Osteoporosis Awareness Month: 5 Groups That Need Bone Screening Sooner Than You Think

Osteoporosis Awareness Month matters more to me now than it used to. Over the last few years, we have worked with hundreds of people who have low bone density and high fracture risk. And many of them do not fit the “normal” picture most people think of.

Yes, many people with osteoporosis are women over 50. That is still the most common group. But there are other groups that get missed. These people often do not think they are at risk. Their doctors often do not screen them. And that means bone loss can stay hidden for years.

In this post, I want to walk you through five groups who should pay close attention to bone health. Some may surprise you. They used to surprise me too. I will also explain what to do if you or someone you love fits one of these groups. The main action is simple. Screen early. Screen smart. Then build a plan based on real data.

The problem: we wait too long to check bone

Bone loss is silent. You do not feel it. You do not get a warning. Many people find out after a fracture. And that is a bad time to start caring.

This is also why osteoporosis is not just a “bone” issue. Bone ties to muscle, hormones, nutrition, and training. If you are in a group that lowers hormones, lowers lean mass, or lowers impact on the skeleton, your risk can rise fast.

That is why this month matters. Awareness is not a ribbon. It is action.

Group 1: Young female athletes with missed cycles

The first group is one that shocked me when I first started this work.

I expected young female athletes to have higher risk later in life. That is well known. But what surprised me was seeing teens, women in their 20s, and women in their 30s who already had low bone density.

The biggest driver is often amenorrhea, meaning a missed or absent menstrual cycle. For bone, a regular cycle is not just a “reproductive” thing. It is a hormone signal. It helps bone build and maintain strength.

When cycles stop, bone can start to drop.

Why this happens

A common cause is low energy availability. The old term was “female athlete triad.” The newer term is RED-S (relative energy deficiency in sport). It means the body is under-fueled for the workload. The body starts to shut down “non-urgent” functions. A normal cycle is one of the first things to go.

Here are common factors that stack together:

• Heavy training load with not enough calories
• Low body fat for the athlete’s personal threshold
• Weight-to-strength sports (where lighter is rewarded)
• Long endurance events that push the system too hard
• Poor protein intake or low total nutrition quality

Oral contraceptives can add confusion

Some birth control options stop ovulation and stop normal cycling. That can hide the signal that the body is under stress. It can also change bone signaling in ways we do not want. This topic deserves its own deep dive, but the main point is simple: if a young athlete is not cycling, do not ignore it.

What I would do

This group needs screening earlier and often more often. If a young athlete has low bone already, I want to watch it closely.

• If bone is low and risk is high: screen as often as every 6 months
• If bone is strong and cycles are normal: screen less often, but still screen

This is one of the most important groups to catch early. Because the earlier you fix it, the better the long-term outcome.

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Group 2: People using GLP-1 weight loss drugs

The second group is growing fast. And it needs better screening.

This group is people using GLP-1 or GLP-1/GIP drugs for weight loss. These include medications like Ozempic-style and tirzepatide-style options.

This is a complex space. I am not here to debate who should or should not use them. I am here to say one thing clearly:

If you are losing weight fast, you must protect lean mass. And you must check bone.

The common misunderstanding

People often say, “You lose 60% muscle on these drugs.” That is not quite right. Many studies report large loss of lean mass, not just muscle. Lean mass includes muscle, water, and also bone-related tissue.

Even more important: many people who are starting these drugs have never had a bone scan. Some may already have low bone. Obesity alone does not protect you from osteoporosis. In fact, some people with obesity also have:

• High inflammation
• Low activity
• Low protein intake
• Low vitamin and mineral intake

So they may start in a weak place. Then weight loss speeds up lean loss. That can make bone risk worse without them knowing.

What I would do

If you use GLP-1 or GLP-1/GIP drugs, you should consider:

• Baseline body composition testing
• Baseline bone density testing
• A plan to keep muscle (protein + strength training)
• Repeat checks over time to be sure lean mass is not dropping too fast

This is not fear. This is smart.

Group 3: Swimmers and ultra endurance runners

This group surprises people because they “work out all the time.” But their skeleton may not be getting the right signal.

Swimmers

Swimming is hard work. But it is also a low-gravity environment. There is no impact. There is less loading on bone. So even if cardio is great, the skeleton may not get the stress it needs to build.

Swimmers can have lower bone density than other athletes. And many swimmers do not realize it until later.

Ultra endurance runners

There is a big difference between light jogging and ultra training.

If you are running 3–5 miles a week, you may be fine. But if you train for 50-mile or 100-mile events, the body changes. It adapts to survive long-distance stress. That often means getting lighter.

In many ultra athletes, you see:

• Very low body fat
• Low muscle mass
• Low overall bone mass
• High training stress with poor recovery

Even though running has “impact,” the light step impact is often not enough to drive bone building. And the catabolic stress can be high.

