Similarly, the USPSTF notes that policy and coverage decisions involve considerations in addition to the evidence of clinical benefits and harms. By , approximately With the aging of the US population, the potential preventable burden is likely to increase in future years. The USPSTF found convincing evidence that bone measurement tests are accurate for predicting osteoporotic fractures in women and men. The most commonly used test is central dual-energy x-ray absorptiometry DXA of the hip and lumbar spine.
Although several bone measurement tests similarly predict risk of fracture, DXA provides measurement of bone mineral density BMD , and most treatment guidelines use central DXA to define osteoporosis and the threshold at which to start drug therapies to prevent osteoporotic fractures. The USPSTF found adequate evidence that clinical risk assessment tools are moderately accurate in identifying risk of osteoporosis and osteoporotic fractures.
The USPSTF found 1 study that evaluated the effect of screening for osteoporosis on fracture rates; the study reported a reduction in hip fractures but did not find a reduction in other types of fractures.
Multiple studies show that drug therapies reduce fractures in postmenopausal women with osteoporosis. For women 65 years and older, the USPSTF found convincing evidence that screening can detect osteoporosis and that treatment of women with osteoporosis can provide at least a moderate benefit in preventing fractures.
For postmenopausal women younger than 65 years who are at increased risk of osteoporosis, the USPSTF found adequate evidence that screening can detect osteoporosis and that treatment provides a moderate benefit in preventing fractures.
For men, the USPSTF found inadequate evidence on the benefits and harms of treating screen-detected osteoporosis to reduce the risk of osteoporotic fractures. It reported no increase in anxiety and no decrease in quality of life from screening. Harms associated with screening may include radiation exposure from DXA and opportunity costs time and effort required by patients and the health care system.
Harms of drug therapies for osteoporosis depend on the specific medication used. The USPSTF found that the risk of serious adverse events, upper gastrointestinal events, or cardiovascular events associated with the most common class of osteoporosis medication bisphosphonates is no greater than small. The USPSTF concludes with moderate certainty that the net benefit of screening for osteoporosis in women 65 years and older is at least moderate.
The USPSTF concludes with moderate certainty that the net benefit of screening for osteoporosis in postmenopausal women younger than 65 years who are at increased risk of osteoporosis is at least moderate. The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis in men.
This recommendation applies to older adults without a history of low-trauma fractures and without conditions that may cause secondary osteoporosis such as metabolic bone disease or untreated hyperthyroidism and patients without conditions that may increase their risk of falls.
This recommendation does not apply to persons who take long-term medications that may cause secondary osteoporosis eg, glucocorticoids, aromatase inhibitors, or gonadotropin-releasing hormone agonists.
In deciding which postmenopausal women younger than 65 years to screen with bone measurement testing, clinicians should first consider factors associated with increased risk of osteoporotic fractures. These include parental history of hip fracture, smoking, excessive alcohol consumption, and low body weight. In addition, menopausal status in women is also an important consideration because studies demonstrating treatment benefit mainly enrolled postmenopausal women.
For postmenopausal women younger than 65 years who have at least 1 risk factor, a reasonable approach to determine who should be screened with bone measurement testing is to use a clinical risk assessment tool. These tools seem to perform similarly and are moderately accurate at predicting osteoporosis.
Because the benefits of treatment are greater in persons at higher risk of fracture, one approach is to perform bone measurement testing in postmenopausal women younger than 65 years who have a year FRAX risk of major osteoporotic fracture MOF without DXA greater than that of a year-old white woman without major risk factors.
Clinicians should note that the presence of a given risk factor or a certain age does not represent a particular risk threshold. Although the risk of osteoporosis and osteoporotic fractures generally increases with age, the presence of multiple risk factors at a younger age may indicate that the risk-benefit profile is favorable for screening with bone measurement testing.
The most commonly used bone measurement test used to screen for osteoporosis is central DXA; other screening tests include peripheral DXA and quantitative ultrasound QUS.
Most treatment guidelines 3 , 4 , recommend using BMD, as measured by central DXA, to define osteoporosis and the treatment threshold to prevent osteoporotic fractures. Quantitative ultrasound also evaluates peripheral sites and has similar accuracy in predicting fracture risk as DXA, while avoiding the risk of radiation exposure; however, it does not measure BMD. Some observational and modeling studies have suggested screening intervals based on age, baseline BMD, and calculated projected time to transition to osteoporosis.
