When to Screen for Bone Density: Age Guidelines and Risk Factors
Bone density screening should begin at age 65 for all women and age 70 for all men, with earlier screening for those with significant risk factors. 1 This recommendation is supported by multiple medical societies and represents the consensus approach to identifying individuals at risk for osteoporosis and related fractures.
Age-Based Screening Recommendations
Women:
- Age 65 and older: Universal screening recommended 2, 1
- Ages 60-64: Screening recommended if increased risk factors present 2, 1
- Ages 50-59: No routine screening unless significant risk factors exist 1
- Postmenopausal women under 60: No routine screening unless specific risk factors present 2
Men:
- Age 70 and older: Universal screening recommended 2, 1
- Ages 50-69: Screening only if significant risk factors present 1
Risk Factors That Warrant Earlier Screening
Individuals with these risk factors should be considered for earlier screening:
- Body weight factors: Low body weight (<70 kg) is the single best predictor of low bone mineral density 2
- Fracture history: Prior fragility fracture 1
- Family history: Parental history of hip fracture 2, 1
- Medication use: Long-term glucocorticoid therapy, proton pump inhibitors, anticoagulants, certain antidepressants 2, 1
- Lifestyle factors: Current smoking, excessive alcohol consumption, inadequate exercise 2, 1
- Medical conditions: Chronic inflammatory conditions, malabsorption, untreated premature menopause or hypogonadism 1
- Cancer treatments: Chemotherapy-induced menopause, hormone therapies that suppress gonadal function 2
Bone Loss Patterns and Age-Related Changes
Understanding the natural history of bone loss helps explain why screening recommendations are age-dependent:
- Bone density decreases by approximately 2% each year during the first 5 years after menopause, followed by an annual loss of about 1% thereafter 2
- By age 80, up to 70% of women have osteoporosis based on commonly used criteria 2
- Both menopause and aging contribute to bone loss, with a 70-year-old woman losing approximately 11% of bone due to menopause and 18% due to aging 3
- Recent research shows that years since final menstrual period is more strongly associated with postmenopausal bone mineral density than chronological age 4
Screening Methods and Follow-up
- DEXA (Dual-Energy X-ray Absorptiometry) is the gold standard for diagnosing osteoporosis 2, 1
- Standard screening should include posteroanterior spine, total hip, and femoral neck scans 1
- The WHO defines osteoporosis as a T-score ≤-2.5, osteopenia as T-score between -1.0 and -2.5, and normal as T-score ≥-1.0 2
- Follow-up DEXA scans should be performed every 2 years for standard risk individuals and every 1-2 years for high-risk individuals 1
Risk Assessment Tools
- The FRAX tool can help determine the need for screening in individuals younger than the standard screening age 1
- The Osteoporosis Risk Assessment Instrument (ORAI) incorporates age, weight, and estrogen use to assess risk 2, 1
Common Pitfalls to Avoid
- Overlooking risk factors: Don't wait until age 65 to screen women with significant risk factors
- Ignoring men: Men also develop osteoporosis, particularly after age 70
- Scanner inconsistency: Follow-up scans should be performed on the same equipment for accurate comparison 1
- False elevations: Osteoarthritis or calcification of the aorta may lead to falsely high BMD readings 2
- Focusing only on T-scores: Z-scores should be used for children, adolescents, and premenopausal women 1
Early detection and treatment of osteoporosis significantly reduces fracture risk, which is crucial as osteoporotic fractures are associated with chronic pain, disability, decreased quality of life, and increased mortality 1.