At what age should a healthy man without risk factors begin bone‑density screening with a DEXA (dual‑energy X‑ray absorptiometry) scan?

DEXA Scan Screening Age for Men Without Risk Factors

Healthy men without risk factors should begin routine DEXA screening at age 70 years. 1, 2

Standard Screening Recommendation

The evidence consistently demonstrates that routine bone density screening is not recommended for men younger than 70 years who lack specific risk factors. 3, 1, 4

• Age 70 and older: All men should undergo DEXA screening regardless of the presence of additional risk factors 1, 2
• Under age 70: Screening is not recommended for routine use in men without documented risk factors 3, 1, 4

The rationale behind this age cutoff is based on the natural history of bone loss in men and cost-effectiveness analyses. While approximately 6% of men have DXA-determined osteoporosis by age 65, the balance of benefits and harms for universal screening before age 70 remains uncertain. 2 The U.S. Preventive Services Task Force concluded that evidence of screening benefits in men is lacking, and the balance of benefits and harms cannot be determined for routine screening below this threshold. 3

Clinical Context and Evidence Quality

Important caveat: The recommendation against screening men under 70 without risk factors is graded as "I" (insufficient evidence) by the USPSTF, not as a recommendation against screening per se. 3 This reflects the lack of direct randomized controlled trial evidence demonstrating that screening improves fracture outcomes in this population, rather than evidence of harm or lack of benefit.

The American College of Physicians similarly found insufficient data to make a firm recommendation for or against screening in younger men without risk factors. 3 However, from a practical standpoint, the absence of evidence supporting benefit, combined with cost considerations (ranging from $30,000 to $248,000 per quality-adjusted life-year depending on age), argues against routine screening before age 70. 3

High-Risk Exceptions Requiring Earlier Screening

Men under age 70 should undergo DEXA screening if they have any of the following major risk factors:

Strong Indications (Well-Established Risk Factors)

• Age greater than 70 years (though this technically falls into routine screening) 3
• Previous fragility fracture (fracture from standing height or less) 3, 2
• Long-term glucocorticoid therapy (oral corticosteroids) 3, 2
• Androgen deprivation therapy for prostate cancer (pharmacologic or surgical castration) 3, 1, 2
• Hypogonadism 1, 2

Moderate-to-Strong Indications

• Low body weight (BMI <20-25 kg/m²) 3, 2
• Significant weight loss (>10% compared with usual adult weight) 3, 2
• Physical inactivity (no regular physical activity) 3, 2
• Spinal cord injury resulting in permanent motor or sensory dysfunction 3, 2
• Chronic alcoholism 1, 4

Medical Conditions Warranting Screening

• Chronic renal failure 2
• Rheumatoid arthritis 3, 2
• Malabsorption disorders 2
• Primary hyperparathyroidism 2
• Hyperthyroidism 2
• Chronic liver disease 2

Medications Associated with Bone Loss

• Anticonvulsant drugs 1, 2
• Chronic heparin therapy 1, 2
• Aromatase inhibitor therapy 1

Practical Algorithm for Decision-Making

For men aged 70 and older:

• Proceed directly to DEXA screening of lumbar spine and bilateral hips 1, 2
• No risk factor assessment needed 1, 2

For men aged 50-69:

1. Assess for major risk factors listed above 2
2. If any major risk factor present: Proceed to DEXA screening 2
3. If no risk factors present: Defer screening until age 70 1, 4, 2
4. Consider using FRAX tool to calculate 10-year fracture risk if clinical picture is unclear 3

For men under age 50:

• DEXA screening only indicated if specific high-risk conditions present (e.g., glucocorticoid therapy, hypogonadism, spinal cord injury) 2
• Use Z-scores rather than T-scores for interpretation in this age group 2

Critical Pitfalls to Avoid

Do not screen men under 70 without documented risk factors. This exposes patients to unnecessary radiation and costs without demonstrated clinical benefit. 1 The cost-effectiveness of screening in this population is poor, and routine screening is not widespread in current practice. 3

Do not delay screening in men with chronic alcoholism, glucocorticoid use, or androgen deprivation therapy. These conditions justify earlier screening regardless of age. 1, 4 Men receiving androgen deprivation therapy should have baseline DEXA before or within 6 months of starting therapy. 2

Do not overlook men after fractures. Men account for 24% of hip fractures but only 10% of BMD tests, indicating significant underdiagnosis. 2 Only 19% of people over 65 undergo BMD testing after a fracture, with rates in men only half those in women. 2

Do not assume obesity protects against osteoporosis when other major risk factors are present. While higher body weight is generally protective, this does not negate the need for screening when significant risk factors exist. 4

Follow-Up Screening Intervals

• Normal bone density or mild osteopenia: Repeat DEXA in 2-3 years 1, 4
• Osteoporosis or on treatment: Repeat DEXA in 1-2 years to monitor treatment effectiveness 1, 4
• High risk for accelerated bone loss (e.g., glucocorticoid therapy, spinal cord injury): Repeat at 1-2 year intervals 1, 2
• Never repeat DEXA at intervals less than 1 year under any circumstances 1