Screening For Osteoporosis

18/10/2017 Screening for osteoporosis - UpToDate
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Screening for osteoporosis
Author: Michael Kleerekoper, MD

Section Editors: Clifford J Rosen, MD, Kenneth E Schmader, MD
Deputy Editor: Jean E Mulder, MD
All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Sep 2017. | This topic last updated: Mar 26, 2017.
INTRODUCTION — Osteoporosis is a common disease that is characterized by low bone mass, microarchitectural disruption, and skeletal fragility,
resulting in an increased risk of fracture. The goal of screening is to identify persons at increased risk of sustaining a low trauma fracture and who
would benefit from intervention to minimize that risk.
Screening for fracture risk involves appropriate history, physical examination, standard biochemical and hematologic studies, and measurement of
bone mineral density (BMD). The clinical history should include inquiring about possible secondary causes of bone loss, such as use of medications
with potential adverse effects on bone health and family history of osteoporosis. A widespread approach to BMD screening alone has not been
universally adopted, in part due to cost and questions regarding the efficacy of a broad population screening policy. The issues surrounding screening
for osteoporosis in postmenopausal women and men are reviewed here. Controversies surrounding screening for osteoporosis in premenopausal
women are reviewed separately. (See "Evaluation and treatment of premenopausal osteoporosis", section on 'Screening'.)
Detailed information about diagnosis, prevention, and treatment of osteoporosis is found elsewhere. (See "Clinical manifestations, diagnosis, and
evaluation of osteoporosis in postmenopausal women" and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in men" and "Prevention
of osteoporosis" and "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men".)
DEFINITION — Osteoporosis is characterized by low bone mass, microarchitectural disruption, and increased skeletal fragility. In addition, the World
Health Organization (WHO) has defined osteoporosis based upon dual-energy x-ray absorptiometry (DXA) measurements (table 1). The relative risk of
fracture increases as BMD decreases. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women", section on
'T-score' and "Overview of dual-energy x-ray absorptiometry".)
EPIDEMIOLOGY — The burden of suffering associated with osteoporosis is related to the increased incidence of fractures in individuals with low bone
mass and microarchitectural deterioration. Fragility fractures are defined as fractures that occur following a fall from standing height or less or with no
trauma. Although the greatest relative risk of fracture is in individuals with osteoporosis, the absolute number of fractures in those with bone mineral
density (BMD) T-scores in the low bone mass (osteopenia) range is the same or greater than in those with T-scores in the osteoporosis range. (See
'Assessment of fracture risk' below and "Osteoporotic fracture risk assessment".)
https://www-uptodate-com.bdigital.ces.edu.co:2443/contents/screening-for-osteoporosis/print?source=search_result&search=OSTEOPOROSIS&selectedTitle=2~150 1/22
There were an estimated nine million osteoporotic fractures worldwide in 2000 [1]. Some estimates predict a continued increase in the number of hip
fractures over the next 40 years [2]. However, other epidemiologic studies suggest a changing trend [3-7]. In one study from Finland, review of a
national discharge registry revealed a decline in hip fracture rates between 1997 and 2004 [5]. Possible reasons for the decline include a healthier
aging population, improved functional ability, increased body weight, and greater use of calcium, vitamin D, and pharmacologic therapy for
osteoporosis.
ASSESSMENT OF FRACTURE RISK — Screening for osteoporosis involves fracture risk assessment and measurement of bone mineral density
(BMD) (see 'Bone density' below). We recommend assessing risk factors for fracture in all adults, especially postmenopausal women, men over 60
years, and in any individual who experiences a fragility or low-trauma fracture (table 2).
Risk factors — Most fractures occur in women and men who do not have osteoporosis by dual-energy x-ray absorptiometry (DXA) criteria. Individuals
with osteoporosis are at the highest relative risk of fracture, but there are more fractures in patients with low bone mass or osteopenia (T-score
between -1.0 and -2.5) because there are so many more patients in this category. Therefore, assessment of risk factors that are independent of BMD
is important for fracture prediction. Validated risk factors that are independent of BMD include the following:
● Advanced age
● Previous fracture
● Long-term glucocorticoid therapy
● Low body weight (less than 58 kg [127 lb])
● Family history of hip fracture
● Cigarette smoking
● Excess alcohol intake
The most robust non-BMD risk factors are age and previous low trauma fracture. (See "Osteoporotic fracture risk assessment".)
Most of these risk factors are easily discernible from a routine history and physical examination; taken together they are highly predictive of low bone
density [8] and future hip fracture, even in the absence of bone density measurement [9]. Although clinical risk factors are predictive of bone density
and fracture risk, they may not be as useful for predicting response to therapy for osteoporosis [10].
Risk factor screening instruments — Several osteoporosis risk assessment instruments have been developed to improve the selection of women
and men for measurement of BMD [11-13]. However, none of the tools were very specific, and most were not validated in other cohorts [14].
In 2008, a World Health Organization (WHO) task force introduced a Fracture Risk Assessment Tool (FRAX), which estimates the 10-year probability
of hip fracture or major osteoporotic fractures combined (hip, spine, shoulder, or wrist) for an untreated woman or man using easily obtainable clinical
risk factors for fracture (table 2) with or without information on BMD. FRAX has been validated in 40 cohorts (over one million patient years). The
technical aspects of FRAX are reviewed in more detail separately. (See "Osteoporotic fracture risk assessment", section on 'Fracture risk assessment
tool'.)
When combined with country-specific economic analyses, FRAX can provide guidance for both BMD testing (assessment threshold) and treatment
(intervention threshold). In countries with limited or no access to DXA, the FRAX algorithm can potentially be used to identify individuals in whom
