Osteoporosis screening

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Today, the risk of fracture due to osteoporosis is threatening one out of two postmenopausal women and also one out of five older men. The 10-year risk for any osteoporosis-related fractures in a 65-year-old white woman with no other risk factor is 9.3%. According to the guidelines of USPSTF, all women ≥ 65 years old along with women < 65 years old with a high risk of fracture are the target of screening for osteoporosis, but there is not any recommendation to screen men for the disease. There are two major methods, suggested for screening osteoporosis: dual energy x-ray absorptiometry (DEXA) of both hip and lumbar spine bones, and quantitative ultrasonography of the calcaneus.

Screening

Risk assessment

Today, the risk of fracture due to osteoporosis is threatening one out of two postmenopausal women and also one out of five older men. Leading ethnicity involved in osteoporosis is white. The rate of osteoporosis is higher in elderly. The 10-year risk for any osteoporosis-related fractures in a 65-year-old white woman with no other risk factor is 9.3%. The 10-year probability of hip fracture can be estimated by the FRAX tool based on the presence or absence of clinical risk factors in addition to the bone mineral density (BMD) at the femoral neck.

Screening criteria

The US Preventive Services Task Force (USPSTF) divides the population into three groups, categorize their need to be screened for osteoporosis; they include:

• Women of 65 years and older, without any fracture history or pathological reason for osteoporosis
• Women of less than 65 years, with 10-year fracture risk of not less than a 65-year-old white woman (who has not any other risk factor)
• Men with no osteoporosis history

Upon the guidelines of USPSTF, the former two groups (women) are the target of screening for osteoporosis; but there is not any recommendation to screen the third group (men) for the disease.

Prior USPSTF recommendations from 2002 were included:

• All women of 65 and older should be screened by bone marrow densitometry.
• The USPSTF recommends screening women aged 60-64 years old, who are at increased risk of fracture. The most significant risk factor for indicating an increased probability of having osteoporosis is lower body weight (< 70 kg).
• Clinical prediction rules are available to guide the selection of women for screening. The Osteoporosis Risk Assessment Instrument (ORAI) may be the most sensitive strategy.
• Regarding the screening process for men, a cost-analysis study suggests that screening may be "cost-effective for men with a self-reported prior fracture beginning at age 65 years, and for men 80 years and older with no prior fracture".

Screening tool

There are two major methods, that are suggested to be used for screening for osteoporosis:

• Dual energy x-ray absorptiometry (DXA) of both hip and lumbar spine bones
• Quantitative ultrasonography of the calcaneus

Although quantitative ultrasonography has numerous advantages when compared to DXA such as; lower cost, more portability, lower ionizing radiation exposure for patients, and otherwise the same power of fracture prediction (in the femoral neck, hip, and spine) but still current diagnostic and treatment criteria rely on DXA of the hip and lumbar spine.

Screening protocol

After an initial screening bone mineral density (BMD), optimal intervals to repeat the test may include the followings:

• 15 years for women with normal bone density or mild osteopenia: T-score of greater than −1.50
• 5 years for women with moderate osteopenia: T-score of −1.50 to −1.99
• 1 year for women with advanced osteopenia: T-score of −2.00 to −2.49

Osteoporosis Screening Recommendations of Other Organizations

Organizations	Women	Men
National Osteoporosis Foundation (NOF)	BMD testing for: All ≥ 65 years old Postmenopausal <65 years old, based on risk factor profile	BMD testing for: All men ≥70 years old Men aged 50-69 years old, based on fracture risk profile §
World Health Organization (WHO)	Indirect records suggest screening women ≥65 years old, while no direct record suggests using BMD testing for holistic screening programs	-
American College of Physicians	-	Clinicians should investigate older men for osteoporosis risk factors; use DXA to screen men with increased risk, maybe candidates of drug therapy for osteoporosis
American Congress of Obstetricians and Gynecologists (ACOG)	BMD testing for: Age ≥65 years Postmenopausal <65 years old, with 1 or more risk factors	-

§ Fracture risk profiles are as the table below.

	Adults ≥ 40 years of age	Adults <40 years of age
High fracture risk	Prior osteoporotic fracture(s) Hip or spine bone mineral density T score ≤ -2.5, in men age ≥50 years and postmenopausal women FRAX 10-year risk of major osteoporotic fracture ≥ 20% FRAX 10-year risk of hip fracture ≥ 3%	Prior osteoporotic fracture(s)
Moderate fracture risk	FRAX 10-year risk of major osteoporotic fracture 10–19% FRAX 10-year risk of hip fracture >1% and <3%	Hip or spine bone mineral density Z score <-3 or Rapid bone loss (≥10% at the hip or spine over 1 year) and Continuing glucocorticoid treatment at ≥7.5 mg/day for ≥6 months
Low fracture risk	FRAX 10-year risk of major osteoporotic fracture <10% FRAX 10-year risk of hip fracture ≤1%	None of above risk factors other than glucocorticoid treatment

References

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