U.S. Preventive Services Task Force banner
U.S. Preventive Services Task Force

You Are Here: U.S. Preventive Services Task Force > Topic Index > Screening: Osteoporosis > Recommendations and Rationale


Screening for Osteoporosis

Recommendations and Rationale

Summary of Recommendation

  • The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures (Go to Clinical Considerations for discussion of women at increased risk).

    Rating: B Recommendation.

    Rationale: 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. 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 or in women aged 60-64 who are not at increased risk for osteoporotic fractures.

    Rating: C Recommendation.

    Rationale: 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.


As part of the U.S. Preventive Services Task Force's ongoing commitment to clarity about its work and methods, it has begun to invite public comment on all draft recommendation statements before publication. Because of this new initiative, the final recommendation on screening for osteoporosis does not appear with this accompanying evidence review, which was published in Annals of Internal Medicine on July 6, 2010.

At that time, the public was offered the opportunity to comment on the draft recommendation statement. The comment period for this recommendation is now closed. After the USPSTF considers the comments and finalizes the recommendation, it will be available in Annals of Internal Medicine (www.annals.org) and on this page.


Screening for Osteoporosis, July 2010
Supporting Article (PDF File. 771 KB; PDF Help)
Systematic Evidence Review (PDF File. 3.2 MB; PDF Help)


Contents

Clinical Considerations
Scientific Evidence
Recommendations of Others
References
Members of the Task Force
Contact the Task Force
Available Products

Task Force Ratings
Strength of Recommendations and Quality of Evidence

Clinical Considerations

Return to Contents

Scientific Evidence

Epidemiology and Clinical Consequences

One-half of all postmenopausal women will have an osteoporosis-related fracture during their lives, including 25 percent who will develop a vertebral deformity6 and 15 percent who will suffer a hip fracture.7 Risk for fracture increases steadily as bone density declines, with no threshold. The commonly used definition of osteoporosis, derived from the World Health Organization (WHO) recommendations for epidemiologic studies, defines a BMD more than 2.5 standard deviations (SD) below the mean for a young healthy adult woman as osteoporosis, and a BMD between 1 and 2.5 SD below the mean as osteopenia. Based on the WHO criteria and DXA measurements at the femoral neck, population-based studies estimate that 41 percent of white women older than 50 have osteopenia.8 When bone density is measured at the hip, spine, and wrist, 15 percent of white women aged 50-59 and 70 percent of white women older than 80 have osteoporosis by WHO criteria at at least one site.9

The prevalence of osteoporosis in Mexican-American women is similar to the prevalence in white women. While rates of osteoporosis in African-American women are approximately one-half those of the other groups, they are still substantial (8 percent among women older than 50). Including all races, an estimated 14 million women older than 50 have osteopenia, and over 5 million have osteoporosis.10 The actuarial risk of a 65-year-old white woman sustaining a fracture by age 90 is 16 percent for the hip, 9 percent for distal forearm, and 5 percent for proximal humerus.9 Sixteen percent of postmenopausal women have osteoporosis of the lumbar spine.11

Accuracy and Reliability of Screening Tests

The USPSTF examined two components of screening:

Predicting Risk for Osteoporosis or Fracture

The USPSTF evaluated both individual risk factors and prescreening assessment tools that incorporate two or more of the risk factors. Risk for osteoporosis increases steadily and substantially with age. Relative to women aged 50-54, the odds of having osteoporosis were 5.9-fold higher in women aged 65-69 and 14.3-fold higher in women aged 75-79, in a study of over 200,000 postmenopausal women.12 Low body weight or body-mass index (BMI) and not using estrogen replacement were also consistently associated with osteoporosis but to a lesser degree than age. Other risk factors for fracture or low bone density found in some, but not all, studies include white or Asian ethnicity, history of fracture, family history of osteoporotic fracture, history of falls, low levels of physical activity, smoking, excessive alcohol or caffeine use, low calcium or vitamin D intake, and the use of various medications.