measurement of BMD would influence management decisions. As an example, measurement of BMD may be indicated in those with an intermediate
fracture probability, in whom the selective addition of BMD testing may result in intervention [15]. In contrast, in those with high fracture probability,
intervention may be justified without BMD measurement. Country-specific economic analyses are required to develop assessment thresholds, ie, the
fracture probability at which BMD testing is cost-effective. Until such economic analyses are available, we do not suggest using the FRAX algorithm to
identify individuals for bone density testing.
The use of the FRAX algorithm to define intervention thresholds is reviewed separately. (See "Osteoporotic fracture risk assessment", section on
'Clinical application of fracture risk assessment' and "Treatment of osteoporosis in men", section on 'Candidates for therapy' and "Overview of the
management of osteoporosis in postmenopausal women", section on 'Candidates for therapy'.)
Biochemical markers of bone remodeling — Biochemical markers that reflect the overall rates of bone resorption and formation are currently
available clinically and have been used extensively in research to help understand the pathogenesis of osteoporosis and responses to therapy. The
mean values of these markers are generally higher in patients with osteoporosis than in matched normal subjects, but there is substantial overlap [16-
19]. Measurement of these markers is not helpful in deciding for or against bone density measurements. However, markers can provide information
about fracture risk beyond that available from measurements of BMD and could conceivably influence a decision for or against pharmacologic
intervention (figure 1) [20,21]. However, most studies indicate that pharmacologic intervention will reduce fracture risk independent of the initial marker
value. (See "Use of biochemical markers of bone turnover in osteoporosis".)
BONE DENSITY — Bone density measurements are used in conjunction with fracture risk assessment for osteoporosis screening [22]. Low bone
mineral density (BMD) is associated with increased risk of fracture, regardless of the technique used for measurement (see "Osteoporotic fracture risk
assessment", section on 'Methods of measurement of BMD'). We suggest BMD testing (dual-energy x-ray absorptiometry [DXA]) in women 65 years of
age and older and in postmenopausal women younger than 65 years of age with clinical risk factors for fracture (table 2). We suggest not performing
routine testing in men. However, we do recommend measurement of BMD in men with clinical manifestations of low bone mass and in those with risk
factors for fracture. (See 'Candidates for BMD testing' below.)
Dual-energy x-ray absorptiometry — DXA is the most widely used method for measuring BMD because it gives very precise measurements at
clinically relevant skeletal sites (ie, those with major clinical consequences when a fracture occurs). The major disadvantages of DXA are that the
machine is large (not portable) and expensive, and that it uses ionizing radiation, albeit in a very low dose. (See "Overview of dual-energy x-ray
absorptiometry".)
Many studies have demonstrated that low bone density (DXA) at any site can predict osteoporotic fracture, although hip measurements are superior to
spine in predicting hip as well as overall osteoporotic fracture. DXA and fracture prediction are discussed in detail elsewhere. (See "Osteoporotic
fracture risk assessment", section on 'Dual-energy x-ray absorptiometry (DXA)'.)
Quantitative computerized tomography (QCT) — QCT measures volumetric bone density of the spine and hip and can analyze cortical and
trabecular bone separately. This method is quite useful in clinical research and may be used in individual patients to follow therapeutic responses to
therapy, where large changes may be observed. However, it is not recommended for screening, largely because the application of T-scores to predict
the risk of fracture has not been validated with QCT. In addition, this method is more costly and results in greater exposure to radiation than DXA. (See
"Osteoporotic fracture risk assessment", section on 'Methods of measurement of BMD'.)
Peripheral measurements — Because of the high cost and lack of portability of DXA, other techniques to measure peripheral sites have been
developed. These include ultrasound, peripheral DXA (pDXA), radiograph absorptiometry, and peripheral QCT (pQCT) of the heel, radius, or hand
[22]. The World Health Organization (WHO) criteria for the diagnosis of osteoporosis are based upon BMD measured by DXA and, therefore, do not
apply to these other technologies. However, these technologies can be used to predict fracture. (See "Osteoporotic fracture risk assessment", section
on 'Methods of measurement of BMD'.)
Ultrasound — Quantitative ultrasound appears to be a good predictor of fractures in men and women, and is at least as good as clinical risk factors
for identifying patients at high risk for osteoporosis. (See "Osteoporotic fracture risk assessment", section on 'Quantitative ultrasonography (QUS)'.)
However, a limitation of ultrasound is that it does not reliably exclude or confirm DXA-determined osteoporosis. A meta-analysis of 25 studies that
evaluated the sensitivity and specificity of calcaneal ultrasound for identifying patients with DXA T-scores ≤-2.5 concluded that currently used
ultrasound cutoff thresholds do not have sufficiently high sensitivity or specificity to definitively exclude or confirm DXA-diagnosed osteoporosis [23].
Another major limitation to using quantitative ultrasound as a screening tool is that the criteria for diagnosing osteoporosis and recommending
treatment based upon ultrasound are not yet well established [24,25]. Furthermore, ultrasound cannot reliably be used to follow patients who are
treated for osteoporosis because of limited precision and a slow rate of change of bone mass at peripheral sites. Thus, most individuals with a high-
risk ultrasound finding will need a confirmatory DXA both to determine the need for treatment based upon well-established guidelines, and as a
baseline for monitoring therapy. A cost-effectiveness analysis using ultrasound to determine which women need DXA did not show this approach to be
more cost-effective than a strategy using DXA alone [26].
Thus, although ultrasound has some utility for fracture prediction, because of the inability to apply ultrasound and other peripheral measurements to
