At what age should a postmenopausal woman or an individual with a history of fractures and other risk factors for osteoporosis start Dual-Energy X-ray Absorptiometry (DEXA) screening?

When to Start DEXA Screening

All women should begin DEXA screening at age 65 years regardless of risk factors, and postmenopausal women younger than 65 years should be screened if their 10-year fracture risk equals or exceeds that of a 65-year-old white woman without additional risk factors (9.3% using FRAX). 1, 2

Standard Screening Ages

Women

• Age 65 and older: Universal screening recommended with DXA of the hip and lumbar spine, regardless of risk factors 1, 2, 3
• Postmenopausal women younger than 65: Screen only if fracture risk assessment indicates risk equivalent to or greater than a 65-year-old white woman (9.3% 10-year fracture risk) 1

Men

• Age 70 and older: Routine screening recommended by specialty societies 2, 4
• Younger than 70: The USPSTF found insufficient evidence to recommend routine screening, though men with risk factors should be considered 1

Risk Assessment for Earlier Screening

Use a two-step approach for postmenopausal women younger than 65: First identify clinical risk factors, then use FRAX or similar validated tools to calculate 10-year fracture risk 1

Key Risk Factors Warranting Earlier Screening:

• Low body weight (BMI < 21 kg/m²) 1, 5
• Parental history of hip fracture 1
• Current smoking 1
• Excess alcohol consumption (≥3 drinks daily) 1
• Previous fragility fracture 2, 4

Examples of Women Age 50-64 Meeting Screening Threshold:

• 50-year-old current smoker with BMI < 21 kg/m², daily alcohol use, and parental fracture history 1
• 55-year-old with parental fracture history 1
• 60-year-old with BMI < 21 kg/m² and daily alcohol use 1
• 60-year-old current smoker with daily alcohol use 1

High-Risk Conditions Requiring Immediate Screening (Any Age)

Screen immediately regardless of age for these conditions: 2, 6

Medications:

• Glucocorticoid therapy ≥5 mg prednisone daily for ≥3 months 2, 6
• Androgen deprivation therapy for prostate cancer 2
• Aromatase inhibitor therapy 2
• Chronic anticonvulsant drugs or heparin 2

Medical Conditions:

• Hyperparathyroidism, hyperthyroidism, or Cushing syndrome 2
• Hypogonadism in men or surgically/chemotherapeutically induced castration 2
• Rheumatoid arthritis or chronic inflammatory arthritides 2
• Gastrointestinal malabsorption, sprue, or vitamin D deficiency 2
• Eating disorders (anorexia nervosa, bulimia) 2
• Organ transplantation 2
• Chronic alcoholism or established cirrhosis 2
• Spinal cord injuries (as soon as medically stable) 2

Screening Intervals After Initial DEXA

The optimal interval depends on baseline bone density and risk factors: 2, 3

• Normal bone density or mild osteopenia: Repeat in 2-3 years 2, 3
• Osteoporosis or on treatment: Repeat in 1-2 years to monitor treatment effectiveness 2
• High-risk for accelerated bone loss (e.g., glucocorticoid therapy): Repeat in 1-2 years 2

Important caveat: A minimum of 2 years is needed to reliably measure BMD change due to testing precision limitations 1, 2. Women with normal BMD at age 65 may not transition to osteoporosis for almost 17 years, suggesting less frequent screening in this group 2, 3

Common Pitfalls to Avoid

• Do not screen too frequently: Repeating DEXA scans less than 2 years apart in patients with normal BMD provides no clinical benefit and exposes patients to unnecessary radiation 2, 3
• Do not ignore racial/ethnic differences: Asian, Black, and Hispanic populations have lower fracture incidence than White populations at the same BMD, so FRAX calculations should use race-specific data 1
• Do not delay screening in high-risk patients: Adults over 65 with multiple risk factors or those on bone-depleting medications should not wait for arbitrary screening intervals 2, 6
• Do not require DEXA before treatment in very high-risk patients: For patients over 65 with multiple risk factors and clear clinical indication, treatment can be initiated while awaiting DEXA confirmation 7, 6