Specific instruments to assess risk for low bone density or fractures generally have moderate-to-high sensitivity and low specificity. The best validated instruments include the 3-item ORAI and the 6-item Simple Calculated Osteoporosis Risk Estimation tool (SCORE). The ORAI uses age, weight, and current use of hormone replacement therapy to identify women at risk for osteoporosis and has a sensitivity of 94 percent and specificity of 41 percent.4 The SCORE has a sensitivity of 91 percent and specificity of 40 percent in one validation population (n = 259), but it has much lower specificity in an older population.11

Among eight studies of prediction instruments for fracture risk, most had only modest sensitivity and specificity. The best performing model for hip fracture outcomes included age, gender, height, use of a walking aid, current smoking, and weight and had a sensitivity of 70 percent with specificity of 84 percent.13

Measurements of Bone Density

To date, bone density measured at the femoral neck by DXA is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites. Recent prospective studies have evaluated QUS measurements at the heel.14,15 While QUS measurements are not highly correlated with DXA measurements, a result in the osteoporotic range on either test is associated with an increased short-term probability of hip fracture. Several other radiologic methods that measure bone density at peripheral sites2 (including sites in the hand, heel, wrist, and forearm) include single photon absorptiometry, quantitative computed tomography, single-energy x-ray absorptiometry, and peripheral quantitative computed tomography.

In a study of over 200,000 women in a primary care setting, women diagnosed with osteoporosis by peripheral bone density measurements were 4 times more likely to have fractures than women with normal bone density over the subsequent year. 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, and the relevance of the reference range.

Effectiveness of Early Treatment

No controlled studies have evaluated the effect of screening on fractures or fracture-related morbidity. The Task Force reviewed the evidence to determine whether treatment for osteoporosis or low bone density in asymptomatic patients reduced fractures.

Available trials that reported fracture outcomes have examined the efficacy of bisphosphonates (alendronate and risendronate), estrogen, and selective estrogen receptor modulators (raloxifene) and calcitonin. A meta-analysis16 of 11 randomized trials17-27 involving a total of 12,855 women, found that alendronate significantly reduced vertebral fractures (RR, 0.52; 95 percent CI, 0.43-0.65), forearm fractures (RR, 0.48; 0.29-0.78), hip fractures (RR, 0.63; 0.43-0.92), and other nonvertebral fractures (RR, 0.51; 0.38-0.69). There were nonsignificant trends toward reduction in hip fractures. No randomized trial of treatment for osteoporosis has demonstrated an impact on mortality. One trial in women aged 70-79 with very low bone density (T-score less than -3) reported that risendronate reduced the risk for hip fracture (RR, 0.60; 95 percent CI, 0.40-0.90).28

There are no direct comparisons of alendronate and estrogen or raloxifene that report fracture outcomes. Estrogen, either alone or with progestin, consistently improves bone density in randomized trials. The effects of estrogen and the selective estrogen receptor modulators on fractures are reviewed in more detail in a separate report.13 Only a few small randomized clinical trials of estrogen indicate mixed results for fracture outcomes, but these studies are methodologically limited. Observational studies report a 25-30 percent reduction in the risk for hip fracture with estrogen use. A good-quality study of raloxifene reported a reduced risk for vertebral fractures (RR, 0.59; 95 percent CI, 0.50-0.70).29

The benefits of treating osteoporosis are larger in women at higher risk for fracture than in women at lower risk. The Fracture Intervention Trial (FIT) was conducted with 2 different groups of participants: 2,027 high-risk women who had T-scores of -1.6 or lower and pre-existing vertebral fractures, and 4,432 women with comparable T-scores but no pre-existing vertebral fracture. Over 3 years of treatment in high-risk women, alendronate reduced the risk for hip fracture (1.1 percent vs. 2.2 percent in the placebo group; relative hazard [RH], 0.49 [0.23-.099]) and the risk for any clinical fracture (18.2 percent vs. 13.6 percent; RH, 0.72 [0.58-0.90]). Among women with no pre-existing fracture, only the subgroup of patients who had a T-score less than -2.5 had a significant reduction in all clinical fractures from treatment, from 19.6 percent to 13.1 percent (RR, 0.64; 0.50-0.82). Alendronate had no effect on fractures among lower risk women who had T-scores between -1.6 and -2.5.

These results suggest that treatment will produce larger benefits in women with more risk factors for fracture, such as those who are older, have very low bone density, or have pre-existing vertebral fractures. FIT, as well as other therapy trials, enrolled highly selected patients thus limiting the generalizability of their results to asymptomatic women detected in a typical primary care setting.

