Beyond the T-Score: A Narrative Clinical Review of Adult Endocrine Osteoporosis Care

Abstract

Background/Objectives: Bone mineral density (BMD) is fundamental to osteoporosis assessment, but fracture risk is also shaped by fracture history, falls, frailty, secondary causes, age, sex, and treatment context. This narrative review examines clinically relevant information that modifies adult endocrine decision-making beyond the T-score. Methods: PubMed/MEDLINE was searched through 28 June 2026; recent guidelines, consensus statements, systematic reviews, meta-analyses, and pivotal fracture-endpoint trials were prioritized. The exact search strings, filters, eligibility criteria, selection process, and prioritized guidance documents are provided in PubMed MEDLINE search strategies. Results: BMD should be interpreted with fracture history and clinical risk factors, while the applicability of T-scores differs by age and sex. FRAX, vertebral imaging, and trabecular bone score can refine assessment in selected patients. Very-high-risk patients may warrant early osteoanabolic or dual-action therapy followed by antiresorptive treatment, whereas antiresorptives remain appropriate for many high-risk patients. Denosumab requires planned continuity and a follow-on strategy; advanced chronic kidney disease requires particular attention to mineral metabolism and hypocalcemia risk. Conclusions: Contemporary osteoporosis care expands rather than replaces densitometry. Endocrine management should integrate valid DXA interpretation, fracture-risk urgency, reversible contributors, drug-specific safety, treatment feasibility, monitoring, and the next treatment phase.