real-world distribution of fracture risk. Effective prevention begins where risk first appears—and that is often in osteopenia.