What are the recommendations for bone density screening in a postmenopausal woman or an adult over 50 with a history of fractures or other risk factors for osteoporosis?

Bone Density Screening Recommendations

All postmenopausal women aged 65 years and older should undergo routine DXA screening regardless of risk factors, and postmenopausal women aged 60-64 years with risk factors should also be screened. 1, 2

Screening by Age and Risk Status

Women ≥65 Years

• Universal DXA screening is recommended for all postmenopausal women in this age group, with no need for risk factor assessment 1, 2
• This represents the strongest consensus across all major guidelines 1, 3, 4

Women 60-64 Years with Risk Factors

• Screen with DXA if any risk factors are present, as the benefits are comparable to routine screening in older women 1
• This age group represents a critical window where risk-based screening is highly effective 1

Women <60 Years

• Do not perform routine screening unless risk factors are present 1, 2
• Risk factor assessment is essential in this younger postmenopausal population to identify candidates for screening 1

Key Risk Factors That Trigger Screening

The following risk factors should prompt DXA screening in postmenopausal women under 65 years:

• Low body weight (<70 kg) - the single best predictor of low bone mineral density 1
• Previous fragility fracture at any age - a critical indicator requiring screening 1
• Long-term glucocorticoid therapy - patients should obtain baseline BMD within 6 months of starting treatment 1, 2
• Medical conditions causing bone loss (hyperparathyroidism, hypogonadism, chronic inflammatory diseases) 1
• No current estrogen therapy use 1
• Family history of osteoporosis (though less strongly supported as a sole trigger) 1

Optimal Testing Method

DXA measurement at the femoral neck is the gold standard and best predictor of hip fracture. 5, 1, 6

• Femoral neck DXA provides the most accurate fracture risk prediction compared to all other sites and methods 5, 1
• Alternative peripheral testing methods (quantitative ultrasonography, radiographic absorptiometry, peripheral DXA) can identify short-term fracture risk but require further validation against central DXA 5, 1

Rescreening Intervals

The frequency of repeat DXA depends on baseline results and clinical status:

Normal Bone Density or Mild Osteopenia

• Repeat DXA in 2-3 years 1
• A minimum 2-year interval is required to reliably detect true bone density changes due to DXA precision limitations 1, 2, 7

Diagnosed Osteoporosis or On Treatment

• Repeat DXA in 1-2 years to monitor treatment effectiveness 1, 2

Glucocorticoid Therapy

• Repeat DXA every 1-3 years, with annual testing for very high-dose glucocorticoids or history of osteoporotic fracture 2

Factors Requiring More Frequent Testing

• New bone-depleting medications 2
• Incident fragility fracture 2
• Development of secondary causes of bone loss 2
• Significant weight loss 2
• Poor medication adherence or absorption concerns 2

Special Populations

Women ≥85 Years

• Do not withhold screening or treatment based solely on advanced age 7
• Limited data exist for this population, but the evidence gap does not indicate lack of benefit 7
• Offer pharmacologic treatment with bisphosphonates as first-line therapy if osteoporosis is diagnosed 7

African-American Women

• Have higher average bone mineral density than white women at the same age and are less likely to benefit from screening 5
• Consider this when determining screening priorities in resource-limited settings 5

Clinical Decision-Making Tools

• Use the FRAX tool to calculate 10-year fracture risk when bone density results are borderline or to guide treatment decisions 1
• Risk assessment tools provide absolute fracture risk estimates that supplement BMD measurements 4
• Some patients with bone mineral density above treatment thresholds may still qualify for treatment based on vertebral fractures detected through vertebral fracture assessment scans 1

Common Pitfalls to Avoid

• Do not screen postmenopausal women under 60 without risk factors - this leads to overdiagnosis and unnecessary treatment 1, 2
• Do not repeat DXA more frequently than every 2 years unless monitoring treatment response, as precision limitations prevent reliable detection of change 1, 2, 7
• Do not rely on peripheral bone density testing alone for diagnosis - use central DXA at the femoral neck for definitive assessment 5, 1
• Do not assume all densitometers and measurement sites are equivalent - diagnosis likelihood varies by site, test type, number of sites tested, and reference ranges used 5, 1