However, limited evidence from 2 good-quality studies found no benefit in predicting fractures from repeating bone measurement testing 4 to 8 years after initial screening. The US Food and Drug Administration FDA has approved multiple drug therapies to reduce osteoporotic fractures, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen.
The choice of therapy should be an individual one based on the patient's clinical situation and the trade-off between benefits and harms. Clinicians should educate patients on how to minimize the adverse effects of drug therapies, such as reducing esophageal irritation from bisphosphonate therapy by taking the medication with a full glass of water and not lying down for at least 30 minutes afterward.
When deciding whether to screen for osteoporosis to prevent osteoporotic fractures in men, clinicians should consider the following factors. The prevalence of osteoporosis in men is generally lower than in women 4. Older age in men is an important risk factor for osteoporotic fracture. In the absence of other risk factors, it is not until age 80 years that the prevalence of osteoporosis in white men starts to reach that of white women at age 65 years. Similar to women, risk factors for fractures in men include low body mass index, excessive alcohol consumption, current smoking, long-term corticosteroid use, previous fractures, and history of falls within the past year.
A recent systematic review of risk factors for osteoporosis in men also found that hypogonadism, history of cerebrovascular accident, and history of diabetes are associated with an increased risk of fractures, although their clinical use in identifying men who need further bone measurement testing is unclear. Although clinical risk assessment tools and imaging tests to diagnose osteoporosis seem to perform as well in men as in women, evidence on the effectiveness of medications to treat osteoporosis in men is lacking.
The review identified limited evidence on the effect of treatment of men with osteoporosis on the prevention of fractures. Potential harms of screening in men are likely to be similar to those in women. Evidence on harms of drug therapies in men is very limited. Data on how frequently men are screened for osteoporosis are limited. Several organizations have issued statements on screening in men at increased risk.
Progress toward the Healthy People objectives for osteoporosis have shown little change in the number of hip fracture hospitalizations among men According to the US Centers for Disease Control and Prevention, engaging in to minutes of at least moderate-intensity aerobic activity each week can reduce the risk of hip fractures, and performing balance and muscle-strengthening activities each week along with moderate-intensity aerobic activity can help prevent falls in older adults.
Additionally, the FRAX tool 8 is a computerized algorithm that calculates the year probability of hip fracture and MOF using clinical risk factors. FRAX models are country specific, as they include country epidemiology. The majority of reviewed studies focused on women. Treatment trials that focus on or include men and report on fracture outcomes rather than BMD as well as harms are needed. More studies are also needed that evaluate the direct effect of screening for osteoporosis either with BMD or clinical risk assessment tools on fracture outcomes.
Additional research is needed to determine whether clinical risk assessment tools alone without BMD could help identify patients at risk of fractures and help guide decisions to initiate medications to prevent fractures. The development of prognostic models incorporating age, baseline BMD, and hormone replacement therapy use 27 , 28 may also help identify optimal screening intervals.
Osteoporosis is a skeletal disorder characterized by loss of bone mass, microarchitectural deterioration of bone tissue, and decline in bone quality leading to increased bone fragility and risk of fractures. In the United States, the estimated prevalence of osteoporosis among the community-dwelling population 50 years and older in was The number of adults 50 years and older with osteoporosis will increase from Dietary reference intakes for calcium and vitamin D. Interventions to prevent falls in community-dwelling older adults: US Preventive Services Task Force recommendation statement.
Vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults: US Preventive Services Task Force recommendation statement. These statements address preventive health services for use in primary care clinical settings, including screening tests, counseling, and preventive medications. Want to use this article elsewhere? Get Permissions. Read the Issue. Sign Up Now. Nov 15, Issue. Am Fam Physician. Summary of Recommendations and Evidence The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older Table 1.
Grade: B Screen for osteoporosis. Grade: B No recommendation. Grade: I insufficient evidence Risk assessment Risk factors for osteoporotic fractures include parental history of hip fracture, smoking, excess alcohol consumption, and low body weight. Screening tests The most commonly used test is central DXA of the hip and lumbar spine. Treatments The U. Other relevant USPSTF recommendations The USPSTF has made recommendations on interventions to prevent falls in community-dwelling older adults and the use of vitamin D, calcium, or combined supplementation for the primary prevention of fractures in community-dwelling adults.
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Women 65 years and older. Postmenopausal women younger than 65 years at increased risk. Screen for osteoporosis. Grade: B. Risk assessment. Screening tests. Log in Best Value! If you have not had that test, you can leave the score blank.
