Osteoporosis Screening and Management

Primary Screening Indications

The American College of Radiology recommends DEXA scanning of the lumbar spine and hip for all women ≥65 years, postmenopausal women <65 years with risk factors, men ≥70 years, and any adult with specific high-risk conditions including glucocorticoid therapy, endocrine disorders, or prior fragility fracture 1, 2
The American College of Radiology suggests that postmenopausal women <65 years with clinical risk factors for fracture require screening 1, 3
Glucocorticoid therapy ≥5 mg prednisone equivalent daily for ≥3 months mandates DEXA scanning regardless of age 1, 2
Endocrine disorders affecting bone metabolism require screening 2
Young adults (20-50 years) with hypogonadism should undergo early screening rather than waiting until standard age thresholds 4
History of hysterectomy at young age increases risk due to premature estrogen deficiency 3
Body weight <127 lb (58 kg) is a risk factor for osteoporosis 2
Parental history of hip fracture is a risk factor for osteoporosis 2
Prolonged immobilization is a risk factor for osteoporosis 2
Malabsorption or malnutrition is a risk factor for osteoporosis 2

The American College of Radiology recommends DXA of lumbar spine and bilateral hips as the primary modality (rated 9/9 for appropriateness) 1, 4
Patients with advanced degenerative spine changes, scoliosis, or ankylosing spondylitis should consider DXA distal forearm or quantitative CT (qCT) of lumbar spine and hip as alternatives 1
DEXA can be falsely elevated by osteophytes and degenerative facet disease in >81% of spuriously elevated measurements 5, 6, 7

T-scores should be used for postmenopausal women and men ≥50 years 2
Z-scores (not T-scores) should be reported for premenopausal women and men <50 years 2
Z-scores ≤-2.0 are considered below expected age range 2

The American College of Radiology recommends every 1-2 years for patients on glucocorticoid therapy 2
Every 1-2 years if osteoporosis is present or treatment initiated 4
Every 2 years for monitoring untreated patients with risk factors 2
Every 2 years if initial scan shows osteopenia or osteoporosis 3

The American College of Radiology recommends 1,000 mg calcium, 600 IU vitamin D daily for ages 19-50 2
1,200 mg calcium, 600 IU vitamin D daily for ages 51-70 2
1,200 mg calcium, 800 IU vitamin D daily for ages 71+ 2
Weight-bearing exercise is recommended for osteoporosis prevention 2
Smoking cessation is recommended for osteoporosis prevention 2
Alcohol moderation is recommended for osteoporosis prevention 2

Do not delay screening in high-risk young adults (e.g., Klinefelter syndrome, hypogonadism) until standard age thresholds 4
Do not rely solely on spine DEXA in patients with degenerative changes; consider alternative sites or modalities 1, 5, 6