Screening for Osteoporosis in Postmenopausal Women: Recommendations and Rationale

Summary of Recommendations

The U.S. Preventive Services Task Force (USPSTF) recommends that women 65 years of age and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at 60 years of age for women at increased risk for osteoporotic fractures (see Clinical Considerations for a discussion of women at increased risk). This is a grade B recommendation. (See Appendix Table 1 for a description of the USPSTF classification of recommendations.)

The USPSTF found good evidence that the risk for osteoporosis and fracture increases with age and other factors, that bone density measurements accurately predict the risk for fractures in the short term, and that treating asymptomatic women with osteoporosis reduces their risk for fracture. (See Appendix Table 2 for a description of the USPSTF classification of levels of evidence.) The USPSTF concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors.

The USPSTF makes no recommendation for or against routine osteoporosis screening in postmenopausal women who are younger than 60 years of age or in women 60 to 64 years of age who are not at increased risk for osteoporotic fractures. This is a grade C recommendation.

The USPSTF found fair evidence that screening women at lower risk for osteoporosis or fracture can identify additional women who may be eligible for treatment for osteoporosis, but it would prevent a small number of fractures. The USPSTF concludes that the balance of benefits and harms of screening and treatment is too close to make a general recommendation for this age group.

Clinical Considerations

Modeling analysis suggests that the absolute benefits of screening for osteoporosis among women 60 to 64 years of age who are at increased risk for osteoporosis and fracture are comparable to those of routine screening in older women. The exact risk factors that should trigger screening in this age group are difficult to specify based on evidence. Lower body weight (weight < 70 kg) is the single best predictor of low bone mineral density (1, 2). Low weight and no current use of estrogen therapy are incorporated with age into the three-item Osteoporosis Risk Assessment Instrument (1). There is less evidence to support the use of other individual risk factors (for example, smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake) as a basis for identifying high-risk women younger than 65 years of age. At any given age, African-American women on average have higher bone mineral density than white women and are thus less likely to benefit from screening.

Among different bone measurement tests performed at various anatomic sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites. Other technologies for measuring peripheral sites include quantitative ultrasonography, radiographic absorptiometry, single-energy x-ray absorptiometry, peripheral dual-energy x-ray absorptiometry, and peripheral quantitative computed tomography. Recent data suggest that peripheral bone density testing in the primary care setting can also identify postmenopausal women who have a higher risk for fracture over the short term (1 year). Further research is needed to determine the accuracy of peripheral bone density testing in comparison with dual-energy x-ray absorptiometry. The likelihood of being diagnosed with osteoporosis varies greatly depending on the site and type of bone measurement test, the number of sites tested, the brand of densitometer used, and the relevance of the reference range.

Estimates of the benefits of detecting and treating osteoporosis are based largely on studies of bisphosphonates. Some women, however, may prefer other treatment options (for example, hormone replacement therapy, selective estrogen receptor modulators, or calcitonin) based on personal preferences or risk factors. Clinicians should review with patients the relative benefits and harms of available treatment options, and uncertainties about their efficacy and safety, to facilitate an informed choice. No studies have evaluated the optimal intervals for repeated screening. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer intervals may be adequate for repeated screening to identify new cases of osteoporosis. Yield of repeated screening will be higher in older women, those with lower bone mineral density at baseline, and those with other risk factors for fracture.

There are no data to determine the appropriate age to stop screening and few data on osteoporosis treatment in women older than 85 years of age. Patients who receive a diagnosis of osteoporosis fall outside the context of screening but may require additional testing for diagnostic purposes or to monitor response to treatment.

The brief review of the evidence and other sections that are normally included in USPSTF recommendations are available in the complete recommendation and rationale statement on the USPSTF Web site (www.preventiveservices.ahrq.gov).

Recommendations of Others

In 1998, the National Osteoporosis Foundation, in collaboration with other professional organizations, issued screening guidelines recommending bone density testing for all women 65 years of age or older, as well as younger postmenopausal women who have had a fracture or who have one or more risk factors for osteoporosis (3). Collaborating groups included the American Academy of Orthopaedic Surgeons, the American College of Obstetricians and Gynecologists, the American Geriatrics Society, the American College of Radiology, the American College of Rheumatology, the American Academy of Physical Medicine and Rehabilitation, the American Association of Clinical Endocrinologists, the Endocrine Society, and the American Society for Bone and Mineral Research. The American Association of Clinical Endocrinologists released revised guidelines in 2001 (4). A 2000 Consensus Development Conference sponsored by the U.S. National Institutes of Health concluded that the value of universal osteoporosis screening was not yet established (5). The conference panel recommended an individualized approach to screening, noting that bone density measurement is appropriate when it will aid the patient's decision to institute treatment. The Canadian Task Force on Preventive Health Care is currently revising its recommendations on screening for osteoporosis.

Appendix

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, MD, MPH, Chair (University of Washington, Seattle, Washington); Janet D. Allan, PhD, RN, CS, Vice-Chair (School of Nursing, University of Maryland, Baltimore, Baltimore, Maryland); Paul S. Frame, MD (Tri-County Family Medicine, Cohocton, and University of Rochester, Rochester, New York); Charles J. Homer, MD, MPH (National Initiative for Children's Healthcare Quality, Boston, Massachusetts); Mark S. Johnson, MD, MPH (University of Medicine and Dentistry of New Jersey–New Jersey Medical School, Newark, New Jersey); Jonathan D. Klein, MD, MPH (University of Rochester School of Medicine, Rochester, New York); Tracy A. Lieu, MD, MPH (Harvard Pilgrim Health Care and Harvard Medical School, Boston, Massachusetts); Cynthia D. Mulrow, MD, MSc (University of Texas Health Science Center, Audie L. Murphy Memorial Veterans Hospital, San Antonio, Texas); C. Tracy Orleans, PhD (The Robert Wood Johnson Foundation, Princeton, New Jersey); Jeffrey F. Peipert, MD, MPH (Women and Infants' Hospital, Providence, Rhode Island); Nola J. Pender, PhD, RN (University of Michigan, Ann Arbor, Michigan); Albert L. Siu, MD, MSPH (Mount Sinai School of Medicine, New York, New York); Steven M. Teutsch, MD, MPH (Merck & Co., Inc., West Point, Pennsylvania); Carolyn Westhoff, MD, MSc (Columbia University College of Physicians and Surgeons, New York, New York); and Steven H. Woolf, MD, MPH (Virginia Commonwealth University, Fairfax, Virginia).

Appendix Table 1. U.S. Preventive Services Task Force Grades and Recommendations

Appendix Table 2. U.S. Preventive Services Task Force Grades for Strength of Overall Evidence