Screening for osteoporosis

Author
Michael Kleerekoper, MD
Section Editors
Clifford J Rosen, MD
Kenneth E Schmader, MD
Deputy Editor
Jean E Mulder, MD
Disclosures: Michael Kleerekoper, MD Nothing to disclose. Clifford J Rosen, MD Nothing to disclose. Kenneth E
Schmader, MD Grant/Research/Clinical Trial Support: Merck [Herpes Zoster (Zoster vaccine)]. Jean E Mulder,
MD Employee of UpToDate, Inc.
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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Jul 2014. | This topic last updated: Oct 17, 2013.
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 dualenergy 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 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".)
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 BMD (see 'Bone density' below). We recommend assessing risk
factors for fracture in all adults, especially postmenopausal women, men over 60, 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 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 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 bone mineral density. 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 costeffective. 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 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 (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 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
dual-energy x-ray absorptiometry (pDXA), x-ray absorptiometry, and peripheral quantitative computed
tomography (pQCT) of the heel, radius, or hand [22]. The 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 metaanalysis 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, bone mineral
density 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 bone mineral density 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 65year-old white woman who has no additional risk factors for fracture [41,43]. The USPSTF used the
World Health Organization 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
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 (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, HR 0.79, 95% CI
0.60-1.04). Limitations of trial include a low (60 percent) response rate and self-report of hormone
therapy (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 bone mineral density (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 pharmacological and nonpharmacological) 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 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 UK, 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 (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 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 "Management of primary hyperparathyroidism", 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 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 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 bone mineral density 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 the response to
therapy' 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 bone mineral
density (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 the response to therapy' and "Treatment of osteoporosis in men",
section on 'Monitoring the response to therapy'.)
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SUMMARY AND RECOMMENDATIONS
Risk factor screening
Assessment of fracture risk in all adults is important (table 2). The principal 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 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 followup 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 Tscore of -1.01 to -1.49 and no clinical risk factors for fracture has a low 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".)
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