Am Fam Physician. 2023;107(3):238-246
Patient information: See related handout on osteoporosis, written by the authors of this article.
Author disclosure: No relevant financial relationships.
Osteoporosis affects 10.2% of adults older than 50 years and is expected to increase to 13.6% by 2030. Osteoporotic fractures, specifically hip fractures, significantly affect morbidity, mortality, and quality of life. Screening for osteoporosis with dual energy x-ray absorptiometry should be considered for all women 65 years and older or women who are postmenopausal with clinical risk factors. The Bone Health and Osteoporosis Foundation recommends screening men 70 years and older and men with clinical risk factors; however, the U.S. Preventive Services Task Force did not find sufficient evidence to support routine screening in men. Osteoporosis can be diagnosed by a T-score of −2.5 or less or the presence of a fragility fracture. All patients with osteoporosis should be counseled on weight-bearing exercise, smoking cessation, moderation of alcohol intake, and calcium and vitamin D supplementation. Treatment of osteoporosis is influenced by the patient’s fracture risk, the effectiveness of fracture risk reduction, and medication safety. Patients at high risk of fracture should consider treatment with antiresorptive therapy, including bisphosphonates and denosumab. Anabolic agents such as teriparatide, abaloparatide, and romosozumab should be considered for patients at very high risk or with previous vertebral fractures.
In 2010, the incidence of osteoporosis was 10.2% in people older than 50 years and is expected to reach 13.6% by 2030 based on projected population demographics.1 Approximately 2 million to 3 million osteoporotic fractures occur annually in the United States, which can significantly affect morbidity, mortality, and quality of life.2 Hip fractures can be especially debilitating and have a one-year mortality risk of 21% to 24%.3 Adequate detection and management can decrease risks and associated comorbidities.
| Recommendation | Sponsoring organization |
|---|---|
| Do not use DEXA screening for osteoporosis in women younger than 65 years or men younger than 70 years with no risk factors. | American Academy of Family Physicians |
| Do not routinely repeat DEXA more often than once every two years. | American College of Rheumatology |
What Are the Current Screening Recommendations for Osteoporosis?
Dual energy x-ray absorptiometry (DEXA) is recommended for all women 65 years and older or women who are postmenopausal and younger than 65 years with clinical risk factors for osteoporotic fracture. Although the U.S. Preventive Services Task Force (USPSTF) does not recommend routine screening for men, the Bone Health and Osteoporosis Foundation recommends screening for men 70 years and older.
EVIDENCE SUMMARY
The USPSTF, the Bone Health and Osteoporosis Foundation, and the American Association of Clinical Endocrinologists/American College of Endocrinology (AACE/ACE) recommend bone mineral density (BMD) measurement by DEXA for all women 65 years and older (Table 1).4–6 Women younger than 65 years who are postmenopausal should undergo an osteoporosis risk assessment, including an evaluation of clinical risk factors and fracture risk assessment to determine the need for DEXA4–6 (Table 24,5). The most used assessment tool is the Fracture Risk Assessment Tool (FRAX; https://www.sheffield.ac.uk/FRAX); however, there is some controversy about the underestimation of risk in some races (Black, Asian, Hispanic) and a relatively low sensitivity. FRAX estimates a 10-year risk of major osteoporotic and hip fractures and should be used as part of the overall risk assessment.7–10 In a clinical trial, using the FRAX score to determine the need for DEXA improved the percentage of patients receiving therapy at one year and decreased hip fractures by 28% (P = .002).11 The USPSTF did not find benefit in routine BMD screening in men; however, the Bone Health and Osteoporosis Foundation recommends screening men 70 years and older and men with high clinical risk.5,6 The Male Osteoporosis Risk Estimation Score uses age, weight, and a history of chronic obstructive pulmonary disease to assess risk, may help determine the need for DEXA in men, and is more sensitive but less specific than the FRAX score.10,12 The American Academy of Family Physicians supports the USPSTF screening recommendations for osteoporosis.
| Population | AACE/ACE | Bone Health and Osteoporosis Foundation | USPSTF |
|---|---|---|---|
| Women | All women 65 years and older Women who are postmenopausal with: History of fragility fracture Long-term treatment with glucocorticoids Radiographic osteopenia Clinical risk factors | All women 65 years and older Women who are postmenopausal and 50 to 64 years of age with clinical fracture risk | All women 65 years and older Women who are postmenopausal and younger than 65 years with an increased risk of osteoporosis |
| Men | — | All men 70 years and older Men 50 to 69 years of age with clinical fracture risk | Insufficient evidence to assess benefit |
| Any adult | — | People 50 years and older with fracture Any condition or medication associated with low bone mass or bone loss | — |
| Type of osteoporosis | Risk factors | |
|---|---|---|
| Primary | Early menopause Excessive alcohol intake Family history of osteoporotic fracture Low body weight (< 57.6 kg [127 lb]) Smoking | |
| Secondary | Medical causes Alcoholism Ankylosing spondylitis Chronic kidney disease Chronic obstructive pulmonary disease Hyperparathyroidism Hyperthyroidism (or on thyroid replacement therapy) Malabsorption disorders (celiac disease, Crohn disease, gastric bypass) Rheumatoid arthritis Type 1 or type 2 diabetes mellitus Vitamin D deficiency | Medications associated with osteoporosis Antiepileptics Aromatase inhibitors Glucocorticoids Gonadotropin-releasing hormone agents Heparin Lithium Medroxyprogesterone (Depo-Provera) Proton pump inhibitors Selective serotonin reuptake inhibitors Thiazolidinediones (pioglitazone [Actos]) Thyroid hormones |
How Is Osteoporosis Diagnosed?
Osteoporosis is diagnosed based on BMD (T-score of −2.5 or less on DEXA) or the presence of a fragility fracture or vertebral fracture.
EVIDENCE SUMMARY
Osteoporosis is diagnosed based on central DEXA BMD measurements at the hip and lumbar spine.6 BMD should be measured at the forearm (1/3 radius) when the hip and lumbar spine cannot be accurately measured due to structural changes (i.e., osteophytes).5 In women who are postmenopausal and men 50 years and older, BMD is classified using the World Health Organization diagnostic T-score criteria based on a young adult reference population (Table 3).5 The International Society of Clinical Densitometry recommends that ethnicity- or race-adjusted z scores (also adjusted for age or sex norms) should be used for patients 20 to 50 years of age with z scores of −2.0 or less for the expected range for age being diagnostic of osteoporosis.5
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