Doubting Your DXA Scan

At 53 I had my first DXA scan because I had lost some height and was experiencing some back issues.

My primary care doctor had first ordered an x-ray to see what was going on with my back, which showed some “indication” of osteopenia so she went ahead and ordered a full DXA to “get a fuller picture,” she said.

My gynecologist on the other hand was surprised to hear that my PCP would order a DXA because “we’re not going to treat you, you’re too young.”

Her statement confounded me until I realized that she felt that the only course of treatment would have been something like Fosomax, and she would hesitate to give it to me due to my age because you can only be on it for a few years. She seemed resigned to the belief that we will precipitously lose bone no matter what as we age, and that the only course of action was with a drug, which just simply isn’t true. Meanwhile my PCP was open to helping me work on diet and lifestyle changes.

And so my journey into this wily and contradictory world of osteoporosis screening protocols and treatment variations began.

That was 3 years ago.

My DXA showed osteopenia and because I have a family history of osteoporosis, I was afraid but also sort of grateful to have this news so early on. Since then I’ve been working with my PCP on post-menopausal hormonal & supplement support and I’ve been on a mission to learn and do all I can on how to improve my bones by refining my nutritional intake, my exercise focus, stress management, and addressing gut and other contributing health issues.

One key thing I’ve learned about low bone density is that everyone’s journey is unique – let me emphasize this – everyone’s journey is really unique.

There are so many factors involved in how we got to this state, and just as many variations on how to get back on track to preserving our skeleton.

As a yoga practitioner I have revamped my personal practice to focus on stimulating bone remodeling and increasing my strength, balance, and proprioception – and most importantly to sustain my sense of calm. All this is known to have a positive effect on bone health.

And this is what I offer as a yoga teacher in the Yoga for Vital Bones classes.

I had my followup DXA scan last month and I just got the results back.

While I wasn’t necessarily expecting I would have gained a lot of bone density given that I’m still in the aftermath of menopause when bone density naturally takes a nose dive, I was thinking it would have shown me holding steady as a win.

However, the results showed some degeneration further into the osteopenic range. Not a lot of change, but some – even though the report uses the word “significant” regarding the % change (average of 3.5%). The spine was a little less dense but most of the change was in the total femurs. According to many experts, it is far more common to lose more in the spine than the hips but my report was the other way around.

So even though the report includes a standard “the technical quality of this scan is good” pat statement from the interpreting physician, I had my doubts – not because the results didn’t match my expectations but because the decline was more in my hips than my spine and because of a couple of red flags during the testing.

You see, while we chatted, I had asked the operator during my scan if he or the interpreting physician was a certified densitometrist and he said no and then went on to disparage that extra training as unessential and unnecessary. (First red flag)

I also vaguely recalled that during my first DXA three years prior, the operator at that time deliberately internally rotated my hips and strapped my feet to a support, but at my most recent, this operator did nothing to my legs whatsoever. When I asked him if he was going to do something to my legs, he dismissed me with a flat “no.” (Second red flag)

Since then, all that I’ve read from studies done on the reliability of DXA scans is that the rate of error without proper leg rotation is quite high. I should have been more persistent but this was only my second DXA, I doubted my own experience.

I have been tempted to dismiss the results as being completely invalid due to operator error but I don’t know that for sure.

I do have serious, rational doubts, though, that this DXA scan actually captured the true nature of my bone density at this time.

We should always approach our DXA scan numbers with a healthy dose of skepticism and curiosity anyway.

It’s not a perfect science. Studies have shown that even with the same operator, same machine, and same patient checked multiple times right in a row, the results can vary in range from 3-5% (this is called “least significant change.”)

And when it comes to overall bone health, DXA is just one data point, and doesn’t even speak to bone quality at all (I’ll share more on that in another post.) [[In the meantime, see notes in comments]]

Yet the standard treatment protocols for low bone density all rely on these DXA numbers. It’s frustrating.

So this is another aspect of where yoga practice comes into play – cultivating discernment, viveka, taking information from all sources and striving to see things as they really are without projection from the past or the future.

