Diagnostic Screening and Testing

In the majority of patients, the first sign of osteoporosis is a fragility fracture of the hip, wrist, or spine.2 Silent vertebral compression fractures (VCFs), which are often painless, can be the first indication of BMD loss (Table 2).2,9-11 VCFs often are discovered when the curvature of the spine becomes visibly noticeable. In the United States, an estimated 1.5 million VCFs occur annually, the vast majority of which do not attract clinical attention.12 Patients with VCFs have a 15% greater risk for death compared to those without VCFs.12

VCFs are imaged using a standard spine radiograph; although they can be found anywhere in the spinal column, they most commonly are found in the mid-thoracic (T7-T8) and thoracolumbar vertebrae (T12-L1).9 Per the National Osteoporosis Foundation, radiography is warranted if there is documented height loss, new back pain, postural changes, or a deformity on a chest radiograph.11 However, Cai et al recommend screening all women older than 50 years of age for VCFs with a 2-view spine radiograph.9 If a compression fracture is noted, the National Osteoporosis Foundation recommends repeat testing at regular intervals to confirm that further fractures are not occurring, regardless of whether the patient is receiving preventive drug therapy. Patients with untreated osteoporosis who experience a VCF have a 50% chance of having another within 3 years.11

All postmenopausal women older than 50 years of age should be screened initially for osteoporosis with the Fracture Risk Assessment (FRAX) tool to determine the need for BMD measurement. The FRAX tool uses risk factors such as age, weight, gender, smoking history, alcohol use, and previous fracture history to evaluate a patient’s risk for sustaining an osteoporotic-related fracture in the next 10 years.11,13 The United States Preventive Services Task Force recommends using a FRAX score (10-year fracture risk) of 9.3% as a cutoff to prompt further screening to assess BMD in women aged 50 to 64 years.13

Bone density is best measured with dual-energy x-ray absorptiometry (DXA) of the hip and spine.12 The BMD results are expressed as a T-score: standard deviations (SDs) from a young, healthy norm, usually female.14 A T-score greater than 2.5 (SDs from the normal) is considered positive for osteoporosis (Table 3).11 DXA is the preferred method for confirming a diagnosis, predicting future fracture risk, and monitoring of patients; if DXA screening is unavailable, calcaneal quantitative ultrasound is useful for screening.10


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The National Osteoporosis Foundation recommends the following indications for BMD testing: age older than 65 years for women and 70 years for men, regardless of clinical risk factors for fracture; fracture at or after age 50 years; and a diagnosis of rheumatoid arthritis or use of drugs associated with low bone mass or bone loss (eg, glucocorticoids) in adults.11 A clinician also should consider testing if a person complains of back pain, height loss of more than 0.5 inches in 1-year, total height loss of 1.5 inches from original height, or a radiograph demonstrating a break or bone loss in the spine.11

Despite the availability of testing, less than one-quarter of women eligible for BMD testing are screened; the compliance rate is 21.2% among women aged 50 to 64 years, 26.5% among women aged 65 to 79 years, and 12.8% among women older than 80 years.15 Even among those who are privately insured, fewer than 1 in 4 women older than of 65 years undergo osteoporosis screening for primary prevention.15