There is little evidence regarding which patients are likely to benefit from screening and treatment. It is not known whether women who have a similar overall risk for fracture, but different bone densities, will benefit similarly from treatment. This uncertainty is clinically important because the lack of accepted criteria for initiating treatment remains a problem.

To estimate the benefits of routine screening for women in different age groups, the USPSTF used estimates from recent studies to project the number of fractures that would be prevented over 5 years from screening and treatment of a hypothetical cohort of 10,000 postmenopausal women.2 For women aged 55-59, more than 4,000 would need to be screened to prevent 1 hip fracture and more than 1,300 to prevent 1 vertebral fracture. For women older than 60, the number needed to screen to prevent 1 hip fracture is 1,856 for women aged 60-64, 731 for women aged 65-69, and 143 for women aged 75-79. The benefits of screening improve substantially in older women because osteoporosis is both more prevalent and more likely to lead to a fracture in older women.

In all age groups, the number needed to screen to prevent fractures is lower in women with important risk factors than it is in women who do not have risk factors. For women aged 60-64 who have a risk factor that increases the risk of osteoporosis by 100 percent and fracture by 70 percent, the number needed to screen is 1,092 and the number need to treat is 72 to prevent 1 hip fracture. These numbers are comparable to those of women aged 65-69 without risk factors.2 These estimates rely on many assumptions that may not apply for specific populations.

Potential Adverse Effects of Screening and Treatment

There are several potential harms of screening, although the empirical data for them are few. Women who undergo screening with bone density tests are more likely to begin hormone replacement therapy than women who do not. However, women who were diagnosed with osteoporosis after screening reported increased fears and anxiety in one study. Other potential harms may arise from inaccuracies and misinterpretations of bone density tests. Clinicians may have difficulty in using test results to provide accurate information to the patients because techniques used to measure bone density vary, test results are reported as T-scores, and information on how to integrate bone density results with other clinical predictors has not been clearly defined.2

In the alendronate treatment trials, gastrointestinal side effects occurred in about 25 percent of patients taking alendronate, but this was usually not higher (or only slightly higher) than the rate for placebo. Higher rates were observed among Medicare enrollees taking alendronate. In the FIT-II trial, the rates of ulcer disease were higher in the alendronate treatment group, with 2.2 percent developing ulcer disease, as opposed to 1.2 percent in the placebo group (P<0.05).30 The long-term adverse effects of alendronate are unknown. Harms of hormone replacement therapy include venous thromboembolic events, endometrial cancer, and cholecystitis, all with relative risks of approximately 2.0.12 Both raloxifene and tamoxifen are associated with thromboembolic events, leg cramps, and hot flashes.2

Return to Contents

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 aged 65 or older and younger postmenopausal women who have had a fracture or who have one or more risk factors for osteoporosis.31 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 of Bone and Mineral Research. The American Association of Clinical Endocrinologists released revised guidelines in 2001.32 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.33 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.

Return to Contents

Source: This recommendation first appeared in Ann Intern Med 2002;137:526-28.

References

1. U.S. Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd ed. Washington, DC: Office of Disease Prevention and Health Promotion; 1996.

2. Nelson HD, Helfand M, Woolf SH, et al. Screening for postmenopausal osteoporosis: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2002;137:529-41. (Available on the AHRQ Web site at http://www.uspreventiveservicestaskforce.org).

3. Nelson HD, Helfand M. Screening for Postmenopausal Osteoporosis. Systematic Evidence Review No. 17. (Prepared by the Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-97-0018.) Rockville, MD: Agency for Healthcare Research and Quality, Research and Quality, 2002. (Available at: http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=hscps2ed1996&part=A14728)

4. Cadarette SM, Jaglal SB, Kreiger N, et al. Development and validation of the Osteoporosis Risk Assessment Instrument to facilitate selection of women for bone densitometry. Can Med Assoc J 2000;162:1289-94.

5. Cadarette SM, Jaglal SB, Murray T, et al. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 2001;286(1):57-63.

6. Melton LJ 3rd, Kan SH, Frye MA, et al. Epidemiology of vertebral fractures in women. Am J Epidemiol 1989;129:1000-11.

7. Barrett JA, Baron JA, Karagas MR, et al. Fracture risk in the US Medicare population. J Clin Epidemiol 1999;52:243-9.

8. Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int 1994;4:368-81.

