An orthopedic surgeon told me this story recently, and it is the best illustration I have found for why I am bringing REMS bone assessment to Wellness Architecture this September.
His wife was diagnosed with severe osteoporosis based on her DEXA scan. She is petite, about five feet tall, around 105 pounds. By her T-score, she was at serious fracture risk. Last winter she went ice skating. She fell. More than once. She broke nothing.
Her husband was not shocked. He had run a REMS scan on her. Her Fragility Score was low, which on the REMS scale means her bones were genuinely strong and her actual fracture risk was low. What the DEXA was reading as severe osteoporosis was, to a significant degree, a reflection of her small body size. DEXA is a two-dimensional measurement that is heavily influenced by how much you weigh and how tall you are. A small thin woman will almost always look worse on paper than her bones actually are.
She was not fragile. She was small. Those are not the same thing, and DEXA cannot always tell the difference.
Why DEXA Has Limits Most Women Are Never Told About
DEXA has been the standard for osteoporosis diagnosis since the 1990s. It measures bone mineral density and produces a T-score comparing you to a healthy young adult reference population. That number then determines whether you are told you are normal, osteopenic, or osteoporotic.
The problem is that bone density is not the same thing as bone strength. And the 2025 International Osteoporosis Foundation Position Paper said it plainly: many individuals who fracture have normal or only modestly reduced bone mineral density. The field is now moving toward assessing absolute fracture risk using multiple clinical factors rather than relying on density alone.
DEXA also cannot distinguish between the two types of bone tissue. Cortical bone is the hard outer shell. Trabecular bone is the inner spongy network where most fractures actually originate. DEXA does not differentiate between them. It gives you a single density number from a two-dimensional image of a three-dimensional structure, and that number is affected by body size, positioning, the technician's experience, and degenerative changes in the spine that can skew results in either direction.
For small thin women, the skew is almost always toward over-diagnosis. Smaller bones produce a lower density reading even when bone quality is excellent. Many women in this group have been placed on osteoporosis medications with real side effects based on a number that did not accurately reflect their fracture risk.
What REMS Sees That DEXA Cannot
REMS uses ultrasound rather than X-rays. It sends sound waves through bone, analyzes the returning signal, and builds a picture of both bone density and bone quality. It examines the same sites as DEXA and produces a T-score, but it also produces something DEXA never can: the Fragility Score.
The Fragility Score runs from 0 to 100. Lower is better. It is calculated by comparing your bone's acoustic profile to reference models built from both fractured and non-fractured patients, and it reflects the internal architecture of your bone, how well it is structured to absorb and distribute force. This is what actually determines whether you fracture when you fall. And it is completely independent of your body size.
That is why the surgeon's wife scored low on the Fragility Score despite a severe DEXA T-score. Her bones were well-structured. Her density reading was skewed by the fact that she weighs 105 pounds. REMS could see past the size. DEXA could not.
What This Means If You Have Been Frightened by a DEXA Result
If you are small, thin, or petite, and you have received an alarming DEXA result, it is worth asking whether that result reflects your actual bone quality or your body size. Those are different questions with different answers and different implications for treatment.
It also means that if you have been told you need osteoporosis medication based on a DEXA scan alone, a REMS assessment could give you and your doctor a more complete picture before making that decision. Osteoporosis medications are not without risk. Getting the diagnosis right matters.
And if you are someone who has fractured despite a normal or near-normal DEXA result, REMS may explain why. Bone quality can be poor even when density looks acceptable, and a low Fragility Score in that direction is clinically meaningful in its own right.
REMS Is Coming to Wellness Architecture This September
I have wanted to bring this technology into my practice for a long time. Too many of my patients have come in frightened by DEXA results that did not match their clinical picture. Too many have been told they need medication when their fracture risk, looked at properly, did not warrant it. And too many have been sent home reassured when the full picture deserved more attention.
REMS bone assessments are coming to Wellness Architecture this September. Dates and availability will be announced in August. Spaces will be limited and will go to the Early Access List first.
If you want to talk through whether this is the right next step for you, schedule a Discovery Call.
For the full clinical breakdown of how DEXA and REMS compare, what the Fragility Score measures, and who benefits most from each test, read the full article here: Why Your DEXA Scan May Be Misleading You About Your Bone Health.
Frequently Asked Questions
Is a DEXA scan still worth doing?
For most women, yes. DEXA remains the clinical standard and is what most physicians and insurance systems recognize. The point is not that DEXA is useless but that it is incomplete, particularly for small thin women and for anyone whose clinical picture does not match their T-score. REMS adds the bone quality piece that DEXA cannot provide.
What does a low Fragility Score mean?
A low Fragility Score, specifically in the 0 to 20 range, means your bone quality is good and your fracture risk is low, regardless of what your T-score shows. It is the number that told the orthopedic surgeon his wife's bones were strong despite a severe osteoporosis diagnosis on DEXA.
Do I need a referral for REMS at Wellness Architecture?
No referral needed. Join the Early Access List now to secure your spot when September appointments open.
How does hormone health connect to bone health?
Directly. Estrogen protects bone density, which is why bone loss accelerates at menopause. But blood sugar, vitamin D, omega-3 levels, thyroid function, and inflammatory burden all play a significant role too. A REMS result is one piece of a complete picture. I look at all of it together.
Related reading:
- What a Complete Lab Panel Reveals That 30 Years of Doctor Visits Missed
- Why Hormone Replacement Alone Is Not Enough
- My Labs Are Normal But I Feel Terrible: What Functional Lab Testing Reveals That Standard Tests Miss
For the source on fracture risk and the evolving role of bone mineral density, see the 2025 International Osteoporosis Foundation Position Paper published in Osteoporosis International.