What I would do

If someone is a swimmer or a high-mileage endurance runner, I want them to:

• Check bone density and quality at least once
• Track menstrual health (for women)
• Build in strength training and impact work when safe
• Make sure nutrition supports the workload

This group often thinks they are the “healthiest” in the room. That is why they get missed.

Group 4: Men on testosterone plus aromatase inhibitors

This one is very important and not talked about enough.

Some men use testosterone replacement therapy (TRT). That can be helpful in the right case. But there is a mistake I see too often: TRT combined with aromatase inhibitors (AIs).

AIs block the conversion of testosterone to estrogen. Some providers were trained to do this to control symptoms. I was trained this way too early on. But over time, it became clear to me that men need estrogen too.

Why estrogen matters in men

Men protect bone, brain, and heart with estradiol. In men, estradiol comes mostly from testosterone through aromatase conversion.

If you block aromatase hard, estradiol can drop to near zero. I have seen labs like this. High testosterone. Estrogen wiped out.

That can raise osteoporosis risk. It can also affect joints, mood, and other systems.

What I would do

If a man is on TRT, I want to see:

• Testosterone levels
• Estradiol levels
• Symptoms plus objective markers
• Bone screening if estradiol has been suppressed for a long time

This is even more important in younger men using TRT + AI for performance or bodybuilding. The long-term cost can be high.

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Group 5: Women in perimenopause and menopause who are not screened

This one drives me crazy.

In the U.S., most women are not screened for osteoporosis until age 65. But bone loss often starts at menopause, around age 50. That is a 15-year gap. That is a long time to lose bone without knowing it.

We already know this:

• Menopause lowers sex hormones
• Lower hormones increase bone breakdown
• Bone loss is predictable during this window

So how do we make good choices without data?

The HRT problem without bone data

We cannot have a real risk-benefit talk about hormone therapy without knowing bone status.

If a woman already has low bone at menopause, that changes the conversation. The potential benefit is bigger. But if we do not screen, we do not know.

I have seen many women in their 60s who regret not getting this conversation earlier. Many went through menopause in the shadow of the WHI era and were told “no hormones.” Now they have osteoporosis and wish they had better options sooner.

What I would do

I think women should have bone screening around the menopause window. Not at 65.

Not everyone needs the same plan. But everyone deserves the data.

What to do if you’re in one of these groups

The main step is simple. Screen.

If you do not measure bone density and bone quality, you are guessing. And guessing is where people lose years.

Screening options

The two most common tools are:

• DEXA: widely available, often insurance-covered, gives density (T-score)
• REMS: ultrasound-based option that can give density plus a quality score; not as widely available and often not covered

If you only have access to DEXA, do DEXA. If you have access to REMS, I like REMS as part of the picture, and in many cases we use both.

Internal link placeholder: [Internal link: REMS vs DEXA scans]

How often should you screen?

This depends on risk and starting point. There is no one rule that fits everyone.

Here are practical examples:

• Young athlete with amenorrhea and low bone: every 6 months (sometimes more)
• Menopause transition with normal baseline bone: every 1–2 years early on
• Stable bone and low risk: every 2–5 years may be enough
• Fast weight loss or major health change: more frequent checks may make sense

The goal is not to scan forever. The goal is to scan at the right time to catch risk early.

The next step: build a plan that matches the risk

Screening is step one. Action is step two.

If you are at risk, the main levers are still the basics:

• Strength training and safe impact work
• Enough protein (and enough total calories)
• Vitamin D and K2 status
• Mineral balance (magnesium matters)
• Hormone support when it makes sense
• Sleep and stress control

You do not need perfection. You need a system you can follow.

If you want help putting this together, you can join our free masterclass. We run it often. We cover the biggest mistakes we see and how to avoid them. We also leave time for live Q&A. Internal link placeholder: [Internal link: Free masterclass signup]

FAQ

What age should women get their first bone scan?

If you ask me, many women should consider screening around perimenopause or menopause, not waiting until 65. It helps guide prevention and hormone conversations.

Do GLP-1 drugs cause osteoporosis?

We do not have a simple answer like that. But rapid weight loss can reduce lean mass, and that can affect bone and fracture risk in some people. Screening and strength training help reduce risk.

Are swimmers really at risk for low bone density?

They can be. Swimming has low impact and low gravity loading. Without strength training and impact work, bone signals may be weaker.

Can men get osteoporosis from blocking estrogen?

Yes. Men need estradiol for bone. If estradiol is driven too low with aromatase inhibitors, bone risk can rise.

Is REMS better than DEXA?

REMS can add a quality score and may reduce some DEXA artifacts, but it is less available and often not covered. If you can do either, do one. If you can do both, that can be helpful.

Medical Disclaimer

This content is for educational purposes only and is not medical advice. It is not intended to diagnose, treat, cure, or prevent any disease. Always consult your licensed healthcare professional before making medical decisions, changing medications, starting supplements, or beginning a new exercise program.

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