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Screening for osteoporosis

Elaine W Yu, MD
Section Editors
Clifford J Rosen, MD
Kenneth E Schmader, MD
Deputy Editor
Jean E Mulder, MD


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. Approaches to BMD screening vary from country to country, 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".)


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 bone mineral density (BMD) decreases. (See "Clinical manifestations, diagnosis, and evaluation of osteoporosis in postmenopausal women", section on 'T-score' and "Overview of dual-energy x-ray absorptiometry".)


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 bone mineral density (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".)

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Literature review current through: Dec 2017. | This topic last updated: Dec 01, 2017.
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  1. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006; 17:1726.
  2. Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int 1997; 7:407.
  3. Burge R, Dawson-Hughes B, Solomon DH, et al. Incidence and economic burden of osteoporosis-related fractures in the United States, 2005-2025. J Bone Miner Res 2007; 22:465.
  4. Rogmark C, Sernbo I, Johnell O, Nilsson JA. Incidence of hip fractures in Malmö, Sweden, 1992-1995. A trend-break. Acta Orthop Scand 1999; 70:19.
  5. Jaglal SB, Weller I, Mamdani M, et al. Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong? J Bone Miner Res 2005; 20:898.
  6. Kannus P, Niemi S, Parkkari J, et al. Nationwide decline in incidence of hip fracture. J Bone Miner Res 2006; 21:1836.
  7. Nymark T, Lauritsen JM, Ovesen O, et al. Decreasing incidence of hip fracture in the Funen County, Denmark. Acta Orthop 2006; 77:109.
  8. Leslie WD, O'Donnell S, Jean S, et al. Trends in hip fracture rates in Canada. JAMA 2009; 302:883.
  9. Johansson H, Oden A, Johnell O, et al. Optimization of BMD measurements to identify high risk groups for treatment--a test analysis. J Bone Miner Res 2004; 19:906.
  10. Cummings SR, Nevitt MC, Browner WS, et al. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med 1995; 332:767.
  11. Johnell O, Kanis JA, Black DM, et al. Associations between baseline risk factors and vertebral fracture risk in the Multiple Outcomes of Raloxifene Evaluation (MORE) Study. J Bone Miner Res 2004; 19:764.
  12. 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.
  13. 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. CMAJ 2000; 162:1289.
  14. Cadarette SM, Jaglal SB, Murray TM, et al. Evaluation of decision rules for referring women for bone densitometry by dual-energy x-ray absorptiometry. JAMA 2001; 286:57.
  15. Mauck KF, Cuddihy MT, Atkinson EJ, Melton LJ 3rd. Use of clinical prediction rules in detecting osteoporosis in a population-based sample of postmenopausal women. Arch Intern Med 2005; 165:530.
  16. Kanis JA, Burlet N, Cooper C, et al. European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2008; 19:399.
  17. Bettica P, Taylor AK, Talbot J, et al. Clinical performances of galactosyl hydroxylysine, pyridinoline, and deoxypyridinoline in postmenopausal osteoporosis. J Clin Endocrinol Metab 1996; 81:542.
  18. Seibel MJ, Woitge H, Scheidt-Nave C, et al. Urinary hydroxypyridinium crosslinks of collagen in population-based screening for overt vertebral osteoporosis: results of a pilot study. J Bone Miner Res 1994; 9:1433.
  19. McLaren AM, Hordon LD, Bird HA, Robins SP. Urinary excretion of pyridinium crosslinks of collagen in patients with osteoporosis and the effects of bone fracture. Ann Rheum Dis 1992; 51:648.
  20. Seibel MJ, Cosman F, Shen V, et al. Urinary hydroxypyridinium crosslinks of collagen as markers of bone resorption and estrogen efficacy in postmenopausal osteoporosis. J Bone Miner Res 1993; 8:881.
  21. Christiansen C, Riis BJ, Rødbro P. Prediction of rapid bone loss in postmenopausal women. Lancet 1987; 1:1105.
  22. Hansen MA, Overgaard K, Riis BJ, Christiansen C. Role of peak bone mass and bone loss in postmenopausal osteoporosis: 12 year study. BMJ 1991; 303:961.
  23. Raisz LG. Clinical practice. Screening for osteoporosis. N Engl J Med 2005; 353:164.
  24. Gausden EB, Nwachukwu BU, Schreiber JJ, et al. Opportunistic Use of CT Imaging for Osteoporosis Screening and Bone Density Assessment: A Qualitative Systematic Review. J Bone Joint Surg Am 2017; 99:1580.
  25. Nayak S, Olkin I, Liu H, et al. Meta-analysis: accuracy of quantitative ultrasound for identifying patients with osteoporosis. Ann Intern Med 2006; 144:832.
