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 who would benefit from intervention to minimize that risk.
Approaches to bone mineral density (BMD) screening vary from country to country, in part due to cost and questions regarding the efficacy of a broad population screening policy. The issues surrounding screening for osteoporosis in older adults are reviewed here. Controversies surrounding screening for osteoporosis in premenopausal women are reviewed separately. (See "Evaluation and treatment of premenopausal osteoporosis", section on 'Screening'.)
DEFINITION — Osteoporosis is characterized by low bone mass, microarchitectural disruption, and increased skeletal fragility, resulting in decreased bone strength and increased risk of fracture. Fragility fractures are defined as fractures that occur with low or minimal trauma, such as a fracture resulting from a fall from standing height. The most common sites of fragility fracture are the spine (vertebral compression fractures), hip, and wrist. Fragility fractures also occur at the humerus, rib, and pelvis. Fractures at certain skeletal locations, including the skull, cervical spine, hands, feet, and ankles, are not considered to be fragility fractures. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women", section on 'Diagnosis' and "Clinical manifestations, diagnosis, and evaluation of osteoporosis in men", section on 'Diagnosis of osteoporosis'.)
The World Health Organization (WHO) has also defined osteoporosis based on dual-energy x-ray absorptiometry (DXA) measurements (table 1). The relative risk of fracture increases as bone mineral density (BMD) decreases. (See "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.
There were an estimated nine million osteoporotic fractures worldwide in 2000 . The incidence of hip fractures increases exponentially with age, although the increase begins approximately 10 years later in males than females (figure 1) . In systematic reviews, the worldwide annual hip fracture rate in women ranged from <100 to nearly 600 per 100,000 and vertebral fracture rate from <100 to almost 1400 per 100,000, depending on the region [3,4]. The highest rates of hip fracture occurred in Scandinavian countries , whereas the highest rates of vertebral fracture occurred in South Korea and the United States . The prevalence of vertebral or hip fracture in older men is approximately one-third that in women (5 to 6 percent versus 16 to 18 percent), and Colles' fracture one-sixth as common (2.5 versus 16 percent) .
Based on bone mineral density (BMD) data from the National Health and Nutrition Examination Survey (NHANES), the prevalence of osteoporosis was 12.6 percent among adults aged 50 years and over in the United States in 2017 to 2018, with a higher prevalence in women (19.6 percent) than in men (4.4 percent) . By the age of 85 years, approximately 70 percent of women and over 30 percent of men will have a femoral neck T-score at or below -2.5 (figure 2) [7,8].
FRACTURE RISK ASSESSMENT — The goal of osteoporosis screening is to identify persons at increased risk of sustaining a low-trauma fracture who would benefit from intervention to minimize that risk. Screening for fracture risk involves appropriate history and physical examination to assess for risk factors and measurement of bone mineral density (BMD). (See "Osteoporotic fracture risk assessment".)
Risk factor assessment — We recommend assessing risk factors for fracture in all adults, especially postmenopausal women, men over 50 years, and in any individual who experiences a fragility or low-trauma fracture (table 2).
Most fractures occur in individuals who do not have osteoporosis by dual-energy x-ray absorptiometry (DXA) criteria (table 1). Although individuals with osteoporosis are at higher relative risk of fracture, there are more fractures in patients with low bone mass (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:
●Long-term glucocorticoid therapy
●Low body weight (less than 58 kg [127 lb])
●Parental history of hip fracture
●Excess alcohol intake
●Race/ethnicity (higher risk in White than in Black, Hispanic, or Asian Americans)
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  and future hip fracture, even in the absence of BMD measurement . 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 .
Biochemical markers that reflect the overall rates of bone resorption and formation are 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 [12-15]. 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 [16,17]. However, current evidence is insufficient to recommend the routine use of bone markers to identify individuals who would benefit from pharmacologic interventions to reduce fracture risk. (See "Use of biochemical markers of bone turnover in osteoporosis".)