You see another data point I have is that my blood marker tests last month were all in the normal ranges so from that perspective I am not necessarily excessively losing bone minerals at this time.

My doctor and I believe I’m on the right path to improve and maintain my bones.

Bones are living tissue and are constantly remodelling, so I will continue what I’m doing and be ever vigilant toward nourishing my bones (and also a better advocate for myself next time on the DXA scan table!)

This is literally a journey of a lifetime, and while there is not much certainty, I truly believe there is no need to panic.

Just B.R.E.A.T.H.E. – this is an acronym for the 7 tools we must use to address low bone density.

Inhale inspiration, exhale action.

Get your tool guide here.

I wish you all a good journey. Head high.

  • Amanda Rittenouse
    Posted at 14:03h, 19 August Reply

    Thank you for posting this about the DEXA. I had my first second scan recently and had some mild osteopenia. What I really appreciated was that my OB who ordered the test suggested a re-test in 2 years while continuing to work on lifestyle changes to improve/maintain my bones. I already do many of the lifestyle suggestions but I truly appreciated that she mentioned yoga. Although, I have been doing yoga for a few years now, I intend to focus more on bone strength . I appreciate that you are sharing your journey and doing yoga for bone health!

    • Mary Beth Ray
      Posted at 15:30h, 19 August Reply

      welcome to the journey Amanda. How wonderful that your OB is open to lifestyle changes – and yoga!

  • Amanda Rittenhouse
    Posted at 14:05h, 19 August Reply

    Correct last name should be Rittenhouse!? Also, just meant to say second scan, not first second! Too early!

    • Mary Beth Ray
      Posted at 15:30h, 19 August Reply


  • Cathy Morrissey
    Posted at 14:58h, 19 August Reply

    Very interesting. Thank you! Can. I ask what type of blood work should be looked at to look for bone loss and bone health?

    • Mary Beth Ray
      Posted at 15:41h, 19 August Reply

      Hi Cathy – there are a number of diagnostic tests that can be done to help determine the cause of or contributing factors to osteoporosis including looking at your vitamin D level, different markers of inflammation (e.g., homocysteine, C-reactive protein), thyroid malfunction, parathyroid malfunction, celiac or gluten sensitivity, and levels of sex hormones post menopause.

      In addition, there are a few that help to assess the current rate of remodelling – bone break down and bone formation. This process should be balanced.

      Tests for Markers of Bone Break Down:
      – N-telopeptides crosslinks (NTx) marker of bone resorption test (either via serum or urine, urine they say is more accurate)
      – CTx serum bone breakdown test

      Tests for Markers of Bone Formation:
      – Osteocalcin
      – P1NP test of bone formation
      – Bone alkaline phosphatase

      Dr. Lani Simpson has a whole chapter in her “No Non-Sense Guide to Bone Health” book on lab tests but I’ve found that some of these tests are so new, that books are somewhat outdated in their coverage (always check the copyright year :-)). More recent insights can be found online.

      • Janice Catona
        Posted at 16:54h, 19 August Reply

        Wow, this is very interesting! Never had my legs secured.
        Thanks for all the blood/urine test reminders

        • Mary Beth Ray
          Posted at 15:43h, 20 August Reply

          Just wanted to share with folks here what we talked about in class yesterday, Janice, that your DEXA technician actually elevated your legs on a bolster type thing. And THIS would also release the upper femurs in a more neutral state, which has the same or similar effect as internally rotating the legs and securing the feet to a a support. What we need to be wary of is when we are told to just lie flat on the table – like in savasana (which is what happened to me in my second DEXA. I personally externally rotate my legs automatically when I’m lying flat.)

  • Gayle W
    Posted at 17:12h, 19 August Reply

    Thank you for this article Mary Beth. I appreciate the info on foot positioning during a DEXA as I have one in a week, then will follow up with my PCP at my next appt. I will ask about these blood tests, as this is all new to me. I had a DEXA at age 32 and was T+2 then and told not to worry about all the Prednisone use, my bones were great. If only I knew then how to keep them that way. Glad I have a new Dr now. I hope to build some back at age 53.

