What is the recommended screening for osteoporosis?

Osteoporosis Screening Recommendations

Primary Recommendation

All women aged 65 years or older should be screened for osteoporosis using dual-energy X-ray absorptiometry (DXA) of the hip and lumbar spine. 1, 2, 3

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Screening by Population

Women

• Women ≥65 years: Universal screening with DXA is recommended (Grade B recommendation) 1, 2, 3

• Women <65 years (postmenopausal): Screen if their 10-year fracture risk equals or exceeds that of a 65-year-old white woman with no additional risk factors (9.3% 10-year fracture risk) 1, 2, 3

  • Use the FRAX tool (available at www.shef.ac.uk/FRAX/) to calculate 10-year fracture risk for women aged 50-64 years 1, 2, 3
  • Body weight <70 kg is the single best predictor of low bone mineral density and should trigger screening consideration 3

Men

• Men ≥70 years: The National Osteoporosis Foundation recommends screening, though evidence is more limited than for women 2, 3

• All men (any age): The USPSTF concludes there is insufficient evidence to assess the balance of benefits and harms of routine screening (Grade I statement) 1

  • However, men most likely to benefit have a 10-year fracture risk equal to or greater than that of a 65-year-old white woman without risk factors 1, 2

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Risk Factors That Should Trigger Screening

The following risk factors warrant screening consideration in younger postmenopausal women and men 2, 3:

• Previous fragility fracture
• Parental history of hip fracture
• Low body mass index or body weight <70 kg
• Current or prolonged glucocorticoid use
• Rheumatoid arthritis
• Secondary causes of osteoporosis (hypogonadism, hyperthyroidism, hyperparathyroidism, malabsorption disorders)
• Excessive alcohol consumption (≥3 drinks/day)
• Current cigarette smoking

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Screening Method

DXA of the hip and lumbar spine is the gold standard for osteoporosis screening and diagnosis. 1, 2, 4, 3, 5

• DXA has 90-95% sensitivity for detecting osteoporosis 4
• Quantitative ultrasonography of the calcaneus can predict fractures but current diagnostic and treatment criteria rely exclusively on DXA measurements 1, 3
• The proximal femur (hip) and lumbar spine are the recommended diagnostic sites 4

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Screening Intervals

• Evidence is lacking about optimal intervals for repeated screening 1, 3

• Practical approach:

  • If initial DXA does not warrant treatment, repeat testing every 2-5 years depending on proximity to treatment thresholds 4
  • A minimum of 2 years is needed to reliably measure a change in bone mineral density due to testing precision limitations 3
  • Patients on bone loss-inducing medications or with baseline BMD near treatment threshold should have DXA every 2 years or more frequently if medically necessary 4

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Interpretation of Results

• Osteoporosis diagnosis: T-score ≤ -2.5 (bone mass ≥2.5 standard deviations below that of young adults) 5, 6
• Osteopenia: T-score between -1.0 and -2.5 1
• Normal: T-score ≥ -1.0 1

Treatment decisions should consider absolute fracture risk rather than BMD alone using tools like FRAX 2, 5

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Common Pitfalls to Avoid

• Don't rely solely on clinical risk assessment instruments without BMD testing, as they have only modest predictive value for low bone density or fractures 1

• Don't forget to assess for secondary causes of osteoporosis (present in 32-85% of previously undiagnosed cases), including vitamin D deficiency, hypogonadism in men, and estrogen deficiency in premenopausal women 4

• Don't screen too frequently: Repeated BMD measurement after 8 years was not more predictive of fracture risk than the original measurement in one study 3

• Recognize that screening harms are small (primarily false-positive results, patient anxiety, and opportunity costs), making the benefit-to-harm ratio favorable in recommended populations 1, 3