FRAX Score in Menopause: What It Measures and What Your Number Means

FRAX, short for the Fracture Risk Assessment Tool, is a free calculator developed by Kanis and colleagues at the University of Sheffield, a World Health Organization Collaborating Centre for Metabolic Bone Diseases. Rather than telling you what your bone density is right now, FRAX estimates your 10-year probability of experiencing a major osteoporotic fracture (hip, spine, wrist, or shoulder) and, separately, your 10-year probability of a hip fracture specifically. This distinction matters enormously at menopause, because the years right around your final period are when bone loss accelerates fastest — research from the SWAN study and earlier work has found postmenopausal women can lose roughly 1 to 2% of bone density per year for several years after menopause, with total losses of up to 20% in the first five to seven years for some women. FRAX was designed specifically to help translate 'my bone density is a bit low' into a more actionable, forward-looking risk estimate that accounts for the fact that two women with identical bone density can have very different real-world fracture risk depending on their age, weight, and other factors.

A [DEXA scan](/blog/dexa-scan-in-menopause-when-to-get-one-t-scores-explained) measures your current bone mineral density and produces a T-score, telling you how your bones compare to a healthy young adult at a single point in time. FRAX takes a different, complementary approach: it can incorporate your femoral neck bone density from a DEXA scan as one input, but it can also generate a risk estimate without a DEXA scan at all, using only clinical risk factors. This makes FRAX particularly useful in two situations — when a DEXA scan isn't readily available, and, more commonly, when a DEXA result comes back as osteopenia (a T-score between -1.0 and -2.5), a large gray zone where bone density alone doesn't clearly indicate whether treatment is warranted. Rather than choosing between the two tools, most clinicians use them together: DEXA establishes where your bone density sits today, and FRAX translates that (plus your other risk factors) into a forward-looking probability that's easier to act on.

The FRAX questionnaire takes just a few minutes and asks about: age, sex, weight and height (to calculate BMI), whether you've had a previous fracture as an adult, whether either parent had a hip fracture, current smoking status, current or past use of oral glucocorticoids (steroid medications) for more than three months, a diagnosis of rheumatoid arthritis, any cause of secondary osteoporosis (such as early menopause, type 1 diabetes, or certain other conditions), and daily alcohol intake of three or more units. If you have a recent femoral neck bone density result, you can add it for a more precise estimate, though the tool still produces a usable result without it. Each of these factors has been shown in large population studies to independently affect fracture risk beyond what bone density alone predicts, which is why FRAX has become standard in osteoporosis guidelines worldwide rather than a niche add-on tool.

In the United States, the Bone Health and Osteoporosis Foundation's clinical guidance generally recommends considering pharmacologic treatment when your FRAX-calculated 10-year hip fracture risk reaches 3% or higher, or your 10-year major osteoporotic fracture risk reaches 20% or higher — even if your DEXA T-score alone (in the osteopenia range) wouldn't have triggered a treatment conversation on its own. This threshold approach is specifically designed to catch women whose combination of moderate bone density and several risk factors adds up to meaningful fracture risk, rather than waiting until bone density alone crosses into the osteoporosis range. It's worth emphasizing that these are general guideline thresholds, not universal rules — your own doctor may factor in additional context, including findings from your [ApoB and lipoprotein(a) testing](/blog/apob-and-lipoprotein-a-in-menopause-tests-to-ask-for) or other cardiovascular risk markers, since bone and cardiovascular health share several common risk factors at menopause.

FRAX is a genuinely useful tool, but it isn't complete. It doesn't ask about falls history, even though falling is one of the strongest predictors of fracture, particularly hip fracture, independent of bone density. It treats glucocorticoid use as present or absent rather than accounting for dose, even though higher steroid doses carry meaningfully higher fracture risk than lower ones. It also doesn't capture recent fracture as a specific, time-sensitive risk factor — a fracture in the past two years carries a notably higher near-term ('imminent') risk of another one than the same fracture history from a decade ago, a distinction FRAX's 10-year model wasn't built to capture. And FRAX was validated primarily in specific population datasets, so its accuracy can vary somewhat across different racial, ethnic, and geographic groups, though country-specific versions have been developed to address some of this. None of these limitations make FRAX not worth using — they just mean it's a strong starting estimate rather than the final word, especially for women who've fallen recently or fractured within the past couple of years.

Bring your FRAX result to your doctor alongside your DEXA scan (if you've had one) rather than interpreting it alone — the two together give a much fuller picture than either does by itself. If your risk falls below treatment thresholds, that's still useful information: it supports continuing with lifestyle measures like [resistance training](/blog/resistance-training-for-menopause-the-bone-density-protocol) and adequate calcium and vitamin D intake, and rechecking in a few years rather than starting medication now. If your risk crosses into treatment-threshold territory, your doctor can walk you through options ranging from bisphosphonates to newer bone-building medications, weighed against your personal preferences and other health conditions. It's also worth mentioning any recent falls or fractures explicitly, even though FRAX's questionnaire doesn't specifically prompt for them, since that context can meaningfully change how your doctor interprets an otherwise moderate-looking score — and it's worth pairing this bone conversation with a broader look at cardiovascular risk, since a [coronary calcium score](/blog/coronary-calcium-score-in-menopause-should-you-get-one) is often a reasonable companion test to discuss at the same appointment.

Between DEXA scans, T-scores, and FRAX percentages, it's easy to come away from a bone health appointment with more numbers than clarity. If you want help understanding what your specific results mean or what questions to bring to your next appointment, that's a good place to start.