How often should a postmenopausal woman or an older adult with a history of fractures or on long-term steroid therapy undergo a bone density exam?

Bone Density Exam Frequency

For postmenopausal women and older adults, bone density testing frequency depends on baseline bone density and risk factors: screen every 15 years for normal bone density, every 5 years for moderate osteopenia, annually for advanced osteopenia, and every 2-3 years for those on long-term steroids or with history of fractures.

Initial Screening Recommendations

• All postmenopausal women aged ≥65 years should undergo routine DXA screening regardless of risk factors 1
• Postmenopausal women aged 60-64 years with risk factors (low body weight <70 kg, previous fragility fracture, long-term glucocorticoid therapy, family history, or medical conditions causing bone loss) should be screened 1
• Men aged ≥70 years should undergo screening 2
• Younger postmenopausal women (<60 years) without risk factors do not need routine screening 1

Rescreening Intervals Based on Baseline Bone Density

The frequency of repeat testing is determined by your initial T-score, as bone loss progresses at different rates:

For Women with Normal Bone Density (T-score ≥-1.0)

• Repeat DXA every 15-17 years 3
• This extended interval is justified because less than 10% of women with normal bone density will develop osteoporosis within 15 years 3

For Women with Mild Osteopenia (T-score -1.01 to approximately -1.5)

• Repeat DXA every 15-17 years 3
• Similar to normal bone density, progression to osteoporosis is slow in this group 3

For Women with Moderate Osteopenia (T-score approximately -1.5 to -2.0)

• Repeat DXA every 5 years 3
• This group has accelerated bone loss requiring more frequent monitoring 3

For Women with Advanced Osteopenia (T-score -2.0 to -2.49)

• Repeat DXA annually 3
• These patients are at imminent risk of transitioning to osteoporosis and require close surveillance 3

Special Populations Requiring More Frequent Testing

Patients on Long-Term Glucocorticoid Therapy

For adults ≥40 years on chronic steroids:

• Obtain baseline BMD within 6 months of starting glucocorticoid treatment 4
• If never treated with osteoporosis medication: Repeat DXA every 1-3 years, with earlier testing (annually) if receiving very high-dose glucocorticoids (prednisone ≥30 mg/day) or have history of osteoporotic fracture 4
• If currently on osteoporosis treatment: Repeat DXA every 2-3 years during treatment, particularly for high-risk patients 4
• If completed osteoporosis treatment: Repeat DXA every 2-3 years 4

For adults <40 years on chronic steroids:

• Obtain baseline BMD within 6 months if history of previous osteoporotic fracture or other significant risk factors 4
• If Z-score <-3 at hip or spine, >10% annual BMD loss, or on very high-dose glucocorticoids: Repeat DXA every 1-3 years whether treated or untreated 4

Patients with History of Fractures

• Patients with previous fragility fractures require more intensive monitoring 5
• Repeat DXA every 1-2 years if on treatment to monitor effectiveness 1
• If not on treatment but have fracture history, follow the glucocorticoid guideline intervals (every 1-3 years) 4

Clinical Factors That Shorten Rescreening Intervals

Beyond baseline bone density, several clinical situations mandate more frequent testing:

• New glucocorticoid therapy or other bone-depleting medications 5
• Incident fragility fracture 5
• Development of secondary causes of bone loss (hyperparathyroidism, hypogonadism, chronic inflammatory diseases) 5
• Significant weight loss, particularly if weight drops below 70 kg 5
• Poor medication adherence or absorption concerns 4
• Osteoporotic fracture occurring after ≥18 months of antifracture medication treatment 4

Technical Considerations

• A minimum 2-year interval between scans is required to reliably detect true bone density changes due to precision limitations of DXA technology 5, 1
• Scanning more frequently than every 2 years may lead to false conclusions about bone loss or gain 5
• The yield of repeated screening is higher in older women, those with lower baseline BMD, and those with additional fracture risk factors 5, 1

Common Pitfalls to Avoid

• Do not order DXA more frequently than every 2 years unless there are exceptional circumstances, as the test precision cannot reliably detect changes in shorter intervals 5, 1
• Do not use the same rescreening interval for all patients—tailor the frequency to baseline T-score and risk factors 3
• Do not forget annual clinical fracture risk reassessment (history, physical exam, falls evaluation) even when not performing DXA 4
• Do not neglect screening in men ≥70 years or those on chronic glucocorticoids, as osteoporosis is underdiagnosed and undertreated in men 6, 2