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.