The Canadian Association of Radiologists and Osteoporosis Canada also have a tool to help predict your risk of having a fracture in the next 10 years. Go to www. Most experts recommend that the decision to test younger women and men be made on an individual basis, depending on the risk of osteoporosis and whether the test results will help with treatment decisions.
To help you decide whether you should be tested for osteoporosis, see:. For more information, see the topic Osteoporosis. Health Tools help you make wise health decisions or take action to improve your health.
Author: Healthwise Staff. This information does not replace the advice of a doctor. Healthwise, Incorporated disclaims any warranty or liability for your use of this information. The USPSTF did not define a specific upper age limit for screening in women because the risk of fractures continues to increase with age, and treatment harms remain no greater than small.
Clinicians should take into account the patient's remaining lifespan when deciding whether to screen patients with significant illness. In the Fracture Intervention Trial, 1 the benefit of treatment emerged 18 to 24 months after initiation of treatment. The quantity and quality of data on osteoporotic fracture risk other than hip fracture are much less for Asian, American Indian or Alaska Native, Hispanic, and black women than for white women.
The USPSTF's recommendation to screen women 65 years or older for osteoporosis applies to all racial and ethnic groups because the harms of the screening tests are no greater than small, the consequences of failing to identify and treat women who have low bone mineral density BMD are considerable, and the optimal alternative age at which to screen nonwhite women is uncertain. Multiple instruments to predict the risk of low BMD and fractures have been developed and validated for use in postmenopausal women, but few have been validated for use in men.
To predict fracture risk, the area under the receiver-operating characteristic curve ranges from 0. Based on the U. FRAX tool, a year-old white woman with no other risk factors has a 9. White women between 50 and 64 years of age with equivalent or greater year fracture risks based on specific risk factors include, but are not limited to, the following persons: 1 a year-old current smoker with a body mass index less than 21 kg per m 2 , daily alcohol use, and parental fracture history; 2 a year-old woman with a parental fracture history; 3 a year-old woman with a body mass index less than 21 kg per m 2 and daily alcohol use; and 4 a year-old current smoker with daily alcohol use.
In general, estimated fracture risks in nonwhite women are lower than those for white women of the same age. Menopausal status is one factor that may affect a decision about screening in this age group. When deciding whether to screen men for osteoporosis, clinicians should consider the following factors: Potential preventable burden. Bone measurement tests may potentially detect osteoporosis in a large number of men and prevent a substantial part of the burden of fractures and fracture-related illness in this population.
The aging of the U. Potential harms. Potential harms of screening men are likely to be small and consist primarily of opportunity costs. Current practice. Routine screening of men currently is not a widespread practice.
Assuming that the relative benefits and harms of therapy in men are similar to those in women, the men most likely to benefit from screening would have year risks of osteoporotic fracture equal to or greater than those of year-old white women with no additional risk factors. The most commonly used bone measurement tests to screen for osteoporosis are DXA of the hip and lumbar spine, and quantitative ultrasonography of the calcaneus. Quantitative ultrasonography is less expensive and more portable than DXA and does not expose patients to ionizing radiation.
Quantitative ultrasonography of the calcaneus predicts fractures of the femoral neck, hip, and spine as effectively as DXA. However, current diagnostic and treatment criteria for osteoporosis rely on DXA measurements only, and criteria based on quantitative ultrasonography or a combination of quantitative ultrasonography and DXA have not been defined. The potential value of rescreening women whose initial screening test did not detect osteoporosis is to improve fracture risk prediction. A lack of evidence exists about optimal intervals for repeated screening and whether repeated screening is necessary in a woman with normal BMD.
Because of limitations in the precision of testing, a minimum of two years may be needed to reliably measure a change in BMD; however, longer intervals may be necessary to improve fracture risk prediction. A prospective study of 4, women 65 years or older found that neither repeated BMD measurement nor the change in BMD after eight years was more predictive of subsequent fracture risk than the original measurement.
In addition to adequate calcium and vitamin D intake and weight-bearing exercise, multiple drug therapies are approved by the U. Food and Drug Administration to reduce fractures, including bisphosphonates, parathyroid hormone, raloxifene, and estrogen. The choice of therapy should be an individual one based on the patient's clinical situation and the tradeoff between benefits and harms. Clinicians should provide patient education on how to use drug therapies to minimize adverse effects.
For example, esophageal irritation from bisphosphonate therapy can be reduced by taking the medication with a full glass of water and by not lying down for at least 30 minutes afterward.
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