Risk factor screening instruments — Several osteoporosis risk assessment instruments have been developed to improve the selection of individuals for measurement of BMD [18-21]. The extent to which each tool has been validated in other cohorts is variable . The Fracture Risk Assessment Tool (FRAX) has been evaluated in the most cohorts .
FRAX was developed to estimate 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. 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 the United States, where access to DXA is relatively widespread, BMD assessment thresholds have been recommended by the US Preventive Services Task Force (USPSTF) (see 'Recommendations by expert groups' below). In countries with limited 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 . In contrast, in those with high fracture probability, intervention may be justified without BMD measurement. Country-specific economic analyses are required to validate these assessment thresholds, ie, the fracture probability at which BMD testing is cost effective.
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 'Patient selection' and "Overview of the management of osteoporosis in postmenopausal women", section on 'Patient selection'.)
Bone mineral density — Bone mineral density (BMD) measurements are used in conjunction with fracture risk assessment for osteoporosis screening . Low 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'.)
Candidates for BMD testing — There are several strategies for incorporating bone mineral density (BMD) measurements into osteoporosis surveillance programs . These include screening all individuals over a certain age (when fracture risk increases), screening only those individuals 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 all 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). These recommendations are 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 fractures when these women are treated, in addition to clinical trial evidence showing a reduction in hip fractures in women identified for treatment through a community-based osteoporosis screening algorithm [27,28]. (See 'Evidence' below.)
●We do not perform routine testing in men based solely on age. Instead, we suggest targeted BMD testing 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. (See "Etiology of osteoporosis in men", section on 'Etiology'.)
Measuring BMD in men solely because they are above a certain age is controversial. Some groups, such as the Bone Health and Osteoporosis Foundation (BHOF; formerly the National Osteoporosis Foundation [NOF]), International Society for Clinical Densitometry (ISCD), and the Endocrine Society recommend BMD testing for all men older than 70 years (and in men 50 to 70 years when risk factors are present) (see 'Recommendations by expert groups' below). This recommendation is supported by data suggesting that total hip bone density predicts fractures as well or better in males than in females [29,30]. Other data, however, do not support routine BMD screening for men based solely on age [31,32]. In general, fracture data from clinical trials of osteoporosis therapies are quite limited in men, so there is less certainty that treatment of men who are identified by routine screening will benefit from therapy.
●BMD screening recommendations for premenopausal women are reviewed separately. (See "Evaluation and treatment of premenopausal osteoporosis", section on 'Screening'.)
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)'.)
Other techniques not used for screening
●Quantitative computed 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 'Quantitative computed tomography'.)
New algorithms have been developed to repurpose CT scans obtained for other clinical reasons as a bone density screening tool; however, these algorithms have yet to be validated on a large scale for osteoporosis screening .
●Quantitative heel ultrasound – Although ultrasound has some utility for fracture prediction, we continue to recommend DXA for screening purposes because of the inability to apply ultrasound to current diagnostic and treatment standards and to monitor response to therapy . In regions without access to DXA, however, peripheral measurements using a validated technique (such as ultrasound) for fracture risk assessment is acceptable. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women" and "Osteoporotic fracture risk assessment", section on 'Quantitative ultrasonography (QUS)'.)
●Other peripheral measurements – Because of the relatively high cost and lack of portability of DXA, other techniques to measure peripheral sites have been developed. In addition to ultrasound, these include peripheral DXA (pDXA), radiograph absorptiometry, and peripheral QCT (pQCT) of the heel, radius, or hand . 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'.)
Skeletal site to measure — For screening site of measurement, we obtain DXA of hip and spine. Spinal osteophytes are common in aging adults, which interferes with the assessment of BMD at this site. In this setting, measurement of hip BMD alone could be sufficient. Some experts have a somewhat different approach, using the hip as the preferred site for measuring BMD, regardless of age [24,35].
