Osteoporosis Screening Guidelines
Screen all women aged ≥65 years and men aged ≥70 years with dual-energy x-ray absorptiometry (DXA) of the hip and lumbar spine, regardless of risk factors. 1
Age-Based Screening Recommendations
Women
- Age ≥65 years: Universal screening recommended with DXA 1
- Age <65 years (postmenopausal): Screen if 10-year fracture risk equals or exceeds that of a 65-year-old white woman without additional risk factors (9.3% baseline risk) 1
Men
- Age ≥70 years: Screen with DXA 1
- Age 50-69 years: Screen if major risk factors present 1
- Note: Evidence for screening men remains less robust than for women, though the 2025 USPSTF guideline now includes men in screening recommendations 1
Risk Factors Triggering Earlier Screening
Major Risk Factors (any age ≥50 years) 1
- Prior fragility fracture (wrist, hip, spine, or proximal humerus with minimal/no trauma) 1
- Chronic glucocorticoid use (≥5 mg prednisone equivalent daily for ≥3 months) 1
- Parental history of hip fracture after age 50 1
- Current smoking 1
- Low body weight (<127 lb or 57.6 kg) 1
- Prolonged amenorrhea (>1 year before age 42) 1
- Height loss (>4 cm historical or >2 cm prospective) 1
- Androgen deprivation therapy for prostate cancer 1
- Medical conditions: hyperparathyroidism, rheumatoid arthritis, hypogonadism 1
Screening Methodology
Primary Test: DXA
- Measure both hip and lumbar spine 1
- DXA provides T-scores: number of standard deviations from young adult mean 1
- Diagnostic thresholds 1:
- Normal: T-score >-1.0
- Osteopenia: T-score -1.0 to -2.4
- Osteoporosis: T-score ≤-2.5
Alternative/Adjunctive Tests
- Quantitative CT: Useful when advanced degenerative spine changes preclude accurate DXA interpretation 1
- Vertebral fracture assessment (VFA): Consider if T-score <-1.0 plus age ≥70 years (women) or ≥80 years (men), height loss >4 cm, or glucocorticoid use 1
- Trabecular bone score (TBS): May enhance fracture prediction in osteopenic patients 1
Risk Assessment Tools
Use FRAX (Fracture Risk Assessment Tool) to calculate 10-year fracture probability when determining screening need in younger individuals 1. The tool is available at www.shef.ac.uk/FRAX/ and can be used with or without BMD values 1.
Rescreening Intervals
Evidence is lacking on optimal rescreening intervals 1. Clinical judgment should guide timing based on:
- Initial T-score results
- Presence and progression of risk factors
- Treatment status
Evidence Supporting Screening
The 2025 European guideline cites the MRC SCOOP trial demonstrating 28% reduction in hip fracture risk with primary care screening using FRAX 1. Meta-analyses from UK, Netherlands, and Denmark trials support screening efficacy 1.
Common Pitfalls to Avoid
- Do not screen with peripheral DXA or quantitative ultrasound alone - these cannot be used to apply WHO diagnostic criteria 1
- Avoid DXA hip measurement in patients with bilateral hip replacements, severe hip dysplasia, or Paget's disease 1
- Do not rely solely on age cutoffs - younger patients with multiple risk factors require screening 1
- Recognize DXA limitations in very short or tall individuals, as two-dimensional imaging may under- or overestimate volumetric bone density 1