current diagnostic and treatment standards, and to monitor response to therapy [27], we continue to recommend DXA for screening purposes. (See
"Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women".)
In regions without access to DXA, however, peripheral measurements using a validated technique (such as ultrasound) for fracture risk assessment is
acceptable.
Skeletal site to measure — For screening site of measurement, we suggest DXA of hip and spine. Measurement of the hip alone could be sufficient
in older individuals. Although overall fracture risk can be predicted by measurement or estimation of BMD at many skeletal sites [28,29], the risk for
fracture at a particular skeletal site is best estimated by measuring BMD at that skeletal site [30-33]. As an example, hip BMD is superior to BMD
measured at other skeletal sites in predicting hip fracture. Therefore, since hip fracture is often associated with significant morbidity and mortality
compared with other fractures, DXA of the hip is generally regarded as the best site for diagnosis of osteoporosis. In contrast, the lumbar spine is often
considered the best skeletal site to monitor because it shows less variability and can detect responses to therapy earlier than hip BMD. (See
"Osteoporotic fracture risk assessment", section on 'Dual-energy x-ray absorptiometry (DXA)' and "Osteoporotic fracture risk assessment", section on
'Skeletal site to measure'.)
The best site to measure for osteoporosis screening is controversial. Measurements from different sites (spine, hip, forearm) are often discordant with
regard to the WHO diagnostic classification [31,34]. Thus, when measurements of different skeletal sites are performed, the diagnosis of osteoporosis
is based upon the lowest T-score for BMD assessed at one of these sites. Measuring more than one site generally increases the number of individuals
categorized as osteoporotic. A meta-analysis of several population-based cohort studies showed that there was no advantage in risk prediction when
measuring multiple sites [35]. Thus, assessment of multiple sites does not appear to improve fracture prediction.
Nevertheless, in younger postmenopausal women with risk factors for fracture, we suggest DXA measurements of both the spine and hip because
early menopause is associated with greater BMD loss at the spine than the hip. In addition, interference from osteophytes and vascular calcifications
on the spine measurement is usually minimal in women less than 65 years of age. In contrast, spinal osteophytes are common in aging women and
men, which interferes with the assessment of BMD at this site. In this setting, measurement of hip BMD alone could be sufficient.
However, if pharmacologic therapy is planned, measurement of spine BMD might be useful for monitoring response to therapy. In the presence of
degenerative changes of the spine, BMD can be monitored at another skeletal site, such as the hip or radius, although the sensitivity for detecting
changes at these locations is lower.
Some authorities have a somewhat different approach, using the hip as the preferred site for measuring BMD, regardless of age [15,33].
Candidates for BMD testing — There are several strategies for incorporating BMD measurements into osteoporosis screening programs [36]. These
include screening all individuals over a certain age (when fracture risk increases), screening only those women and men over a certain age with
clinical risk factors for fracture, or screening those with clinical risk factors who are close to an intervention threshold and in whom the selective
addition of BMD testing may result in intervention.
We suggest BMD testing (DXA) in women 65 years of age and older and in postmenopausal women younger than 65 years of age with clinical risk
factors for fracture (table 2). This recommendation is based upon the findings of an increased incidence of fracture that occurs in conjunction with low
BMD after age 65 years and clinical trial data demonstrating a reduction in fracture when these women are treated [22]. (See 'Effectiveness of early
detection' below.)
In the absence of data supporting routine BMD testing in men above a certain age, we suggest not performing routine testing in men. However, we do
recommend measurement of BMD in men with clinical manifestations of low bone mass, such as radiographic osteopenia, history of low trauma
fractures, and loss of more than 1.5 inches in height, as well as in those with risk factors for fracture, such as long-term glucocorticoid therapy,
androgen deprivation therapy for prostate cancer, hypogonadism, primary hyperparathyroidism, and intestinal disorders (table 2). (See "Osteoporotic
fracture risk assessment", section on 'Clinical risk factor assessment' and "Epidemiology and etiology of osteoporosis in men", section on 'Risk
factors'.)
BMD screening recommendations for premenopausal women are reviewed separately. (See "Evaluation and treatment of premenopausal
osteoporosis", section on 'Screening'.)
Recommendations by expert groups — In the United States and Canada, the majority of groups recommend BMD assessment in
postmenopausal women 65 years and older regardless of risk factors (table 3) [37-45]. BMD screening recommendations for men and for women
younger than 65 years vary (table 3). The United States Preventive Services Task Force (USPSTF) found insufficient evidence to make a
recommendation for screening men [41,43]. The USPSTF recommends BMD screening in women younger than 65 years whose fracture risk is equal
to or greater than that of a 65-year-old white woman who has no additional risk factors for fracture [41,43]. The USPSTF used the Fracture Risk
Assessment (FRAX) algorithm to select a threshold above which bone density testing is recommended. Although this approach to bone density
screening may have merit, the selected threshold (9.3 percent) was not subject to cost-effectiveness analysis nor validated in any patient population.
(See 'Risk factor screening instruments' above.)
Other groups, such as the National Osteoporosis Foundation (NOF), the International Society for Clinical Densitometry (ISCD), and the Endocrine
Society, recommend BMD testing for all men older than 70 years, and in men and women 50 to 70 years when risk factors are present [37,45,46]. The
Canadian Osteoporosis Society recommends testing in men and women 50 to 64 years with clinical risk factors for fracture (table 2) [42], whereas the
American College of Physicians recommends measurement of BMD in men who are at increased risk for osteoporosis (including men >70 years of