Although overall fracture risk can be predicted by measurement or estimation of BMD at many skeletal sites [36,37], the risk for fracture at a particular skeletal site is best estimated by measuring BMD at that skeletal site [35,38-40]. 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 early menopause, however, there is greater BMD loss at the spine than the hip, and therefore, lumbar spine measurement may be helpful in this setting. If pharmacologic therapy is planned, measurement of lumbar spine BMD is also useful because the lumbar spine is often considered the best skeletal site for monitoring response to therapy. The lumbar spine has improved precision and can detect responses to therapy earlier than hip BMD. 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. (See "Osteoporotic fracture risk assessment", section on 'Dual-energy x-ray absorptiometry (DXA)' and "Osteoporotic fracture risk assessment", section on 'Skeletal site to measure'.)
Measurements from different sites (spine, hip, forearm) are often discordant with regard to the WHO diagnostic classification [39,41]. Some experts suggest that 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. However, this will substantially increase 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 . Thus, assessment of multiple sites does not appear to improve fracture prediction.
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) [31,43-52].
There is no universal agreement about BMD testing in older men. The USPSTF found insufficient evidence to make a recommendation for screening older men . Other groups, such as the BHOF, the ISCD, the Endocrine Society, the American College of Preventive Medicine, and the American College of Physicians (ACP) recommend BMD testing for all men older than 70 years, and the Canadian Osteoporosis Society recommends BMD testing for all men older than 65 years.
BMD screening recommendations for individuals younger than 65 years also vary (table 3). The USPSTF recommends BMD screening in women younger than 65 years who are at increased risk for osteoporosis based on a clinical risk assessment tool . One approach is to obtain a BMD in women younger than 65 years whose 10-year risk of major osteoporotic fracture (calculated without DXA) is greater than that of a 65-year-old White American or European woman who has no additional risk factors for fracture. In the United States, this threshold (using FRAX) is 8.4 percent. Although this approach to bone density screening may have merit, the selected threshold (8.4 percent) has not been subject to cost-effectiveness analysis nor validated in any patient population [53,54].
The BHOF, ISCD, the Endocrine Society, and the Canadian Osteoporosis Society recommend testing in individuals 50 years and older with any clinical risk factors for fracture (table 2) [46,49,55,56], whereas the ACP 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 .
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 [26,47]. Only individuals 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) [26,58-60].
EFFECTIVENESS OF OSTEOPOROSIS SCREENING
Evidence — There are a few trials that directly evaluate the effectiveness of osteoporosis screening [27,28,61-63]. There was a reduction in hip fractures in the screening compared with control group in one of the trials , but not in others [61-63]. In these trials, determining the relative effectiveness of screening depends 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 a meta-analysis of the three population-based randomized controlled trials that evaluated screening for high fracture risk in postmenopausal women using bone densitometry and provided recommendations for subsequent osteoporosis treatment, there was a reduction in hip fractures (2.2 versus 2.7 percent in the control group [hazard ratio (HR) 0.80, 95% CI 0.71-0.91]), major osteoporotic fractures (7.8 versus 8.4 percent [HR 0.91, 95% CI 0.84-0.98]), and in osteoporotic fractures (11.2 versus 11.7 percent [HR 0.95, 95% CI 0.89-1.00]) . There was no difference in all-cause mortality, a secondary outcome. All three trials used the Fracture Risk Assessment Tool (FRAX) in combination with bone densitometry for screening, and 11 to 18 percent of participants in the intervention group initiated osteoporosis medication after screening.
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 .
Cost effectiveness — The results of cost-effectiveness analyses of screening and 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, with history of falls, and with decreasing T-score values [64-69].
A community-based osteoporosis screening algorithm was determined to be highly cost effective in the United Kingdom, with cost savings due to reduction of osteoporotic fractures . Differences in cost effectiveness among countries are related to differences in health care costs and fracture risks. Use of less expensive pharmacologic interventions, such as generic drugs, would further decrease costs.
FOLLOW-UP TO SCREENING
General principles — 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 'Fracture risk assessment' above), especially with regard to smoking cessation, limiting alcohol intake, and participating in regular weightbearing 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 international units as a minimum and others recommending 1000 international 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, 25-hydroxyvitamin D, and possibly a measure of urine calcium (spot fasting or 24 hour) excretion. 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 'Patient selection' and "Overview of the management of osteoporosis in postmenopausal women", section on 'Patient selection'.)