  26. Díez-Pérez A, Marín F, Vila J, et al. Evaluation of calcaneal quantitative ultrasound in a primary care setting as a screening tool for osteoporosis in postmenopausal women. J Clin Densitom 2003; 6:237.
  27. Varney LF, Parker RA, Vincelette A, Greenspan SL. Classification of osteoporosis and osteopenia in postmenopausal women is dependent on site-specific analysis. J Clin Densitom 1999; 2:275.
  28. Marín F, López-Bastida J, Díez-Pérez A, et al. Bone mineral density referral for dual-energy X-ray absorptiometry using quantitative ultrasound as a prescreening tool in postmenopausal women from the general population: a cost-effectiveness analysis. Calcif Tissue Int 2004; 74:277.
  29. Bouxsein M, Parker RA, Greenspan SL. Forearm bone mineral densitometry cannot be used to monitor improvements in hip and spine bone density after 2.5 years of alendronate therapy. Bone 1998; 23:S312.
  30. Black DM, Cummings SR, Genant HK, et al. Axial and appendicular bone density predict fractures in older women. J Bone Miner Res 1992; 7:633.
  31. 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.
  32. Blake GM, Fogelman I. Peripheral or central densitometry: does it matter which technique we use? J Clin Densitom 2001; 4:83.
  33. Eastell R, Wahner HW, O'Fallon WM, et al. Unequal decrease in bone density of lumbar spine and ultradistal radius in Colles' and vertebral fracture syndromes. J Clin Invest 1989; 83:168.
  34. Melton LJ 3rd, Atkinson EJ, O'Fallon WM, et al. Long-term fracture prediction by bone mineral assessed at different skeletal sites. J Bone Miner Res 1993; 8:1227.
  35. Cummings SR, Black D. Bone mass measurements and risk of fracture in Caucasian women: a review of findings from prospective studies. Am J Med 1995; 98:24S.
  36. Davis JW, Ross PD, Wasnich RD. Evidence for both generalized and regional low bone mass among elderly women. J Bone Miner Res 1994; 9:305.
  37. Kanis JA, Johnell O, Oden A, et al. The use of multiple sites for the diagnosis of osteoporosis. Osteoporos Int 2006; 17:527.
  38. Kanis JA, Johnell O. Requirements for DXA for the management of osteoporosis in Europe. Osteoporos Int 2005; 16:229.
  39. Baim S, Binkley N, Bilezikian JP, et al. Official Positions of the International Society for Clinical Densitometry and executive summary of the 2007 ISCD Position Development Conference. J Clin Densitom 2008; 11:75.
  40. Cummings SR, Bates D, Black DM. Clinical use of bone densitometry: scientific review. JAMA 2002; 288:1889.
  41. Consensus development conference: diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 1993; 94:646.
  42. http://www.aace.com/pub/pdf/guidelines/OsteoGuidelines2010.pdf (Accessed on January 10, 2011).
  43. http://www.uspreventiveservicestaskforce.org/uspstf10/osteoporosis/osteors.htm (Accessed on February 09, 2011).
  44. Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ 2010; 182:1864.
  45. U.S. Preventive Services Task Force. Screening for osteoporosis: U.S. preventive services task force recommendation statement. Ann Intern Med 2011; 154:356.
  46. Leslie WD, Schousboe JT. A review of osteoporosis diagnosis and treatment options in new and recently updated guidelines on case finding around the world. Curr Osteoporos Rep 2011; 9:129.
  47. Cosman F, de Beur SJ, LeBoff MS, et al. Clinician's Guide to Prevention and Treatment of Osteoporosis. Osteoporos Int 2014; 25:2359.
  48. https://www.uspreventiveservicestaskforce.org/Page/Name/us-preventive-services-task-force-opportunities-for-public-comment (Accessed on November 28, 2017).
  49. Watts NB, Adler RA, Bilezikian JP, et al. Osteoporosis in men: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab 2012; 97:1802.
  50. Qaseem A, Snow V, Shekelle P, et al. Screening for osteoporosis in men: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008; 148:680.
  51. Compston J, Cooper A, Cooper C, et al. Guidelines for the diagnosis and management of osteoporosis in postmenopausal women and men from the age of 50 years in the UK. Maturitas 2009; 62:105.
  52. National Osteoporosis Guideline Group (NOGG). http://www.shef.ac.uk/NOGG/index.html (Accessed on June 29, 2011).
  53. Rabar S, Lau R, O'Flynn N, et al. Risk assessment of fragility fractures: summary of NICE guidance. BMJ 2012; 345:e3698.
  54. Barr RJ, Stewart A, Torgerson DJ, Reid DM. Population screening for osteoporosis risk: a randomised control trial of medication use and fracture risk. Osteoporos Int 2010; 21:561.
  55. Shepstone L, Fordham R, Lenaghan E, et al. A pragmatic randomised controlled trial of the effectiveness and cost-effectiveness of screening older women for the prevention of fractures: rationale, design and methods for the SCOOP study. Osteoporos Int 2012; 23:2507.
