Osteoporosis Screening Guidelines
Primary Screening Recommendations
All women aged 65 years and older should undergo routine screening with dual-energy X-ray absorptiometry (DXA) of the hip and lumbar spine, regardless of risk factors. 1, 2, 3
Women Under Age 65
Screen postmenopausal women younger than 65 years if their 10-year fracture risk equals or exceeds 9.3% (the risk of a 65-year-old white woman with no additional risk factors). 1, 3
Use the FRAX tool (Fracture Risk Assessment Tool) to calculate 10-year fracture risk for women aged 50-64 years. 1, 2
Examples of younger women meeting the 9.3% threshold include:
Body weight less than 70 kg is the single best predictor of low bone mineral density and should trigger screening consideration in younger postmenopausal women. 1, 3
Men
The USPSTF found insufficient evidence to recommend routine screening in men, though men most likely to benefit have 10-year fracture risk equal to or greater than that of a 65-year-old white woman without risk factors. 1, 2
The National Osteoporosis Foundation recommends screening all men aged 70 years or older and men with clinical risk factors. 3, 4
For men at increased risk, the American College of Physicians recommends obtaining DXA after individualized risk assessment. 1
Key Risk Factors to Assess
Assess these risk factors to determine who needs screening before standard age cutoffs: 2, 3
- Age >70 years 1
- Previous fragility fracture 2, 3
- Parental history of hip fracture 2, 3
- Low body mass index (<20-25 kg/m²) 1, 2
- Weight loss >10% 1
- Glucocorticoid use 2, 3
- Rheumatoid arthritis 2, 3
- Androgen deprivation therapy 1
- Excessive alcohol consumption 2, 3
- Current smoking 2, 3
- Physical inactivity 1
Screening Method
DXA of the hip and lumbar spine is the gold standard for osteoporosis screening and diagnosis. 2, 3, 5
Quantitative ultrasonography of the calcaneus can predict fractures as effectively as DXA, but current diagnostic and treatment criteria rely exclusively on DXA measurements, so ultrasonography cannot be used to guide treatment decisions. 1, 3
Bone density measured at the femoral neck by DXA is the best predictor of hip fracture. 1
Screening Intervals
A minimum of 2 years is needed between DXA scans to reliably measure a change in bone mineral density due to testing precision limitations. 1, 3
One prospective study of 4,124 women aged 65 years or older found that repeated BMD measurement after 8 years was not more predictive of fracture risk than the original measurement. 1, 3
Women with normal BMD at age 65 may not transition to osteoporosis for almost 17 years, suggesting less frequent screening in this group. 5
Evidence is lacking about optimal intervals for repeated screening, but longer intervals may be adequate for women with normal baseline bone density. 1, 3
When to Stop Screening
Continue screening as long as the patient is a candidate for treatment and has sufficient life expectancy to benefit from fracture prevention. 5
Stop screening when: 5
- Patient has limited life expectancy (generally less than 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 the burden of screening and treatment outweighs potential benefits
Do not arbitrarily stop screening at a specific age without considering individual factors, as fracture risk increases with age and hip fractures carry significant one-year mortality risk even in older adults. 5
Treatment Decisions Based on Screening
Treatment decisions should consider absolute fracture risk rather than BMD alone. 2
Treat women with osteoporosis (T-score ≤ -2.5) or those with a fragility fracture. 3
Women with a 10-year risk of any major fracture ≥20% or hip fracture ≥3% should be treated. 6
Bisphosphonates are first-line treatment for postmenopausal women with osteoporosis, reducing vertebral fractures by 34%. 3
Common Pitfalls to Avoid
Do not repeat DXA scans more frequently than every 2 years in patients with normal BMD, as this provides no clinical benefit and exposes patients to unnecessary radiation. 5
Do not overlook that African-American women have higher average bone mineral density than white women at any given age and are less likely to benefit from screening. 1
Avoid using quantitative ultrasonography results to guide treatment decisions, as treatment criteria are based exclusively on DXA measurements. 1, 3
Do not screen patients who would not be candidates for treatment regardless of results. 5