USPSTF Updates Osteoporosis Screening Guidelines: Recommends DXA Testing for Women 65 and Older

Key Insights

• The U.S. Preventive Services Task Force has issued new recommendations for osteoporosis screening, maintaining its guidance for women 65 and older while specifying DXA testing as the preferred screening method.
• Clinical data shows significant benefits of screening, with a 17% reduction in hip fractures and 6% reduction in major osteoporotic fractures among screened populations.
• For postmenopausal women under 65, the guidelines now emphasize clinical risk assessment tools like FRAX, though experts suggest simpler tools may be more effective for younger populations.

The U.S. Preventive Services Task Force (USPSTF) has released its final recommendation statement on osteoporosis screening, maintaining strong support for screening in women 65 and older while providing more specific guidance on screening methods and risk assessment approaches.

The task force issued a Grade B recommendation for screening all women aged 65 and older, as well as younger postmenopausal women aged 40-64 who have elevated risk factors. The recommendations, published in JAMA, are based on moderate certainty evidence showing meaningful benefits in fracture prevention.

Clinical Evidence Supporting Screening

A comprehensive systematic review of 145 studies demonstrated significant benefits of osteoporosis screening programs. Compared to usual care, screening was associated with:

• 17% reduction in hip fractures (RR 0.83, 95% CI 0.73-0.93)
• 6% reduction in major osteoporotic fractures (RR 0.94, 95% CI 0.88-0.99)
• Absolute risk reduction of 5 fewer hip fractures and 6 fewer major osteoporotic fractures per 1,000 screened participants

Key Updates to Screening Recommendations

The 2024 guidelines include several important refinements from the 2018 version:

• Specifically designates central dual-energy x-ray absorptiometry (DXA) of hip or lumbar spine as the preferred screening method
• Provides more detailed guidance on risk assessment approaches for younger postmenopausal women
• Maintains an "insufficient evidence" (I statement) regarding screening recommendations for men

Risk Assessment Strategy

For postmenopausal women under 65, the USPSTF recommends a two-step approach:

1. Initial evaluation of risk factors including:
   • Low body weight
   • Parental history of hip fracture
   • Smoking status
   • Excessive alcohol consumption
2. Use of clinical risk assessment tools for those with identified risk factors, with options including:
   • Fracture Risk Assessment Tool (FRAX)
   • Fracture Risk Calculator
   • Garvan Fracture Risk Calculator

Treatment Considerations

For patients requiring intervention, the task force outlined several approved treatment options:

• Bisphosphonates
• Denosumab
• Romosozumab (Evenity)
• Parathyroid hormone
• Raloxifene
• Calcitonin
• Estrogen (with or without progesterone)

The guidelines emphasize the importance of considering racial and ethnic differences in risk assessment, noting that current tools may underestimate risk in Asian, Black, and Hispanic patients. Additionally, comorbidities such as diabetes may affect fracture risk beyond what standard assessment tools capture.

Expert Commentary

Dr. Kristine Ensrud and Dr. Carolyn Crandall, in an accompanying editorial, raised concerns about the continued recommendation of FRAX for younger postmenopausal women, citing its poor performance in this population. They suggest simpler tools like the Osteoporosis Self Assessment Tool (OST) might be more appropriate for this age group.

Dr. Susan Marie Ott of the University of Washington highlighted the importance of the task force's specific recommendation against using radius measurements for screening, differentiating these guidelines from other recent recommendations.