age) and are candidates for drug therapy [47].
In contrast, some European groups recommend BMD screening based upon risk stratification, ie, the decision to measure BMD is based upon age-
specific fracture probability thresholds calculated using FRAX (without BMD information) or other risk assessment tool [36,44]. Only women and men
with a fracture probability near an intervention threshold, in whom the selective addition of BMD testing may result in intervention, are referred for BMD
testing (table 3) [36,48-50].
EFFECTIVENESS OF EARLY DETECTION — The gold standard that would support screening for osteoporosis is the demonstration in a well-
designed randomized trial that screening reduces fracture risk. Determining the relative effectiveness of screening would also depend upon the quality
of the bone mineral density (BMD) measurements and the risk factor analysis, the ability of the clinician to prescribe appropriate treatment, and the
compliance of the patient.
In the only published trial, 4800 postmenopausal women (aged 45 to 54 years) were randomly assigned to osteoporosis screening (BMD
measurement) or no screening [51]. Follow-up data were obtained via questionnaire. After a mean of nine years, a greater proportion of screened
women reported current or past use of hormone therapy (HT) (52 versus 45 percent) or other osteoporosis medications (37 versus 22 percent). In an
intention-to-treat analysis, there was a nonsignificant reduction in the incidence of fracture in the screened group (8.8 versus 9.4 percent, hazard ratio
[HR] 0.79, 95% CI 0.60-1.04). Limitations of trial include a low (60 percent) response rate and self-report of HT or other osteoporosis medications.
Other estimates of the fracture prevention benefits of screening and intervention are largely based upon trials of bisphosphonates that enrolled
postmenopausal women who were at high risk for fracture. The fracture benefits noted are not applicable to a screening program because patients
were not identified for participation in the trials by screening the general population [52].
In the absence of definitive data, population-based screening remains controversial.
Arguments supporting screening — There are a number of arguments to support screening for osteoporosis:
● It is a common disease with significant morbidity and mortality and without screening many high-risk patients would go undetected. (See
'Epidemiology' above.)
● Screening through risk factor assessment and BMD testing is available to many clinicians in some countries.
● The risk for most fractures is inversely proportional to BMD (figure 1) [53-60].
● A number of effective therapies (both pharmacologic and nonpharmacologic) are available to reduce fracture risk in patients who are diagnosed
with osteoporosis. (See "Overview of the management of osteoporosis in postmenopausal women" and "Treatment of osteoporosis in men" and
"Calcium and vitamin D supplementation in osteoporosis".)
● Knowledge of fracture risk, which includes but is not limited to BMD, could improve compliance with both lifestyle changes and pharmacotherapy.
Arguments against screening — There are several arguments against widespread screening for osteoporosis [41].
● As noted above, the only published randomized trial did not find a significant fracture benefit from screening but had some design limitations [51].
● There is no discrete value for BMD that discriminates clearly between patients who will fracture and those who will not. In addition, many fractures
occur in those without osteoporosis by BMD criteria, which decreases the value of using BMD (alone) as a tool for identifying individuals at high
risk for fracture.
● A single measurement indicates only current BMD, not the anticipated rate of bone loss. Other factors may be more important in predicting the risk
of fracture than BMD [9] (see 'Assessment of fracture risk' above). As an example, fall-related risk factors may be more important in predicting hip
fracture than BMD since more than 90 percent of hip fractures result from falls onto the greater trochanter [61]. (See "Falls in older persons: Risk
factors and patient evaluation".)
● Certain preventive measures, such as adequate calcium and vitamin D intake, exercise, and smoking cessation, should be recommended
regardless of BMD. Furthermore, there is some evidence that women with normal BMD are less likely to follow these preventive measures [62].
● The availability of dual-energy x-ray absorptiometry (DXA) and willingness to pay for healthcare varies from country to country and with differing
clinical practices [63].
Cost-effectiveness — The results of cost-effectiveness analyses of pharmacologic therapy for the primary or secondary prevention of osteoporotic
fractures have not been uniform. Cost-effectiveness varies from country to country, but generally increases the later in life that screening and treatment
occur, with history of prior vertebral fracture, and with decreasing T-score values [64-68].
In one study, treatment with risedronate in a 70-year-old woman with a T-score of -2.5 and prior vertebral fracture was cost-effective in Sweden,
Finland, Belgium, and Spain [65]. However, when the same individual did not have a history of prior fracture, similar treatment was cost effective in
Sweden only. In another report from the United Kingdom, treatment with alendronate was cost effective for primary and secondary prevention of
osteoporotic fractures [69]. In addition, alendronate was found to be cost effective in women with low BMD or in women with BMD above the threshold
for osteoporosis in the presence of clinical risk factors. In another study, alendronate was noted to be cost-effective, whereas teriparatide was not [70].
Differences in cost-effectiveness among countries are related to differences in health care costs and fracture risks. Use of less expensive
pharmacologic intervention, such as generic drugs, would further decrease costs.
FOLLOW-UP TO SCREENING — In conjunction with osteoporosis screening, individuals require counseling regarding fracture prevention, including
lifestyle modification, fall prevention, and possibly pharmacologic intervention.
● All individuals should be counseled about risk factor reduction (see 'Assessment of fracture risk' above), especially with regard to smoking
cessation, limiting alcohol intake, and participating in regular weight-bearing and muscle-strengthening exercise.
● Adults with low bone mass should be advised to consume at least 1200 mg of calcium per day (total diet plus supplement). Adequate vitamin D
