This is the current release of the guideline.

This release updates a previously published guideline: U.S. Preventive Services Task Force. Screening for postmenopausal osteoporosis. In: Guide to clinical preventive services. 2nd ed. Baltimore (MD): Williams & Wilkins; 1996.

Osteoporosis

Risk Assessment
Screening

Family Practice
Internal Medicine
Obstetrics and Gynecology

Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Physician Assistants
Physicians
Students

• To summarize the current U.S. Preventive Services Task Force (USPSTF) recommendations on screening for osteoporosis and the supporting scientific evidence
• To update the 1996 recommendations contained in the Guide to Clinical Preventive Services, Second Edition

• Postmenopausal women aged 65 and older
• Postmenopausal women aged 60 to 64 at increased risk for osteoporotic fractures

1. Risk assessment using individual risk factors or instruments, such as the Osteoporosis Risk Assessment Instrument (ORAI), and the Simple Calculated Osteoporosis Risk Estimation (SCORE) tools
2. Bone mineral density (BMD) measurements using:
   • Dual-energy X-ray absorptiometry (DXA)
   • Quantitative ultrasonography (QUS)
   • Radiographic absorptiometry
   • Single energy x-ray absorptiometry
   • Peripheral dual-energy x-ray absorptiometry
   • Peripheral quantitative computed tomography

Screening

Sensitivity and specificity of screening interventions

Treatment

Effectiveness of treatment, measured by fracture reduction

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Risk Factors

The initial literature search included 6,194 titles and abstracts about risk factors. Of these, 230 were reviewed, and 18 studies about risk factor assessment were included.

Bone Measurement

For bone measurement tests, 2,125 titles and abstracts were initially found, and 85 studies were reviewed.

Treatment

Not stated

Weighting According to a Rating Scheme (Scheme Given)

The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence on a 3-point scale (good, fair, or poor).

Good

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of evidence on health outcomes.

Poor

Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

Note: See the companion document titled "Current Methods of the U.S. Preventive Services Task Force: a Review of the Process" (Am J Prev Med 2001 Apr;20[3S]:21-35) for a more detailed description of the methods used to assess the quality and strength of the evidence for the three strata at which the evidence was reviewed.

Review of Published Meta-Analyses
Systematic Review with Evidence Tables

Note from the National Guideline Clearinghouse (NGC): A systematic evidence review was prepared by the Oregon Health Sciences University, Evidence-based Practice Center (EPC) for the Agency for Healthcare Research and Quality (AHRQ) for use by the U.S. Preventive Services Task Force (USPSTF) (see the "Companion Documents" field).

After assessing the internal validity of individual studies, the Evidence-based Practice Center (EPC) staff created an outcomes table to summarize the number of hip and vertebral fractures prevented based on age-specific prevalence rates, and treatment effects obtained from results of the reviewed studies. They conducted a sensitivity analysis to determine the influence of risk factors on the number needed to screen.

Balance Sheets
Expert Consensus

When the overall quality of the evidence is judged to be good or fair, the U.S. Preventive Services Task Force (USPSTF) proceeds to consider the magnitude of net benefit to be expected from implementation of the preventive service. Determining net benefit requires assessing both the magnitude of benefits and the magnitude of harms and weighing the two.

The USPSTF classifies benefits, harms, and net benefits on a 4-point scale: "substantial," "moderate," "small," and "zero/negative."

"Outcomes tables" (similar to 'balance sheets') are the USPSTF's standard resource for estimating the magnitude of benefit. These tables, prepared by the topic teams for use at USPSTF meetings, compare the condition specific outcomes expected for a hypothetical primary care population with and without use of the preventive service. These comparisons may be extended to consider only people of specified age or risk groups or other aspects of implementation. Thus, outcomes tables allow the USPSTF to examine directly how the preventive services affects benefits for various groups.

When evidence on harms is available, the topic teams assess its quality in a manner like that for benefits and include adverse events in the outcomes tables. When few harms data are available, the USPSTF does not assume that harms are small or nonexistent. It recognizes a responsibility to consider which harms are likely and judge their potential frequency and the severity that might ensue from implementing the service. It uses whatever evidence exists to construct a general confidence interval on the 4-point scale (e.g., substantial, moderate, small, and zero/negative).

Value judgments are involved in using the information in an outcomes table to rate either benefits or harms on the USPSTF's 4-point scale. Value judgments are also needed to weigh benefits against harms to arrive a rating of net benefit.