    • Mary Beth Ray
      Posted at 23:40h, 19 August Reply

      I’m sorry the prednisone took such a toll. Good luck with your DEXA and your new Dr. Keep the faith!

  • Angele Gallego
    Posted at 20:20h, 19 August Reply

    Thank you Mary Beth for this article. Sorry the results weren’t optimal. I do hope they can one day come up with something that measures for bone strength. That is interesting that different techs have different ideas on how to perform a dexa test. Wouldn’t it be nice to find one certified in densometry. I wonder if there is also a specific way to measure spine density.
    Also I did have some tests run recently including he NTx which showed that I was losing bone 🙁 I will have to pull out Lani’s book as I’m not sure if I should also request the other CTx, Osteocalcin and P1NP tests.

    • Mary Beth Ray
      Posted at 18:33h, 20 August Reply

      Thanks Angele. I’m sorry to hear about your NTx. I think getting a fuller picture of the whole remodelling activity is a good idea – so checking the other side of the equation on formation gives you that information, right? There is a lot to say about this, and, like I said everyone’s situation is unique. Maybe we could talk on the phone one day if you’d like. Did you know there is software that can be added to a DEXA scan machine that measures the quality of the internal architecture of the bone – the trabecular structure within the bone itself? Measuring the “TBS” (trabecular bone score) is a far greater indicator of bone strength and health than DEXA – especially in the spine! – but it is, for some reason, not readily available on all machines. I’m not sure why. But folks with the same BMD could have very different TBS, which explains why some within osteopenic levels fracture easily and others deeply osteoporotic don’t fracture. Inquire with your screening facility whether you can get the TBS measured. Alternatively you can go here:

  • Angele Gallego
    Posted at 04:02h, 21 August Reply

    I had no idea about the TBS Marybeth. Have you ever had that tested? I’d be happy to talk with you anytime! Just visited with my mom today who has had osteoporosis for many years. She no longer gets dexa scans. She does her own thing eating pretty healthy and doing some stretches and low weight bearing exercises. She feels great she’s never fractured. She must have a great TBS.?

    • Mary Beth Ray
      Posted at 13:17h, 21 August Reply

      Sadly, they don’t do TBS testing at my facility but I’m looking for one nearby that does to see if my next DEXA could be done there. Yes I suspect your mom does have a good TBS! 🙂 Email me and we’ll find a time to talk.

  • Angele Gallego
    Posted at 16:25h, 21 August Reply

    Just called my Dexa facility and spoke with one of the techs asking if they had the TBS. Of course they don’t, but I think I sounded like I was a rep for the software. I explained the advantages for patients and even doctors. as It could give them the confidence to make more informed recommendations to their patients with OP to move more and even lift heavier weights b/c their TBS was positive. She said she would speak to the radiologist. I’ll email you.

  • Kathryn Mangascle
    Posted at 16:04h, 11 September Reply

    If you enter your state and address at this site, they should reply to let you know where the TBS (measure bone quality) machines are in your area. I just filled out a form and am waiting to hear!

    • Mary Beth Ray
      Posted at 21:37h, 11 September Reply

      Hi Kathryn – that’s right! good luck! I hope you have one near you.

  • Maria Shrayev
    Posted at 18:49h, 02 December Reply

    I personally rely more on REMS Echolight test, which is kind of ultrasound and doesn’t depend on your position. It’s a new technology her in US (I think it’s used in Europe for a while). In US it’s just a couple locations. Insurance doesn’t cover this test yet, but the cost is $95.. It tells you as well your bones quality (mineral density). No radiation, pretty awesome technology

    • Mary Beth Ray
      Posted at 23:30h, 11 January Reply

      Hi Maria,
      that’s great to hear. I know Echolight is new. From what I understand it isn’t quite up to snuff yet on how well it measures density and quality and there is some confusion on the Fracture Risk Assessment being inaccurately read as percentage vs per mille (the symbol is 0/00 being read as a percentage and not as “per mille”, which is a whole decimal point difference)…but I agree, it is promising. Fingers crossed they work out the kinks.

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