intake (diet and supplement) is also essential, but there are conflicting guidelines concerning the ideal/optimal supplement, with some guidelines
recommending 600 int. units as a minimum and others recommending 1000 units. (See "Calcium and vitamin D supplementation in
osteoporosis".)
● Initial laboratory evaluation in individuals with low bone mass (bone mineral density [BMD] T-score below -1.0) should include standard
biochemical and hematologic profiles and a measure of urine calcium (spot fasting or 24-hour) excretion. There is an increasing trend for 25-
hydroxyvitamin D measurement, but the cost-effectiveness of this is uncertain. Further recommendations regarding initial evaluation of low bone
mass are discussed separately. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women".)
● The World Health Organization (WHO) BMD definitions for osteoporosis and low bone mass are diagnostic thresholds rather than intervention
thresholds. Pharmacologic intervention thresholds to prevent fracture should be based upon the absolute risk of fracture, using a combination of
BMD and clinical risk factors (table 2). Intervention thresholds are reviewed separately. (See "Treatment of osteoporosis in men", section on
'Candidates for therapy' and "Overview of the management of osteoporosis in postmenopausal women", section on 'Candidates for therapy'.)
Repeat BMD measurements — Our approach in women and men without osteoporosis at baseline measurement and who are not candidates for
pharmacologic therapy is as follows:
● In the presence of low bone mass (T-score -2.00 to -2.49) at any site or risk factors that may cause ongoing bone loss (eg, glucocorticoid use,
hyperparathyroidism), we perform follow-up measurements approximately every two years, as long as risk factors persist. (See "Primary
hyperparathyroidism: Management", section on 'Monitoring' and "Prevention and treatment of glucocorticoid-induced osteoporosis", section on
'Summary and Recommendations'.)
● In the presence of low bone mass (T-score -1.50 to -1.99) at any site, and with no risk factors for accelerated bone loss, we will typically perform a
follow-up dual energy x-ray absorptiometry (DXA) in three to five years.
● In the presence of normal or slightly low bone mass (T-score -1.01 to -1.49), and with no risk factors for accelerated bone loss, we will typically
perform a follow-up DXA in 10 to 15 years. A 65-year-old woman with a femoral neck BMD T-score of -1.01 to -1.49 and no clinical risk factors for
fracture has a low Fracture Risk Assessment Tool (FRAX)-calculated (FRAX) 10-year absolute risk of hip fracture (approximately 0.9 percent).
Any properly installed and validated DXA instrument is appropriate for initial BMD measurement. However, to the extent possible, it is essential that all
subsequent BMD studies on an individual patient should be performed on the same DXA instrument as the baseline study.
Follow-up testing for individuals whose baseline BMD shows osteoporosis (T-score <-2.5) and for patients receiving osteoporosis treatment is
discussed elsewhere. (See "Overview of the management of osteoporosis in postmenopausal women", section on 'Monitoring' and "Treatment of
osteoporosis in men", section on 'Monitoring the response to therapy'.)
Data regarding the frequency of follow-up BMD testing in women and men who have had an initial screening test and do not have osteoporosis at
baseline are limited. The goal of follow-up testing is to detect low bone density before a major fracture occurs. However, whether rate of BMD loss is
an independent risk factor for fracture is uncertain [71-75]. In a retrospective cohort study using a database of all clinical BMD results from Manitoba,
Canada, 146 women (mean age 65 years) sustained one or more osteoporotic fractures after the second BMD test [72]. Compared with women who
remained fracture free, women who fractured were older, had lower baseline (T-scores lumbar spine -1.0 versus -1.6 and femoral neck -1.2 versus
-1.7, respectively) and final BMD, and a higher prevalence of other risk factors for fracture (ie, glucocorticoid use). However, the annualized
percentage change in BMD did not differ in women who did and did not sustain major osteoporotic fractures.
In contrast, the Framingham Osteoporosis study, a population-based cohort study of 800 older men and women (mean age at baseline BMD test 74.8
years) who had two BMD tests and were followed for a median of 9.6 years, showed that the change in BMD of the femoral neck was associated with
hip and major osteoporotic fracture [76]. However, the change in BMD over a four-year interval provided little additional clinically-valuable information
beyond the baseline BMD.
Similarly, in the Study of Osteoporotic Fractures (SOF), a repeat BMD measurement performed a mean of eight years after the initial measurement did
not improve the overall predictive value of hip, spine, or nonspine fracture risk in 4124 community dwelling women 65 years and older (mean age 72
years) [71]. The mean initial T-score was -1.37. In a subsequent analysis from SOF, 4957 women (67 years and older) who did not have osteoporosis
at baseline testing were followed for up to 15 years [77]. The interval for 10 percent of participants to make the transition from normal BMD or
osteopenia at baseline to osteoporosis (before a hip or clinical vertebral fracture occurred and before initiation of osteoporosis treatment) was
estimated. For women with normal (T-score -1.0 or better) or slightly low (T-score -1.01 to -1.49) bone mass at baseline, the interval between baseline
testing and the development of osteoporosis was approximately 17 years. For women with moderately low (T-score -1.50 to -1.99) or low (T-score
-2.00 to -2.49) bone mass at baseline, the interval was 4.7 and 1.1 years, respectively. These data suggest that healthy women 65 years of age and
older who have a screening bone density study and are found to have normal bone density or only slightly low bone mass do not require repeat testing
for 17 years, whereas women found to have moderately low or low bone mass at baseline require follow-up bone density testing within one to five
years.
These results are not applicable to women with osteoporosis (T-scores below -2.5) at baseline, women already receiving osteoporosis treatment, or
women younger than 65 years of age at time of first bone density screening. Women younger than 65 years of age with clinical risk factors for fracture
(table 2) may require more frequent monitoring of bone density, depending upon risk factors.