Repeat BMD measurements — Our approach in individuals 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), with no risk factors for accelerated bone loss and with low absolute fracture risk, we will typically perform a follow-up DXA in 10 to 15 years. In our practice, we also recommend periodic redetermination of Fracture Risk Assessment Tool (FRAX) 10-year probability of fracture every five years, with the further recommendation to perform a follow-up DXA earlier if the absolute fracture risk is close to the treatment threshold (ie, ≥3 percent for hip fracture, ≥20 percent for major osteoporotic fracture).
Any properly installed and validated DXA instrument is appropriate for initial BMD measurement. However, to the extent possible, it is preferable 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 when the initial screening test does not show osteoporosis 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 [72-76]. 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 . 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 adults (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 . 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 non-spine fracture risk in 4124 community-dwelling women 65 years and older (mean age 72 years) . 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 . The interval for 10 percent of participants to make the transition from normal BMD or osteopenia at baseline to osteoporosis (defined as a T-score -2.50 or lower) 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 may 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. Note, however, that treatment thresholds (for example, based on absolute fracture risk) may differ from diagnostic thresholds (based on T-score of -2.5 or lower), and therefore, it is possible that some women who do not have osteoporosis but who have moderate or high absolute fracture risk may benefit from more frequent bone density testing to identify the proper timing for intervention. (See "Overview of the management of osteoporosis in postmenopausal women", section on 'Patient selection'.)
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" and "Society guideline links: Clinical densitometry".)
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SUMMARY AND RECOMMENDATIONS
●Initial fracture risk assessment – The goal of osteoporosis screening is to identify persons at increased risk of sustaining a low-trauma fracture who would benefit from intervention to minimize that risk. Screening for fracture risk involves appropriate history and physical examination to assess for risk factors (table 2) and measurement of bone mineral density (BMD). (See 'Fracture risk assessment' above and "Osteoporotic fracture risk assessment".)
•BMD: Women <65 years – We suggest BMD assessment in postmenopausal women less than 65 years if one or more risk factors are present (table 2) (Grade 2B). (See 'Candidates for BMD testing' above and 'Evidence' above.)
•BMD: Men – We suggest targeted BMD testing in men rather than routine testing based solely on age (Grade 2C). Some expert groups advocate for screening men based on age alone (eg, 70 years or above). (See 'Candidates for BMD testing' above and 'Recommendations by expert groups' above.)
We 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 men 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).
•BMD: Skeletal site to measure – We measure BMD of the hip and spine using DXA. However, measurement of the hip alone could be sufficient in older individuals. (See 'Dual-energy x-ray absorptiometry' above and 'Skeletal site to measure' above.)
●Follow-up to screening – Individuals require counseling regarding fracture prevention, including lifestyle modification, fall prevention, and possibly pharmacologic intervention. (See 'General principles' above and "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".)
●Repeat BMD measurements – Repeat BMD measurements may be most valuable for individual patients on therapy or with underlying clinical risk factors that might lead to accelerated bone loss. (See 'Repeat BMD measurements' above.)
•T-score -2.00 to -2.49 at any site or risk factors – In adults 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).
•T-score -1.50 to -1.99 at any site, no risk factors – 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).
•T-score -1.01 to -1.49 at any site, no risk factors – 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 and with low absolute fracture risk, we suggest a follow-up DXA in 10 to 15 years (Grade 2C). In our practice, we also recommend periodic redetermination of Fracture Risk Assessment Tool (FRAX) 10-year probability of fracture every five years, with the further recommendation to perform a follow-up DXA earlier if the absolute fracture risk is close to the treatment threshold (ie, ≥3 percent for hip fracture, ≥20 percent for major osteoporotic fracture).
ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Michael Kleerekoper, MD, who contributed to earlier versions of this topic review.
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