Are Asian women, especially post‑menopausal, at increased risk for osteoporosis compared with women of other ethnic groups?

Are Asian Women at Increased Risk for Osteoporosis?

Asian women have a higher prevalence of osteoporosis by bone density criteria but paradoxically face a lower risk of fractures—particularly hip fractures—compared to White women. 1

Understanding the Osteoporosis Paradox in Asian Women

Prevalence vs. Fracture Risk: A Critical Distinction

• Asian women consistently demonstrate lower bone mineral density (BMD) than White women, resulting in higher rates of osteoporosis diagnosis when using the standard WHO definition (T-score ≤ -2.5 based on young White female reference populations). 1

• Despite lower BMD, Asian women experience significantly lower fracture incidence than White women, including reduced rates of hip, vertebral, and other major osteoporotic fractures. 1

• This protective effect against fractures persists even when BMD is equivalent between Asian and White women, suggesting that bone density alone does not explain ethnic differences in fracture outcomes. 1

Why Asian Women Break Fewer Bones Despite Lower BMD

The lower fracture risk in Asian women appears multifactorial:

• Favorable skeletal geometry and bone quality: Asian women demonstrate superior hip geometry, higher volumetric bone density, and better bone microarchitecture compared to White women with similar areal BMD measurements. 2

• Lower fall risk: Asian populations have documented lower rates of falls, which are the proximate cause of most osteoporotic fractures in elderly women. 1

• Social and environmental factors: Differences in clinical risk profiles and lifestyle factors contribute to the ethnic variation in fracture incidence. 1

Clinical Implications for Screening and Diagnosis

The 2025 USPSTF guidelines recommend screening all women ≥65 years regardless of ethnicity, but clinicians must interpret results carefully in Asian women. 1

For postmenopausal Asian women younger than 65 years:

• Use the FRAX tool to estimate 10-year fracture risk, which has been specifically calibrated to account for the lower hip fracture risk in US Asian populations. 1

• Screen if the 10-year risk for major osteoporotic fracture equals or exceeds 9.3% (the baseline risk of a 65-year-old White woman with no additional risk factors). 1

• Risk factors warranting earlier screening include: low body weight (BMI <21 kg/m²), parental history of hip fracture, current smoking, excessive alcohol consumption, early menopause, and chronic glucocorticoid use. 1

The T-Score Controversy: Should Asian-Specific Reference Data Be Used?

Using Chinese American BMD reference data instead of Caucasian norms increases T-scores by approximately 0.4-0.5 units, which would reclassify many Asian women from osteoporosis to osteopenia and reduce osteoporosis prevalence from 29.6% to 12.6%. 3

However, current clinical practice and WHO guidelines continue to use White female reference populations for all ethnic groups, meaning Asian women are more likely to be labeled as having osteoporosis despite their lower actual fracture risk. 1

Treatment Considerations Specific to Asian Women

When treatment is indicated, Asian women require special consideration:

• Asian race is a documented risk factor for atypical femur fractures during bisphosphonate therapy, an uncommon but serious complication associated with treatment duration. 2

• Recent clinical trial data on lower bisphosphonate doses and longer dosing intervals may be particularly relevant for Asian women, though definitive guidance is still evolving. 2

• The FRAX tool appropriately adjusts fracture risk estimates downward for Asian ethnicity, helping to avoid overtreatment of women at genuinely low fracture risk. 1

Common Pitfalls to Avoid

• Do not assume that lower BMD in an Asian woman automatically translates to higher fracture risk—the relationship between BMD and fractures differs by ethnicity. 1, 2

• Do not overlook screening in Asian women based on their lower population-level fracture rates—individual risk assessment using validated tools like FRAX remains essential. 1

• Do not ignore the increased risk of atypical femur fractures in Asian women on long-term bisphosphonates—consider treatment duration carefully and monitor for thigh, hip, or groin pain. 2

Summary of Risk Assessment

For postmenopausal Asian women, osteoporosis prevalence is higher than in White women (by BMD criteria), but fracture risk is lower. 1 The key is to:

1. Screen all Asian women ≥65 years with DEXA scanning 1
2. For women 50-64 years, calculate FRAX score using Asian ethnicity selection 1
3. Screen younger women if 10-year fracture risk ≥9.3% or if high-risk factors present 1
4. Interpret T-scores cautiously, recognizing that the same T-score carries lower fracture risk in Asian vs. White women 1, 2
5. When treating, monitor carefully for atypical femur fractures given the elevated risk in Asian women on bisphosphonates 2