Repeat BMD measurements may be most valuable for individual patients on therapy or to document stability of bone density in untreated patients with
underlying clinical factors that might lead to accelerated bone loss. (See "Prevention and treatment of glucocorticoid-induced osteoporosis", section on
'Monitoring' and "Overview of the management of osteoporosis in postmenopausal women", section on 'Monitoring' and "Treatment of osteoporosis in
men", section on 'Monitoring the response to therapy'.)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are
provided separately. (See "Society guideline links: Osteoporosis".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, “The Basics” and “Beyond the Basics.” The Basics
patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient
might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.
Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade
reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on “patient info” and the keyword(s) of interest.)
● Basics topics (see "Patient education: Osteoporosis (The Basics)" and "Patient education: Calcium and vitamin D for bone health (The Basics)")
● Beyond the Basics topics (see "Patient education: Osteoporosis prevention and treatment (Beyond the Basics)" and "Patient education: Calcium
and vitamin D for bone health (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
Risk factor screening
● Assessment of fracture risk in all adults is important (table 2). The principal bone mineral density (BMD)-independent risk factors to consider
include advanced age, previous fragility fracture, glucocorticoids, risk of falls, smoking, alcohol, and family history of fracture. (See 'Assessment of
fracture risk' above and "Osteoporotic fracture risk assessment".)
BMD screening
● We suggest BMD assessment in all women 65 years of age and older (Grade 2B). (See 'Recommendations by expert groups' above.)
● We suggest BMD assessment in postmenopausal women less than 65 years if one or more risk factors are present (table 2) (Grade 2B).
● We suggest not performing routine BMD measurements in premenopausal women (Grade 2C). (See "Evaluation and treatment of
premenopausal osteoporosis", section on 'Screening'.)
● We suggest not performing routine BMD measurements in all men (Grade 2C), but we do measure BMD in men who have clinical manifestations
of low bone mass, such as radiographic osteopenia, history of low trauma fractures, and loss of more than 1.5 inches in height, as well as in those
with risk factors for fracture, such as long-term glucocorticoid therapy, androgen deprivation therapy for prostate cancer, hypogonadism, primary
hyperparathyroidism, hyperthyroidism, and intestinal disorders (table 2). (See "Treatment of osteoporosis in men".)
● For screening BMD, we suggest dual-energy x-ray absorptiometry (DXA) over peripheral measurements (Grade 2B). If data demonstrating the
ability of a peripheral measurement to successfully monitor response to therapy becomes available, screening with a peripheral measurement
would be preferred due to cost, portability, and availability.
● For screening site of measurement, we suggest DXA of hip and spine (Grade 2C). However, measurement of the hip alone could be sufficient in
older individuals. (See 'Skeletal site to measure' above.)
● Repeat BMD measurements may be most valuable for individual patients on therapy or with underlying clinical factors that might lead to
accelerated bone loss. (See 'Repeat BMD measurements' above.)
● In women and men with low bone mass (T-score -2.00 to -2.49) at any site or who have risk factors for ongoing bone loss (eg, glucocorticoid use,
hyperparathyroidism), we suggest follow-up measurements (approximately every two years), as long as the risk factor persists (Grade 2C). (See
'Repeat BMD measurements' above.)
● In women 65 years of age and older at baseline screening, with low bone mass (T-score -1.50 to -1.99) at any site, and with no risk factors for
accelerated bone loss, we suggest a follow-up DXA in three to five years (Grade 2C).
● In women 65 years of age and older with normal or slightly low bone mass (T-score -1.01 to -1.49) at baseline measurement and no risk factors
for accelerated bone loss, we suggest a follow-up DXA in 10 to 15 years (Grade 2C). A 65-year-old woman with a femoral neck BMD T-score of
-1.01 to -1.49 and no clinical risk factors for fracture has a low Fracture Risk Assessment Tool (FRAX)-calculated (FRAX) 10-year absolute risk of
hip fracture (approximately 0.9 percent).
After screening — Screening is only useful if there is appropriate evaluation and management of those found to be at high risk for fracture. Evaluation
and management of women and men with low bone mass are discussed separately. (See "Clinical manifestations, diagnosis, and evaluation of
osteoporosis in postmenopausal women" and "Overview of the management of osteoporosis in postmenopausal women" and "Evaluation and
treatment of premenopausal osteoporosis" and "Treatment of osteoporosis in men".)
Use of UpToDate is subject to the Subscription and License Agreement.
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Topic 2046 Version 33.0
GRAPHICS
Diagnostic categories for osteoporosis and low bone mass based upon BMD measurement by DXA
Category Bone mass
Normal A value for BMD within 1 SD of the young adult female reference mean (T-score greater than or equal to -1 SD).
Low bone mass (osteopenia) A value for BMD more than 1 but less than 2.5 SD below the young adult female reference mean (T-score less than -1 and greater
than -2.5 SD).
Osteoporosis A value for BMD 2.5 or more SD below the young adult female reference mean (T-score less than or equal to -2.5 SD).
Severe (established) A value for BMD more than 2.5 SD below the young adult female reference mean in the presence of one or more fragility fractures.
osteoporosis
BMD: bone mineral density; DXA: dual-energy x-ray absorptiometry; SD: standard deviation.
Data from: WHO scientific group on the assessment of osteoporosis at the primary health care level: Summary meeting report, 2004. Geneva: World Health
Organization, 2007.
Graphic 74190 Version 8.0
Clinical risk factors for fracture
Advancing age
Previous fracture
Glucocorticoid therapy
Parental history of hip fracture
Low body weight
Current cigarette smoking
Excessive alcohol consumption
Rheumatoid arthritis
Secondary osteoporosis (eg, hypogonadism or premature menopause, malabsorption, chronic liver disease, inflammatory bowel disease)
Data from: Kanis JA, Borgstrom F, De Laet C, et al. Assessment of fracture risk. Osteoporos Int 2005; 16:581.
BMD and bone turnover markers are independent