In making its determinations of net benefit, the USPSTF strives to consider what it believes are the general values of most people. It does this with greater confidence for certain outcomes (e.g., death) about which there is little disagreement about undesirability, but it recognizes that the degree of risk people are willing to accept to avert other outcomes (e.g., cataracts) can vary considerably. When the USPSTF perceives that preferences among individuals vary greatly, and that these variations are sufficient to make trade-off of benefits and harms a 'close-call', then it will often assign a C recommendation (see the "Recommendation Rating Scheme" field). This recommendation indicates the decision is likely to be sensitive to individual patient preferences.

The USPSTF uses its assessment of the evidence and magnitude of net benefit to make recommendations. The general principles the USPSTF follows in making recommendations are outlined in Table 5 of the companion document cited below. The USPSTF liaisons on the topic team compose the first drafts of the recommendations and rationale statements, which the full panel then reviews and edits. Recommendations are based on formal voting procedures that include explicit rules for determining the views of the majority.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, or I), reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A

The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians provide [the service] to eligible patients. (The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.)

B

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians provide [the service] to eligible patients. (The USPSTF found at least fair evidence that [the service] improves health outcomes and concludes that benefits outweigh harms.)

C

The U.S. Preventive Services Task Force (USPSTF) makes no recommendation for or against routine provision of [the service]. (The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms it too close to justify a general recommendation.)

D

The U.S. Preventive Services Task Force (USPSTF) recommends against routinely providing [the service] to asymptomatic patients. (The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.)

I

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. (Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.)

A formal cost analysis was not performed and published cost analyses were not reviewed.

External Peer Review
Internal Peer Review

Peer Review. Before the U.S. Preventive Services Task Force makes its final determinations about recommendations on a given preventive service, the Evidence-based Practice Center and the Agency for Healthcare Research and Quality send a draft systematic evidence review to 4 to 6 external experts and to federal agencies and professional and disease-based health organizations with interests in the topic. They ask the experts to examine the review critically for accuracy and completeness and to respond to a series of specific questions about the document. After assembling these external review comments and documenting the proposed response to key comments, the topic team presents this information to the Task Force in memo form. In this way, the Task Force can consider these external comments and a final version of the systematic review before it votes on its recommendations about the service. Draft recommendations are then circulated for comment from reviewers representing professional societies, voluntary organizations and Federal agencies. These comments are discussed before the whole U.S. Preventive Services Task Force before final recommendations are confirmed.

Recommendations of Others. Recommendations for osteoporosis screening from the following groups were discussed: National Osteoporosis Foundation (in collaboration with other professional organizations), American Association of Clinical Endocrinologists, U.S. National Institutes of Health Consensus Development Conference, and the Canadian Task Force on Preventive Health Care.

The U.S. Preventive Services Task Force grades its recommendations (A, B, C, D, or I) and the quality of the overall evidence for a service (good, fair, poor). The definitions of these grades can be found at the end of the "Major Recommendations" field.

The 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 (see Clinical Considerations for discussion of women at increased risk). B recommendation.

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. C recommendation.

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.

Clinical Considerations

• Modeling analysis suggests that the absolute benefits of screening for osteoporosis among women aged 60-64 who are at increased risk for osteoporosis and fracture are comparable to those of routine screening in older women. The exact risk factors that should trigger screening in this age group are difficult to specify based on evidence. Lower body weight (weight <70 kg) is the single best predictor of low bone mineral density. Low weight and no current use of estrogen therapy are incorporated with age into the 3-item Osteoporosis Risk Assessment Instrument (ORAI). There is less evidence to support the use of other individual risk factors (for example, smoking, weight loss, family history, decreased physical activity, alcohol or caffeine use, or low calcium and vitamin D intake) as a basis for identifying high-risk women under age 65. At any given age, African American women on average have higher bone mineral density (BMD) than white women and are thus less likely to benefit from screening. Additional characteristics of screening tools are discussed in the "Accuracy and Reliability of Screening Tests" section of the original guideline document.
• Among different bone measurement tests performed at various anatomical sites, bone density measured at the femoral neck by dual-energy x-ray absorptiometry (DXA) is the best predictor of hip fracture and is comparable to forearm measurements for predicting fractures at other sites. Other technologies for measuring peripheral sites include quantitative ultrasonography (QUS), radiographic absorptiometry, single energy x-ray absorptiometry, peripheral dual-energy x-ray absorptiometry, and peripheral quantitative computed tomography. Recent data suggest that peripheral bone density testing in the primary care setting can also identify postmenopausal women who have a higher risk for fracture over the short term (1 year). Further research is needed to determine the accuracy of peripheral bone density testing in comparison with dual-energy x-ray absorptiometry (DXA). 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 used, and the relevance of the reference range.
• Estimates of the benefits of detecting and treating osteoporosis are based largely on studies of bisphosphonates. Some women, however, may prefer other treatment options (for example, hormone replacement therapy, selective estrogen receptor modulators, or calcitonin) based on personal preferences or risk factors. Clinicians should review with patients the relative benefits and harms of available treatment options, and uncertainties about their efficacy and safety, to facilitate an informed choice.
• No studies have evaluated the optimal intervals for repeated screening. Because of limitations in the precision of testing, a minimum of 2 years may be needed to reliably measure a change in bone mineral density; however, longer intervals may be adequate for repeated screening to identify new cases of osteoporosis. Yield of repeated screening will be higher in older women, those with lower BMD at baseline, and those with other risk factors for fracture.
• There are no data to determine the appropriate age to stop screening and few data on osteoporosis treatment in women older than 85. Patients who receive a diagnosis of osteoporosis fall outside the context of screening but may require additional testing for diagnostic purposes or to monitor response to treatment.

