Objective <p>To investigate the relationship between computed tomography (CT)-assessed visceral adiposity and impaired bone quality, reflected by a low trabecular bone score, in postmenopausal women with osteopenia.</p> Materials and methods <p>This retrospective study included postmenopausal women with osteopenia who underwent dual-energy X-ray absorptiometry and abdominopelvic CT on the same day between May 2022 and September 2024. Visceral fat area was measured on CT images obtained at the L3 vertebral level. Trabecular bone score was assessed on lumbar spine dual-energy X-ray absorptiometry at the L1 − L4 levels, with a low trabecular bone score defined as &lt; 1.350. Logistic regression analysis was employed to evaluate the association between visceral fat area and low trabecular bone score.</p> Results <p>Among the 205 women included (median age, 60&#xa0;years; interquartile range, 56–66&#xa0;years), 65 (31.7%) had a low trabecular bone score. A 10-cm² increase in visceral fat area was associated with an increased likelihood of having a low trabecular bone score (odds ratio, 1.08; 95% confidence interval, 1.02–1.15). This association remained significant after adjusting for age, spine bone mineral density, and skeletal muscle area (odds ratio, 1.09; 95% confidence interval, 1.02–1.18).</p> Conclusion <p>Visceral adiposity was associated with impaired bone quality in postmenopausal women with osteopenia, independent of age, bone mineral density, and skeletal muscle area. These findings suggest that visceral adiposity measured by opportunistic CT may serve as a potential biomarker for identifying postmenopausal women with osteopenia who are at an increased risk of fracture.</p>