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In a cross-sectional retrospective study, we examined the prevalence of significant opposite hip bone mineral density difference among white and black women. Left–right hip bone mineral density difference was a common finding in both races, raising the possibility that osteoporosis can be missed if only one hip is imaged. We examined the prevalence of significant left–right hip bone mineral density (BMD) difference among black and white female subjects and its implications on the diagnosis of osteoporosis. This was a retrospective review of dual energy X-ray absorptiometry (DXA) data in black and white subjects age 50 years and older. One thousand four hundred seventy-seven scans obtained using a GE Lunar Prodigy scanner in dual hip mode were analyzed (24% black, 76% white). Significant left–right hip BMD difference was considered present when the subregion least significant change (LSC) was exceeded. Its prevalence was determined, along with consequences on the diagnosis of osteoporosis. Significant differences in BMD were common in both races; the LSC was exceeded in 47% of the patients at the total hip, 37% at the femoral neck, and 53% at the trochanter. Diagnostic agreement was lower when the LSC was exceeded than when it was not. The LSC was exceeded in a statistically significant number of black and white patients with normal or osteopenic spines and unilateral hip osteoporosis. Significant left–right hip BMD difference is a common finding among black and white women and can result in osteoporosis being missed if only one hip is imaged. [ABSTRACT FROM AUTHOR]