  56. Elders PJM, Merlijn T, Swart KMA, et al. Design of the SALT Osteoporosis Study: a randomised pragmatic trial, to study a primary care screening and treatment program for the prevention of fractures in women aged 65 years or older. BMC Musculoskelet Disord 2017; 18:424.
  57. Nelson HD, Haney EM, Dana T, et al. Screening for osteoporosis: an update for the U.S. Preventive Services Task Force. Ann Intern Med 2010; 153:99.
  58. Genant HK, Engelke K, Fuerst T, et al. Noninvasive assessment of bone mineral and structure: state of the art. J Bone Miner Res 1996; 11:707.
  59. Yamada M, Ito M, Hayashi K, et al. Dual energy X-ray absorptiometry of the calcaneus: comparison with other techniques to assess bone density and value in predicting risk of spine fracture. AJR Am J Roentgenol 1994; 163:1435.
  60. Kelly TL, Slovik DM, Schoenfeld DA, Neer RM. Quantitative digital radiography versus dual photon absorptiometry of the lumbar spine. J Clin Endocrinol Metab 1988; 67:839.
  61. Ross PD, Davis JW, Epstein RS, Wasnich RD. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med 1991; 114:919.
  62. Seeley DG, Browner WS, Nevitt MC, et al. Which fractures are associated with low appendicular bone mass in elderly women? The Study of Osteoporotic Fractures Research Group. Ann Intern Med 1991; 115:837.
  63. Hui SL, Slemenda CW, Johnston CC Jr. Baseline measurement of bone mass predicts fracture in white women. Ann Intern Med 1989; 111:355.
  64. Cummings SR, Black DM, Nevitt MC, et al. Bone density at various sites for prediction of hip fractures. The Study of Osteoporotic Fractures Research Group. Lancet 1993; 341:72.
  65. Cummings SR, Black DM, Nevitt MC, et al. Appendicular bone density and age predict hip fracture in women. The Study of Osteoporotic Fractures Research Group. JAMA 1990; 263:665.
  66. Greenspan SL, Myers ER, Maitland LA, et al. Fall severity and bone mineral density as risk factors for hip fracture in ambulatory elderly. JAMA 1994; 271:128.
  67. Rubin SM, Cummings SR. Results of bone densitometry affect women's decisions about taking measures to prevent fractures. Ann Intern Med 1992; 116:990.
  68. Kanis JA, Seeman E, Johnell O, et al. The perspective of the International Osteoporosis Foundation on the official positions of the International Society for Clinical Densitometry. Osteoporos Int 2005; 16:456.
  69. Ankjaer-Jensen A, Johnell O. Prevention of osteoporosis: cost-effectiveness of different pharmaceutical treatments. Osteoporos Int 1996; 6:265.
  70. Borgström F, Carlsson A, Sintonen H, et al. The cost-effectiveness of risedronate in the treatment of osteoporosis: an international perspective. Osteoporos Int 2006; 17:996.
  71. Johnell O, Jönsson B, Jönsson L, Black D. Cost effectiveness of alendronate (fosamax) for the treatment of osteoporosis and prevention of fractures. Pharmacoeconomics 2003; 21:305.
  72. Ström O, Borgström F, Sen SS, et al. Cost-effectiveness of alendronate in the treatment of postmenopausal women in 9 European countries--an economic evaluation based on the fracture intervention trial. Osteoporos Int 2007; 18:1047.
  73. Ito K, Elkin EB, Girotra M, Morris MJ. Cost-effectiveness of fracture prevention in men who receive androgen deprivation therapy for localized prostate cancer. Ann Intern Med 2010; 152:621.
  74. Kanis JA, Adams J, Borgström F, et al. The cost-effectiveness of alendronate in the management of osteoporosis. Bone 2008; 42:4.
  75. Liu H, Michaud K, Nayak S, et al. The cost-effectiveness of therapy with teriparatide and alendronate in women with severe osteoporosis. Arch Intern Med 2006; 166:1209.
  76. Hillier TA, Stone KL, Bauer DC, et al. Evaluating the value of repeat bone mineral density measurement and prediction of fractures in older women: the study of osteoporotic fractures. Arch Intern Med 2007; 167:155.
  77. Leslie WD, Morin SN, Lix LM, Manitoba Bone Density Program. Rate of bone density change does not enhance fracture prediction in routine clinical practice. J Clin Endocrinol Metab 2012; 97:1211.
  78. Berger C, Langsetmo L, Joseph L, et al. Association between change in BMD and fragility fracture in women and men. J Bone Miner Res 2009; 24:361.
  79. Nguyen TV, Center JR, Eisman JA. Femoral neck bone loss predicts fracture risk independent of baseline BMD. J Bone Miner Res 2005; 20:1195.
  80. Ahmed LA, Emaus N, Berntsen GK, et al. Bone loss and the risk of non-vertebral fractures in women and men: the Tromsø study. Osteoporos Int 2010; 21:1503.
  81. Berry SD, Samelson EJ, Pencina MJ, et al. Repeat bone mineral density screening and prediction of hip and major osteoporotic fracture. JAMA 2013; 310:1256.
  82. Gourlay ML, Fine JP, Preisser JS, et al. Bone-density testing interval and transition to osteoporosis in older women. N Engl J Med 2012; 366:225.