What to Ask Before Your Next Bone Density Scan

Questions for Your Doctor Series

In a small New Hampshire emergency room about forty years ago, an elderly woman was wheeled in from a nursing home. She had stood up from her bed and fractured both hips simultaneously. The X-ray told the expected story at first: her bones were so demineralised the femurs were barely visible. But it told an unexpected story as well. Running alongside each nearly invisible femur, about a quarter of an inch to the outside, were two bright white crystalline pipes — vivid and unmistakable on the film.

Her calcified femoral arteries.

The woman did not lack calcium. Her body had plenty of the minerals that ought to mineralise a bone. It had simply deposited them a quarter of an inch from where they were supposed to go. The emergency physician — a young Dr Tom Cowan, recounting the story decades later — looked at the film and said something that contains the seed of everything mainstream osteoporosis medicine misses: “She doesn’t have osteoporosis. She has bad aim.”

Around the same time, possibly the same day, a baby arrived in the same ER with suspected pneumonia. The chest X-ray captured most of the infant’s skeleton. Its bone mineral density was almost identical to that of the elderly woman who had just broken both hips. If low bone density caused fractures, babies would be the most fracture-prone humans alive. They are the opposite. A baby’s bone bends rather than breaks because its collagen matrix — the protein scaffolding onto which minerals are deposited — is intact and supple. The elderly woman’s bones snapped under her own body weight because her matrix was degraded, and the minerals her body could mobilise were ending up in her arteries.

This is the architecture mainstream osteoporosis medicine does not see. The DEXA scan measures one variable: how much mineral is packed into a section of bone. It counts the bricks without assessing the frame they sit on. The conversation a patient has with their doctor when the scan returns a low T-score has not caught up with this. Most are told they have osteopenia or osteoporosis, offered a bisphosphonate — Fosamax, Boniva, Actonel, Reclast — and told the drug will strengthen their bones. What they are not told is the specific mechanism by which these drugs change the structure of bone, or what the signature side effect reveals about that mechanism.

The document is a 14-page formatted guide — ten questions with their Key Facts, two paragraphs of context behind each, a routing table to find the questions that match your situation, and a one-page Quick Reference to print and take to the appointment.

Here is Question 5, one of the ten:

Question 5: What are the documented side effects of bisphosphonates, including atypical femur fractures and osteonecrosis of the jaw?

Key Fact: Long-term bisphosphonate use is associated with atypical femur fractures — the femur is the strongest bone in the body, yet the drug prescribed to prevent fractures causes it to crumble under minimal stress. Osteonecrosis of the jaw occurs in approximately 1 in 1,000 users. The FDA warned in 2008 that these drugs cause severe and sometimes incapacitating bone, joint, and muscle pain that may not resolve after the medication is stopped.

Bisphosphonates work by disabling osteoclasts — the cells responsible for the natural process of removing old bone. With the breakdown side of the bone-remodelling cycle suppressed, mineral accumulates on the existing matrix and the DEXA score improves. The bone, however, becomes a different kind of bone. The collagen matrix continues to age and degrade without the ongoing renewal that osteoclast activity normally enables, and heavier mineral loads accumulate on a scaffolding that is no longer being maintained. The mechanical consequence is brittleness. The drug increases density without increasing strength, and in some cases reduces strength outright.

One context paragraph above. A second, going deeper into the mechanism and the implications, sits inside the document along with the other nine questions.

The other nine cover what the DEXA scan measures and what it cannot, how the diagnostic thresholds were set in 1994 against the peak bone mass of a young adult, the absolute risk reduction from bisphosphonate treatment when stripped of the relative-risk framing, the trial data and who controls it, the role of collagen and dietary protein in building the bone matrix, the mineral cofactors that determine where calcium is deposited, and the lifestyle factors that maintain bone strength.

The evidence in this document is drawn from Unbekoming’s research compilation on bone health, which assembles work from Dr Tom Cowan, Dr Carolyn Dean (The Magnesium Miracle), Dr Robert Thompson (The Calcium Lie), Vivian Goldschmidt (Osteoporosis Reversed), Dr Thomas Levy (Death by Calcium), Lara Pizzorno (Your Bones), Kate Rhéaume-Bleue (Vitamin K2 and the Calcium Paradox), Barbara O’Neill, and the work of A Midwestern Doctor on the limits of DEXA scanning and the harms of bisphosphonate prescribing.

If you or someone you know has an appointment coming up — yours or a family member’s, a first DEXA scan or a long-term bisphosphonate review — print the Quick Reference page and take it with you.

If there is a screening test, a prescription, or a procedure where you needed the right questions before you walked into the room, put it in the comments. The next topics will come from what you need most.

A paid subscription unlocks the full Questions for Your Doctor series — every instalment as it publishes, the back catalogue of guides already available, and the underlying books and essay summaries that make the case in depth.

Bone Density Screening: Questions for Your Doctor is available for download below.