Definitions:

The U.S. Preventive Services Task Force (USPSTF) grades its recommendations according to one of five classifications (A, B, C, D, or I), reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).

A

The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians provide [the service] to eligible patients. (The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.)

B

The U.S. Preventive Services Task Force (USPSTF) recommends that clinicians provide [the service] to eligible patients. (The USPSTF found at least fair evidence that [the service] improves health outcomes and concludes that benefits outweigh harms.)

C

The U.S. Preventive Services Task Force (USPSTF) makes no recommendation for or against routine provision of [the service]. (The US Preventive Services Task Force found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms it too close to justify a general recommendation.)

D

The U.S. Preventive Services Task Force (USPSTF) recommends against routinely providing [the service] to asymptomatic patients. (The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.)

I

The U.S. Preventive Services Task Force (USPSTF) concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. (Evidence that [the service] is effective is lacking, of poor quality, or conflicting and the balance of benefits and harms cannot be determined.)

The U.S. Preventive Services Task Force (USPSTF) grades the quality of the overall evidence for a service on a 3-point scale (good, fair, or poor).

Good

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.

Fair

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of evidence on health outcomes.

Poor

Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

None provided

The type of evidence supporting each recommendation is identified in the "Major Recommendations" field.

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.
• In the alendronate treatment trials, gastrointestinal side effects occurred in about 25% 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 Fracture Intervention Trial (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). 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. Both raloxifene and tamoxifen are associated with thromboembolic events, leg cramps, and hot flashes.

Staying Healthy

Effectiveness
Patient-centeredness

Not applicable: The guideline was not adapted from another source.

1996 (revised 2002 Sep 17)

United States Preventive Services Task Force - Independent Expert Panel

The U.S. Preventive Services Task Force (USPSTF) is a Federally-appointed panel of independent experts. Conclusions of the USPSTF do not necessarily reflect policy of the U.S. Department of Health and Human Services (DHHS) or DHHS agencies.

United States Government

U.S. Preventive Services Task Force (USPSTF)

Task Force Members: Alfred O. Berg, MD, MPH (Chair); Janet D. Allan, PhD, RN, CS, FAAN (Vice-chair); Paul Frame, MD; Charles J. Homer, MD, MPH; Mark S. Johnson, MD, MPH; Jonathan D. Klein, MD, MPH; Tracy A. Lieu, MD, MPH; Cynthia D. Mulrow, MD, MSc; Tracy C. Orleans, PhD; Jeffrey F. Peipert, MD, MPH; Nola J. Pender, PhD, RN, FAAN; Albert L. Siu, MD, MSPH; Steven M. Teutsch, MD, MPH; Carolyn Westhoff, MD, MSc; Steven H. Woolf, MD, MPH.

The U.S. Preventive Services Task force has an explicit policy concerning conflict of interest. All members and evidence-based practice center (EPC) staff disclose at each meeting if they have an important financial conflict for each topic being discussed. Task Force members and EPC staff with conflicts can participate in discussions about evidence, but members abstain from voting on recommendations about the topic in question.

From: Harris RP, Helfand M, Woolf SH, Lohr KN, Mulrow, CD, Teutsch SM, Atkins D. Current methods of the U.S. Preventive Services Task Force: a review of the process. Methods Work Group, Third U.S. Preventive Services Task Force. Am J Prev Med 2001 Apr;20(3S):21-35.

This is the current release of the guideline.

This release updates a previously published guideline: U.S. Preventive Services Task Force. Screening for postmenopausal osteoporosis. In: Guide to clinical preventive services. 2nd ed. Baltimore (MD): Williams & Wilkins; 1996.

This summary was completed by ECRI on June 30, 1998. The information was verified by the guideline developer on December 1, 1998. This summary was updated on September 9, 2002. The information was verified by the guideline developer on September 10, 2002.