predictors of hip fracture risk
Low BMD was defined according to the WHO guidelines, ie, by a value 2.5 SD or
more below the young-adult mean (T-score ≤2.5). High bone resorption was
defined by CTX or free D-Pyr values higher than the upper limit (mean +2 SD)
of the premenopausal range. Women with both low hip BMD and high bone
resorption were at a higher risk of hip fracture than women with either low hip
BMD or high bone resorption.
BMD: bone mineral density; CTX: C-telopeptide; D-Pyr: free deoxypyridinoline; SD:
standard deviation; WHO: World Health Organization.
Reproduced with permission from: Garnero, P, Hausherr, E, Chapuy, MC, et al.

Markers of bone resorption predict hip fracture in elderly women: the EPIDOS
Prospective Study. J Bone Miner Res 1996; 11:1531. Copyright ©1996 American
Society for Bone and Mineral Research.
Osteoporosis screening recommendations
National Osteoporosis Foundation The NOF recommends measurement of BMD (DXA of the hip and spine) in [1]:
(NOF) • Women age 65 years and older and men age 70 years and older, regardless of clinical risk factors
• Younger postmenopausal women, women in the menopausal transition, and men age 50 to 69 years with clinical risk factors for fracture
• Adults who have a fracture after age 50 years
• Adults with a condition (eg, rheumatoid arthritis) or taking a medication (eg, glucocorticoids in a daily dose ≥5 mg prednisone or
equivalent for ≥3 months) associated with low bone mass or bone loss
International Society for Clinical The ISCD recommends measurement of BMD (DXA of the hip and spine) in [2]:
Densitometry (ISCD) • All women age 65 years and older and men age 70 years and older regardless of risk factors
• Postmenopausal women and men age 50 to 70 years when risk factors are present
• Adults with a fragility fracture
• Adults with a condition or taking a medication associated with low bone mass or bone loss
• Anyone being considered for pharmacologic therapy for osteoporosis
• Anyone being treated for osteoporosis to monitor response to therapy
• Anyone not receiving therapy when evidence of bone loss would lead to treatment
• Women in the menopausal transition if there is a specific risk factor associated with increased fracture, such as low body weight, prior
low-trauma fracture, or high-risk medication
• Postmenopausal women discontinuing estrogen should be considered for bone density testing
• The 33 percent forearm (1/3 radius) site is recommended in the following cases:
- If hip and/or spine cannot be measured or interpreted
- Hyperparathyroidism
- Severe obesity (over the weight limit of DXA table)
Association of Clinical AACE recommends measurement of BMD (DXA) in [4]:

