US Preventive Task Force Upholds Osteoporosis Screening Recommendations

A recent review of osteoporosis screening practices highlights the challenges in screening younger postmenopausal women.

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New osteoporosis screening guidelines maintain recommendations for women 65 and older to get bone density tests but raise fresh concerns about overdiagnosis and the reliability of risk assessments for younger postmenopausal women, according to an updated evidence review from the U.S. Preventive Services Task Force (USPSTF).

According to 2018 guidelines from the USPSTF, women aged 65 and older should be screened for osteoporosis using bone density testing, and postmenopausal women younger than 65 with an increased risk of fractures should also be screened using a clinical risk assessment tool.

The updated recommendation upholds the former guidelines.

Mortality Unchanged, Overdiagnosis Concerns Emerge

The primary purpose of screening for osteoporosis is to identify individuals who may benefit from medications that can reduce the risk of fractures resulting from low-energy trauma, such as falling from a standing height.

For the new recommendation statement, published in JAMA on Tuesday, the USPSTF analyzed clinical trials and studies from April 2016 to January 2024. Three randomized clinical trials focusing on European women aged 71 to 76 found that systematic screening led to a meaningful reduction in hip fractures: five or six fewer fractures per 1,000 women screened.

The review found no significant improvement in all-cause mortality rates associated with screening. There was insufficient data to evaluate the effectiveness of screening for fracture prevention in men.

During an osteoporosis screening, an X-ray is taken to measure bone density and assess the person’s fracture risk. Both men and women are at risk of osteoporosis when they get older, but postmenopausal women are particularly at risk.

During menopause, estrogen levels, one of the main sex hormones in women, decline dramatically, leading to a significant acceleration of bone loss. Estrogen plays a crucial role in maintaining bone density.

With lower estrogen levels, the body breaks down bone tissue faster than it rebuilds it, leading to a decrease in bone mass and density.

The researchers also found a substantial risk of overdiagnosis in their review. Around 12 percent to 24 percent of people may be overdiagnosed following osteoporosis screening.

Currently, osteoporosis is diagnosed by measuring bone mass density, assuming that a bone with lower bone mass density would be prone to fracture.

However, not all people with lower bone mass density fall and experience a fracture. For these people, a diagnosis of osteoporosis could lead to unnecessary anxiety, treatment with medications (which may carry potential side effects), and harm from overtreatment.

Modest Risk Reduction Using Medications

The review examined several osteoporosis medications, including bisphosphonates, which slow the actions of bone-breaking osteoclast cells, and denosumab, which helps strengthen bones and prevent fractures.

Evidence from the review suggests that these treatments could significantly reduce fracture occurrence without increasing severe adverse events. However, since most studies focused on postmenopausal women, the findings may not apply equally to men and younger populations.

Overall, systematic screening in older women showed only modest absolute risk reduction for hip and major fractures. The authors emphasized the need for more research on screening younger populations and men, calling for studies including more diverse demographic groups.

Challenges in Screening Younger Postmenopausal Women

One change the USPSTF made to the screening recommendations was suggesting postmenopausal women younger than 65 who are at an increased risk of fractures be clinically assessed for fracture risk before they get screened for osteoporosis.

In an accompanying editorial, Drs. Kristine E. Ensrud and Carolyn J. Crandall highlighted the challenges and complexities associated with identifying osteoporosis risk in younger postmenopausal women, stating that no existing instrument accurately estimates the long-term risk of osteoporotic fracture in this population.

Therefore, a clinical assessment for fracture risk relies more heavily on physicians’ judgment of various risk factors, which can lead to variable outcomes. This also demands more time and clinical expertise—resources already stretched thin in many primary care practices.