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Clinical application
Fracture risk in endocrine disorders
Osteoporosis isn't only a post-menopausal condition — it also affects men and people with long-term endocrine disorders, who are often underdiagnosed. TBS® captures bone-quality changes that BMD can miss.
An under-recognised risk
While osteoporosis is commonly associated with post-menopausal women, it also significantly affects men and individuals with long-term endocrine disorders. These populations are frequently underdiagnosed, yet they face a heightened risk of osteoporotic fractures due to changes in bone quality that standard BMD may not capture.
Endocrine disorders are highly heterogeneous, spanning vastly different underlying causes, genetic profiles, and clinical presentations across individual patients. As a result, their effect on bone health and the appropriate approach to assessing and managing osteoporosis risk varies considerably by condition. Clinicians should look to research specific to the disorder at hand rather than relying on general patterns alone.
Trabecular Bone Score® is emerging as a valuable tool for assessing bone microarchitecture and fracture risk in endocrine-related conditions, whether the condition is caused by hormone production or response.
Three sample studies illustrate TBS®'s potential:
Cushing's disease & bone recovery
Patients with Cushing's disease showed improved TBS® following normalisation of hypercortisolism, suggesting TBS® is sensitive to changes in bone quality during disease management.
Balomenaki, M., Vassiliadi, D.A. and Stylianos Tsagarakis (2022). Cushing’s disease: risk of recurrence following trans-sphenoidal surgery, timing and methods for evaluation. Pituitary, 25(5), pp.718–721. doi:10.1007/s11102-022-01226-y.
Insulin resistance & bone quality
Insulin resistance was shown to impair bone quality — not quantity — underscoring the importance of evaluating microarchitecture in metabolic conditions.
de Araújo, I.M., Parreiras-E-Silva, L.T., Carvalho, A.L., Elias, J., Salmon, C.E.G. and de Paula, F.J.A. (2020). Insulin resistance negatively affects bone quality not quantity: the relationship between bone and adipose tissue. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, [online] 31(6), pp.1125–1133. doi:10.1007/s00198-020-05365-5.
Primary hyperparathyroidism & fracture risk
Women with primary hyperparathyroidism (PHPT) showed significantly degraded bone microarchitecture, making TBS® a powerful predictor of fracture probability in this group.
Santos, L.M. dos, Ohe, M.N., Pallone, S.G., Nacaguma, I.O., Kunii, I.S., da Silva, R.E.C., Vieira, J.G.H. and Lazaretti-Castro, M. (2021). Trabecular Bone Score (TBS) in Primary Hyperparathyroidism (PHPT): A Useful Tool? Journal of Clinical Densitometry, [online] 24(4), pp.563–570. doi:10.1016/j.jocd.2021.04.001.
Summary
These three studies are a small sample of a larger body of evidence, chosen to illustrate a pattern, not to summarize it. They underscore the value of incorporating TBS® into the fracture-risk toolkit, especially for patients with endocrine disorders, where bone health can be compromised in less obvious ways.
Given how much endocrine disorders vary from one another, the right takeaway isn't a single rule but a habit: When managing a patient with any long-term endocrine disorder, consider whether bone quality deserves a closer look, and let the specific condition guide what "closer look" should mean.
TBS in secondary osteoporsis
Cancer
Diabetes
HIV
Endocrine disorders
Chronic kidney disease, coming soon
Glucocorticoid-induced, coming soon
This content is for educational purposes for healthcare professionals and does not constitute medical advice or clinical guidance. It is not a substitute for the independent judgement of a qualified physician or specialist. Diagnostic and treatment decisions must be individualised to each patient, based on their complete clinical picture, locally applicable guidelines, and the most current evidence, which are determinations only a licensed healthcare provider is positioned to make.
References (3)
1. Balomenaki, M., Vassiliadi, D.A. and Stylianos Tsagarakis (2022). Cushing’s disease: risk of recurrence following trans-sphenoidal surgery, timing and methods for evaluation. Pituitary, 25(5), pp.718–721. doi:10.1007/s11102-022-01226-y.
2. de Araújo, I.M., Parreiras-E-Silva, L.T., Carvalho, A.L., Elias, J., Salmon, C.E.G. and de Paula, F.J.A. (2020). Insulin resistance negatively affects bone quality not quantity: the relationship between bone and adipose tissue. Osteoporosis international : a journal established as result of cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA, [online] 31(6), pp.1125–1133. doi:10.1007/s00198-020-05365-5.
3. Santos, L.M. dos, Ohe, M.N., Pallone, S.G., Nacaguma, I.O., Kunii, I.S., da Silva, R.E.C., Vieira, J.G.H. and Lazaretti-Castro, M. (2021). Trabecular Bone Score (TBS) in Primary Hyperparathyroidism (PHPT): A Useful Tool? Journal of Clinical Densitometry, [online] 24(4), pp.563–570. doi:10.1016/j.jocd.2021.04.001.