Osteoporosis Screening May Be Necessary for Younger Postmenopausal Women

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The need for a baseline measurement is not a strong rationale for ordering bone mineral density (BMD) testing in younger postmenopausal women, according to a clinical review published in the Journal of the American Medical Association.

In this Q&A with author Carolyn J. Crandall, M.D., F.A.C.P., a professor of medicine at University of California, Los Angeles, we discuss osteoporosis screening in younger postmenopausal women.

The prevalence of primary osteoporosis increases with age and differs by sex and race/ethnicity. Osteoporosis should be diagnosed in patients with a history of hip or vertebral fracture not due to excessive trauma and in those with a BMD T-score of −2.5 or lower at the hip or lumbar spine. While osteoporotic fractures are associated with poor mobility, disability and reduced quality of life, drug treatment has been shown to reduce such fractures. Fracture risk for any given BMD is much lower in younger postmenopausal women compared with older women. The US Preventive Services Task Force (USPSTF) recommends routine osteoporosis screening with BMD testing among women aged 65 years and older, but there is controversy regarding osteoporosis screening in postmenopausal women younger than 65 years.

What are the main takeaways from your review?

Screening for osteoporosis among postmenopausal women younger than age 65 years should be performed selectively among women who have risk factors, and with the use of a formal risk prediction tool. Many such tools are available free of charge and are recommended by the USPSTF.

Should all women younger than 65 years at increased risk of osteoporosis undergo BMD testing?

For postmenopausal women younger than 65 years, those who have clinical risk factors (e.g. low body weight, parental history of hip fracture, smoking) should undergo further assessment with one of the five risk prediction tools recommended by the USPSTF guidelines to determine which ones should undergo BMD testing.

Of the five risk assessment tools suggested by the USPSTF, the Osteoporosis Self-Assessment Tool (OST), the Osteoporosis Risk Assessment Instrument (ORAI), the Osteoporosis Index of Risk (OSIRIS), and the Simple Calculated Osteoporosis Risk Estimation (SCORE) identify individuals with a BMD T-score of −2.5 or lower. Meanwhile, the Fracture Risk Assessment Tool (FRAX), a web-based calculator, estimates ten-year probabilities of hip and major osteoporotic fracture using clinical risk factors with or without femoral neck BMD.

How is the OST risk calculator of greater benefit than the FRAX, ORAI, OSIRIS, SCORE screening tools?

OST performs at least as well, and sometimes better than, the other tools recommended by the USPSTF for selecting screening candidates among postmenopausal women aged 50-64 years. Among the recommended tools, the OST score is probably the easiest to use, because it is based only on two clinical risk factors: weight and age.

What is the optimal osteoporosis screening strategy in younger postmenopausal women?

Women in this age group who meet the criteria for screening based on any of the five recommended risk prediction tools should undergo BMD screening. We recommend the OST tools as the simplest one because it is based only on two risk factors: weight and age.

Aside from BMD testing, what can clinicians do to help such women?

Regardless of BMD level, all postmenopausal women should adhere to the recommended daily intakes of calcium and vitamin D (per the Institute of Medicine recommendations), avoiding excessive alcohol intake, avoiding smoking, and obtaining recommended amounts of physical activity (a combination of weight-bearing and gentle resistance exercise).

Clinicians should remain aware of medications and medical conditions that may increase the risk of osteoporosis and fracture (e.g. rheumatoid arthritis, glucocorticoid use, uncontrolled hyperthyroidism, malabsorption, chronic liver disease, premature menopause at age <45 years).

How do your findings help clinicians and benefit patients?

We hope that this review will make clinicians more comfortable regarding how to approach the challenge of appropriately selecting candidates for BMD testing among young postmenopausal women.

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REFERENCE

Carolyn J. Crandall, Kristine E. Ensrud. “Osteoporosis Screening in Younger Postmenopausal Women.”JAMA. January 9, 2020. doi:10.1001/jama.2019.18343