Endocrinologists (AACE) • All women age 65 years and older
• Any adult with a history of fracture not caused by severe trauma
• Younger postmenopausal women with clinical risk factors for fracture
• The lumbar spine (PA) and proximal femur are recommended sites of measurement
United States Preventive Services USPSTF recommends measurements of BMD in [5]:

Task Force (USPSTF) • All women age 65 years and older
• In addition, they recommend screening in younger women whose fracture risk is equal to or greater than that of a 65-year-old white
woman who has no additional risk factors
• The best site to screen is not mentioned, although the report agrees that DXA of the hip is the best predictor of hip fracture
American Academy of Family The AAFP recommends measurement of BMD in [6]:

Physicians (AAFP) • Women age 65 years and older
• Women age 60 years and older at increased risk for osteoporotic fracture
National Institutes of Health (NIH) The NIH recommends [7]:

• BMD measurements for individuals at high risk for osteoporosis. They do not recommend universal screening.
UK National Osteoporosis The NOGG does not recommend population screening. They are in favor of performing BMD measurements using a case-
Guideline Group (NOGG) finding strategy based upon age-specific fracture probability thresholds [8].
Canadian Osteoporosis Society The Canadian Osteoporosis Society recommends BMD measurement in [9]:
• Postmenopausal women age ≥65 years
• Men age ≥65 years
• Younger men and women with additional clinical risk factors for fracture
BMD: bone mineral density: DXA: dual-energy x-ray absorptiometry.
References:
1. National Ostoporosis Foundation. 2013 Clinician's Guide to Prevention and Treatment of Osteoporosis. http://nof/public/content/resource/913/files/580.pdf
(Accessed on November 14, 2013).
2. International Society for Clinical Densitometry. 2013 ISCD Official Positions - Adult. www.iscd.org/official-positions/2013-iscd-official-positions-adult/ (Accessed on
November 14, 2013).
3. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Diagnosis and Treatment of Postmenopausal Osteoporosis.
www.aace.com/pub/pdf/guidelines/OsteoGuidelines2010.pdf (Accessed on January 10, 2011).
4. U.S. Preventive Services Task Force. Screening for Osteoporosis Recommendation Statement.
www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.htm (Accessed on February 10, 2011).
5. American Academy of Family Physicians. Recommendations for clinical preventative services. www.aafp.org/exam.xml (Accessed on January 10, 2011).
6. www.consensus.nih.gov (Accessed on January 10, 2011).
7. National Osteoporosis Guideline Group (NOGG). www.shef.ac.uk/NOGG/index.html (Accessed on June 29, 2011).
8. Papaioannou A, Morin S, Cheung AM, et al. 2010 Clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: Summary. CMAJ 2010;
182:1864.
Contributor Disclosures
Michael Kleerekoper, MD Nothing to disclose Clifford J Rosen, MD Grant/Research/Clinical Trial Support: Alexion [Hypophosphatasia
(Recombinant alkaline phosphatase)]. Kenneth E Schmader, MD Grant/Research/Clinical Trial Support: Merck [Herpes zoster (Zoster vaccine)];
GlaxoSmithKline [Herpes zoster (Zoster vaccine)]. Jean E Mulder, MD Nothing to disclose
Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level
review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all
authors and must conform to UpToDate standards of evidence.
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Author: Michael Kleerekoper, MD

In the absence of definitive data, population-based screening remains controversial.

SUMMARY AND RECOMMENDATIONS

Risk factor screening

would be preferred due to cost, portability, and availability.

Use of UpToDate is subject to the Subscription and License Agreement.

Topic 2046 Version 33.0

Category Bone mass

Graphic 74190 Version 8.0

Clinical risk factors for fracture

Parental history of hip fracture

Low body weight

Current cigarette smoking

Excessive alcohol consumption

Graphic 76445 Version 3.0

BMD and bone turnover markers are independent

Reproduced with permission from: Garnero, P, Hausherr, E, Chapuy, MC, et al.

Graphic 77540 Version 2.0

Osteoporosis screening recommendations

Association of Clinical AACE recommends measurement of BMD (DXA) in [4]:

United States Preventive Services USPSTF recommends measurements of BMD in [5]:

American Academy of Family The AAFP recommends measurement of BMD in [6]:

National Institutes of Health (NIH) The NIH recommends [7]:

BMD: bone mineral density: DXA: dual-energy x-ray absorptiometry.

Graphic 62866 Version 11.0

Conflict of interest policy

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