When is an osteoporosis workup recommended?

When to Perform Osteoporosis Workup

All women aged 65 years or older should undergo osteoporosis screening with DXA of the hip and lumbar spine, regardless of risk factors. 1, 2, 3

Screening Recommendations by Population

Women

• Age ≥65 years: Universal screening recommended (Grade B) 1
• Age <65 years (postmenopausal): Screen if 10-year fracture risk equals or exceeds that of a 65-year-old white woman without additional risk factors (approximately 9.3% 10-year fracture risk) 1, 2
• Age 60-64 years with risk factors: Screening recommended 1

Men

• Age ≥70 years: The National Osteoporosis Foundation recommends screening, though USPSTF found insufficient evidence for routine screening (Grade I statement) 1
• Age 50-69 years: Screen only if clinical risk factors present 1, 4
• Any age: Consider screening in men at increased risk who are candidates for drug therapy 1

Key Risk Factors Triggering Earlier Screening

Screen postmenopausal women <65 years or men 50-69 years if they have:

• Low body weight (<127 lb or <70 kg) 1, 2
• History of fragility fracture (low-trauma fracture) 1, 5
• Parental history of hip fracture 1
• Current smoking 1, 6
• Glucocorticoid use (≥6 months, such as prednisone) 1, 6
• Medications or diseases causing bone loss (inflammatory bowel disease, rheumatoid arthritis, chronic liver/kidney disease) 1, 6
• Excess alcohol consumption 6, 7

Screening Method

DXA of the hip and lumbar spine is the gold standard for osteoporosis screening. 1, 2

• Bone density measured at the femoral neck by DXA is the best predictor of hip fracture 2
• Alternative methods (quantitative ultrasound, quantitative CT) are less validated 4

Risk Assessment Tools

• Use FRAX (Fracture Risk Assessment Tool) to estimate 10-year fracture risk in patients with borderline indications for screening 1, 2
• FRAX can be used with or without BMD results to guide treatment decisions 2, 4
• The 10-year fracture risk threshold for a 65-year-old white woman without risk factors is 9.3% 1, 2

Screening Intervals

• Minimum 2-year interval needed to reliably measure BMD changes due to testing precision limitations 2, 3
• Women with normal BMD at age 65 may not transition to osteoporosis for almost 17 years, suggesting less frequent screening 3
• Patients with osteopenia may need screening every 4-8 years unless baseline T-score is below -2.0 3
• Higher-risk patients (older age, lower baseline BMD, multiple risk factors) benefit from more frequent screening 2

Diagnostic Criteria for Osteoporosis

Osteoporosis can be diagnosed by any of the following:

• T-score ≤-2.5 at spine, femoral neck, or total hip 1, 6, 5
• Hip fracture (with or without BMD testing) 5
• Vertebral, proximal humerus, pelvis, or distal forearm fracture in the setting of osteopenia 5
• FRAX score indicating ≥3% 10-year hip fracture risk or ≥20% major osteoporotic fracture risk 1, 5

Common Pitfalls to Avoid

• Do not wait for symptoms: Osteoporosis is subclinical until complicated by fracture 7
• Do not overlook race/ethnicity: While most common in white women, osteoporosis affects all racial groups 1, 2
• Do not screen more frequently than every 2 years in patients with normal BMD—this provides no clinical benefit and causes unnecessary radiation exposure 3
• Do not arbitrarily stop screening at a specific age: Continue screening as long as the patient is a treatment candidate with sufficient life expectancy to benefit from fracture prevention 3
• Do not dismiss fractures as "accidents": Any fracture in adults ≥50 years signals imminent elevated risk for subsequent fractures, particularly within the first year 7

When to Stop Screening

Discontinue screening when: 3

• Patient has limited life expectancy (<5-10 years) where fracture prevention would not meaningfully impact quality of life
• Patient would not be a candidate for osteoporosis treatment due to contraindications, severe comorbidities, or patient preference
• Patient has severe functional limitations where screening/treatment burden outweighs potential benefits

Clinical Context

Hip fractures carry devastating consequences: More than one-third of men who experience hip fractures die within one year, and 25% of postmenopausal women with osteoporotic fractures develop vertebral deformities. 1, 3 This high morbidity and mortality justifies aggressive screening in appropriate populations, as effective treatments (bisphosphonates, denosumab) reduce vertebral fractures by 52 per 1000 person-years and hip fractures by 6 per 1000 person-years. 6