Although adrenal incidentalomas (AI) are not associated with clinically evident syndromes, some patients display biochemical features of subclinical hypercortisolism (SH). Previous studies indicated a negative effect of SH on bone in AI patients, but the prevalence of vertebral fractures and the roles of SH and gonadal status in volumetric bone mineral density are unknown. In 70 female AI patients and 84 controls, the prevalence of vertebral fractures and spinal bone mineral density (by quantitative computed tomography) were evaluated. Subjects were subdivided according to menopausal status into groups Pre (21 patients and 23 controls) and Post (49 patients and 61 controls); there were 14 and 35 patients without SH (SH⁻) and 7 and 14 patients with SH (SH⁺) in groups Pre and Post, respectively. The prevalence of fractures was higher in SH⁺ than in controls and in SH⁻ subjects in both groups Pre [SH⁺, 42.9%; controls, 0% (P = 0.001); SH⁻, 7.1% (P = 0.049)] and post [SH⁺, 78.6%; controls, 37.7% (P = 0.006); SH⁻ 42.9% (P = 0.024)]. In group Post, the mean z-score quantitative computed tomography values were lower in SH⁺ patients (−0.78 ± 0.29) than in controls (0.06 ± 0.14; P = 0.011) and SH⁻ patients (0.02 ± 0.19; P = 0.034). Evaluation of spinal bone is indicated in female AI patients with SH.