DEXA Scanning and Osteoporosis Management in Women
DEXA scans should be performed in all women aged 65 years and older, and in younger postmenopausal women with risk factors for osteoporosis, with bisphosphonates as first-line treatment for those diagnosed with osteoporosis. 1
DEXA Scan Indications for Women
Who Should Get DEXA Scans
- All women aged 65 years and older 1
- Postmenopausal women younger than 65 years with risk factors 1, 2:
- History of fragility fracture
- Weight less than 127 lb (58 kg)
- Medications or diseases causing bone loss
- Parental history of hip fracture
- Current smoking
- Excessive alcohol consumption (≥3 drinks daily)
- Rheumatoid arthritis
When to Perform Follow-up DEXA Scans
- The American College of Physicians recommends against bone density monitoring during the 5-year pharmacologic treatment period for osteoporosis in women 1
- For monitoring purposes, standard interval is typically 2 years, with shorter intervals (1 year) for patients:
- Initiating osteoporosis therapy
- At high risk for rapid bone loss
- After cessation of pharmacologic therapy 2
Diagnostic Criteria for Osteoporosis
World Health Organization (WHO) definitions:
T-score Diagnosis > -1.0 Normal -1.0 to -2.4 Osteopenia ≤ -2.5 Osteoporosis A previous fragility fracture, regardless of bone mineral density, is also diagnostic for osteoporosis 2
Treatment Recommendations
When to Initiate Treatment
- Women with T-score ≤ -2.5 (osteoporosis) 1
- Women with history of fragility fracture regardless of T-score 1
- Women with T-scores between -1.0 and -2.5 (osteopenia) and:
- 10-year risk of major osteoporotic fracture ≥20% based on FRAX
- 10-year risk of hip fracture ≥3% based on FRAX 1
First-Line Pharmacologic Therapy
- Bisphosphonates are the first-line therapy, with selection based on patient preference 1
- Options include alendronate, risedronate, ibandronate, and zoledronic acid
Alternative Treatments
- Denosumab is recommended for women with high fracture risk 1
- Teriparatide is typically reserved for women with severe osteoporosis or previous fractures 1
- The American College of Physicians recommends against using menopausal estrogen therapy, estrogen plus progestogen therapy, or raloxifene for osteoporosis treatment 1
Calcium and Vitamin D Recommendations
Daily calcium intake recommendations:
- Ages 19-50 years: 1,000 mg
- Ages 51-70 years: 1,200 mg
- Ages 71+ years: 1,200 mg 1
Daily vitamin D intake recommendations:
- Ages 19-70 years: 600 IU
- Ages 71+ years: 800 IU 1
A serum vitamin D level of 20 ng/mL (50 nmol/L) is recommended for good bone health 1
Lifestyle Modifications
- Weight-bearing exercise
- Smoking cessation
- Reducing alcohol intake
- Adequate calcium and vitamin D intake 1
Common Pitfalls and Caveats
- Underuse of DEXA in high-risk populations: Research shows that only 58.8% of women aged 60-64 years with risk factors and 57.8% of women aged 65-74 years receive appropriate DEXA screening 3
- Overuse of DEXA in low-risk populations: Studies indicate that 45.5% of women aged 50-59 years without risk factors receive unnecessary DEXA scans 3
- Poor post-fracture care: Only 19% of people over 65 years undergo BMD testing after a fracture 4
- Monitoring during treatment: Avoid unnecessary repeat DEXA scans during the 5-year treatment period as recommended by the American College of Physicians 1
By following these evidence-based guidelines for DEXA scanning and osteoporosis management, clinicians can effectively identify and treat women at risk for osteoporotic fractures, thereby reducing morbidity and mortality associated with this condition.