9. Melton LJ 3rd. How many women have osteoporosis now? J Bone Miner Res 1995;10:175-7.

10. Looker AC, Wahner HW, Dunn WL, et al. Updated data on proximal femur bone mineral levels of US adults. Osteoporos Int 1998;8:468-89.

11. Lydick E, Cook K, Turpin J, et al. Development and validation of a simple questionnaire to facilitate identification of women likely to have low bone density. Am J Manag Care 1998;4:37-48.

12. Siris ES, Miller PD, Barrett-Connor E, et al. Identification and fracture outcomes of undiagnosed low bone mineral density in postmenopausal women: Results from the National Osteoporosis Risk Assessment. JAMA 2001;286:2815-22.

13. Nelson HD, Helfand M. Hormone Replacement Therapy and Osteoporosis. Systematic Evidence Review No 12. (Prepared by the Oregon Health & Science University Evidence-based Practice Center under Contract No. 290-97-0018.) Rockville, MD: Agency for Healthcare Research and Quality 2002. (Available at http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=es12)

14. Burger H, de Laet CE, Weel AE, et al. Added value of bone mineral density in hip fracture risk scores. Bone 1999;25:369-74.

15. Bouxsein ML, Radloff SE. Quantitative ultrasound of the calcaneus reflects the mechanical properties of calcaneal trabecular bone. J Bone Miner Res 1997;12:839-46.

16. Cranney A, Wells G, Willan A, et al. Meta-analysis of alendronate for the treatment of postmenopausal women. Endocr Rev 2002; 23: 517-23.

17. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 1996:1535-41.

18. Adami S, Passeri M, Ortolani S, et al. Effects of oral alendronate and intranasal salmon calcitonin on bone mass and biochemical markers of bone turnover in postmenopausal women with osteoporosis. Bone 1995:383-90.

19. Bone HG, Downs RW Jr, Tucci JR, et al. Dose-response relationships for alendronate treatment in osteoporotic elderly women. Alendronate Elderly Osteoporosis Study Centers. J Clin Endocrinol Metab 1997:265-74.

20. Chesnut CH, 3rd, McClung MR, Ensrud KE, et al. Alendronate treatment of the postmenopausal osteoporotic woman: effect of multiple dosages on bone mass and bone remodeling. Am J Med 1995:144-52.

21. Hosking D, Chilvers CE, Christiansen C, et al. Prevention of bone loss with alendronate in postmenopausal women under 60 years of age. Early Postmenopausal Intervention Cohort Study Group. NEJM 1998:485-92.

22. Liberman UA, Weiss SR, Broll J, et al. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. NEJM 1995:1437-43.

23. McClung M, Clemmesen B, Daifotis A, et al. Alendronate prevents postmenopausal bone loss in women without osteoporosis. A double-blind, randomized, controlled trial. Alendronate Osteoporosis Prevention Study Group. Ann Intern Med 1998:253-61.

24. Greenspan SL, Parker RA, Ferguson L, et al. Early changes in biochemical markers of bone turnover predict the long-term response to alendronate therapy in representative elderly women: A randomized clinical trial. J Bone Miner Res 1998;13:1431-8.

25. Pols HA, Felsenberg D, Hanley DA, et al. Multinational, placebo-controlled, randomized trial of the effects of alendronate on bone density and fracture risk in postmenopausal women with low bone mass: results of the FOSIT study. Fosamax International Trial Study Group. Osteo Intern 1999:461-8.

26. Cummings SR, Black DM, Thompson DE, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 1998:2077-82.

27. Bonnick S, Rosen C, Mako B, et al. Alendronate vs calcium for treatment of osteoporosis in postmenopausal women. Bone 1998:23(5S):S476.

28. McClung M, Geusens P, Miller P, et al. Effect of risedronate on the risk of hip fracture in elderly women. NEJM 2001;344:333-40.

29. Lufkin EG, Whitaker MD, Nickelsen T, et al. Treatment of established postmenopausal osteoporosis with raloxifene: a randomized trial. J Bone Miner Res 1998;13:1747-54.

