Osteoporosis Screening in Women Without Risk Factors
All women should begin osteoporosis screening at age 65 years, regardless of the absence of risk factors. This is a Grade B recommendation from the U.S. Preventive Services Task Force and represents the standard of care across all major guideline organizations 1, 2.
Primary Recommendation
- Screen all women at age 65 years with DXA of the hip and lumbar spine, even when no risk factors are present 1, 2, 3.
- This recommendation is based on the fact that the 10-year fracture risk in a 65-year-old white woman without any additional risk factors is 9.3%, which represents the threshold at which screening becomes beneficial 1, 2.
- The femoral neck measurement by DXA is the best predictor of hip fracture risk 2, 3.
Why Age 65 Is the Universal Threshold
- Fracture risk increases substantially with age, making screening cost-effective and clinically beneficial starting at this age 1, 3.
- The USPSTF explicitly recommends screening for all women aged 65 years or older without requiring the presence of risk factors 1.
- Multiple organizations including the National Osteoporosis Foundation, American College of Physicians, and American Congress of Obstetricians and Gynecologists all align on age 65 as the starting point for universal screening 1, 2, 4.
Screening Before Age 65
Women younger than 65 years should only be screened if their 10-year fracture risk equals or exceeds that of a 65-year-old white woman without risk factors (9.3% 10-year fracture risk) 1, 2. Since the question specifies no risk factors are present, screening before age 65 is not indicated 1.
Screening Intervals After Initial Test
- Wait at least 2 years between screening tests to reliably measure changes in bone mineral density due to testing precision limitations 2, 3, 4.
- Women with normal BMD at age 65 may not transition to osteoporosis for almost 17 years, suggesting less frequent screening in those with normal initial results 2, 4.
- Higher-risk patients require more frequent screening (every 2-3 years), while those with normal bone density can be screened less frequently 4, 5.
Common Pitfalls to Avoid
- Do not screen women under age 65 without risk factors, as this represents overuse and can lead to overdiagnosis and inappropriate treatment 6, 7.
- Studies show that 45-86% of women under 65 who undergo DXA screening do not meet appropriate screening criteria 6, 7.
- Do not arbitrarily stop screening at a specific upper age limit; continue as long as the patient is a treatment candidate with sufficient life expectancy to benefit from fracture prevention 2, 4.
- Avoid screening more frequently than every 2 years in patients with normal BMD, as this provides no clinical benefit and causes unnecessary radiation exposure 2, 4.