30. Cummings SR, Black DM, Thompson DE. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 1998;280:2077-82.

31. National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. Washington, DC: NOF; 1999. Available at: http://www.nof.org/physguide. Accessed July 29, 2002.

32. American Association of Clinical Endocrinologists. 2001 Medical Guidelines for Clinical Practice for the Prevention and Management of Postmenopausal Osteoporosis. Available at: http://www.aace.com/clin/guidelines/osteoporosis2001.pdf. Accessed February 27, 2002.

33. Osteoporosis Prevention, Diagnosis, and Therapy. NIH Consensus Statement Online 2000 March 27-29; 17(1): 1-36. Available at: http://odp.od.nih.gov/consensus/cons/111/111_statement.htm. Accessed February 27, 2002.

Return to Contents

Members of the Task Force

Members of the U.S. Preventive Services Task Force are Alfred O. Berg, M.D., M.P.H., Chair, USPSTF (Professor and Chair, Department of Family Medicine, University of Washington, Seattle, WA); Janet D. Allan, Ph.D., R.N., C.S., F.A.A.N., Vice-chair, USPSTF (Dean, School of Nursing, University of Maryland Baltimore, Baltimore, M.D.); Paul Frame, M.D. (Tri-County Family Medicine, Cohocton, NY, and Clinical Professor of Family Medicine, University of Rochester, Rochester, NY); Charles J. Homer, M.D., M.P.H. (Executive Director, National Initiative for Children's Healthcare Quality, Boston, MA); Mark S. Johnson, M.D., M.P.H. (Chair, Department of Family Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School, Newark, NJ); Jonathan D. Klein, M.D., M.P.H. (Associate Professor, Department of Pediatrics, University of Rochester School of Medicine, Rochester, NY); Tracy A. Lieu, M.D., M.P.H. (Associate Professor, Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, MA); Cynthia D. Mulrow, M.D., M.Sc. (Clinical Professor and Director, Department of Medicine, University of Texas Health Science Center, and Director, National Program Office for Robert Wood Johnson Generalist Physician Faculty Scholars Program, San Antonio, TX); C. Tracy Orleans, Ph.D. (Senior Scientist and Senior Program Officer, The Robert Wood Johnson Foundation, Princeton, NJ); Jeffrey F. Peipert, M.D., M.P.H. (Director of Research, Women and Infants' Hospital, Providence, RI), Nola J. Pender, Ph.D., R.N., F.A.A.N. (Professor Emeritus, University of Michigan, Ann Arbor, MI); Albert L. Siu, M.D., M.S.P.H. (Professor of Medicine, Chief of Division of General Internal Medicine, Mount Sinai School of Medicine, New York, NY); Steven M. Teutsch, M.D., M.P.H. (Senior Director, Outcomes Research and Management, Merck & Company, Inc., West Point, PA); Carolyn Westhoff, M.D., M.Sc. (Professor of Obstetrics and Gynecology and Professor of Public Health, Columbia University, New York, NY); and Steven H. Woolf, M.D., M.P.H. (Professor, Department of Family Practice and Department of Preventive and Community Medicine and Director of Research, Department of Family Practice, Virginia Commonwealth University, Fairfax, VA).

Return to Contents

Contact the Task Force

Address correspondence to: Chair, U.S. Preventive Services Task Force; c/o Project Director, USPSTF; 540 Gaither Road; Rockville, MD 20850..

Return to Contents

Available Products

This recommendation and rationale statement, plus complete information on which this statement is based, including evidence tables and references, are available on the USPSTF Web site at http://www.uspreventiveservicestaskforce.org.

Recommendations made by the USPSTF are independent of the U.S. Government. They should not be construed as an official position of AHRQ or the U.S. Department of Health and Human Services.

Source: This recommendation first appeared in Ann Intern Med 2002;137(6):526-8.

Return to Contents

Current as of September 2002


Internet Citation:

U.S. Preventive Services Task Force. Screening for Osteoporosis: Recommendations and Rationale. September 2002. http://www.uspreventiveservicestaskforce.org/3rduspstf/osteoporosis/osteorr.htm


 


USPSTF Program Office   540 Gaither Road, Rockville, MD 20850