Screening for Osteoporosis

Australian guidance recommends case finding rather than universal population DXA screening. In people aged >50 years, assess fracture risk and use FRAX → DXA where indicated → reassess fracture risk.

  1. Who should be assessed
    • Postmenopausal women and men aged >50 years with risk factors for minimal-trauma fracture.
    • Anyone aged >50 years with a current or previous minimal-trauma fracture should be assessed and appropriately treated.
    • A minimal-trauma hip or vertebral fracture is sufficient for a presumptive diagnosis of osteoporosis; DXA is not required to establish the diagnosis before treatment.
  2. Lifestyle and non-modifiable risk factors
    • increasing age
    • parental history of hip fracture
    • previous minimal-trauma fracture
    • recurrent falls
    • premature menopause / hypogonadism
    • low body weight
    • low physical activity / immobility
    • low muscle mass or poor balance
    • smoking
    • excess alcohol
    • poor calcium/protein intake
    • vitamin D deficiency.
    • In people >50 with these risk factors, calculate FRAX first.
  3. FRAX → DXA
    • FRAX estimates the 10-year risk of:
      • major osteoporotic fracture (MOF), and
      • hip fracture.
    • FRAX MOF <10% → DXA generally not recommended.
    • FRAX MOF ≥10% → DXA.
    • FRAX can then be recalculated using the BMD result.
    • FRAX does not include falls; the Garvan Fracture Risk Calculator may be useful when recurrent falls are an important risk factor.
  4. Conditions and medications → direct DXA
    • In people aged >50 years, proceed directly to DXA when diseases, conditions or medications substantially increase fracture risk.
    • Important examples include:
      • rheumatoid arthritis
      • type 1 or type 2 diabetes
      • hyperthyroidism / excess thyroxine
      • hyperparathyroidism
      • Cushing syndrome
      • chronic kidney disease
      • chronic liver disease
      • coeliac disease / inflammatory bowel disease / malabsorption
      • premature menopause / hypogonadism
      • aromatase inhibitors
      • androgen deprivation therapy
      • prolonged glucocorticoids: approximately prednisone ≥7.5 mg/day for ≥4 months cumulative exposure.
  5. Interpreting DXA
    • T-score >–1.0: normal BMD
    • T-score –1.0 to –2.5: osteopenia
    • T-score ≤–2.5: osteoporosis
    • After DXA, treatment is generally indicated when:
      • T-score ≤–2.5, or
      • T-score –1.5 to –2.5 AND FRAX MOF ≥20% and/or hip fracture risk ≥3%.
    • For expanded detail: Osteomalacia, Osteopenia & Osteoporosis
  6. Very high fracture risk
    • Think particularly about:
      • recent minimal-trauma fracture
      • multiple fragility fractures
      • very low BMD, particularly T-score ≤–3.0
      • multiple major clinical risk factors
      • very high FRAX risk.
    • Very high or imminent fracture risk should prompt specialist referral, particularly when osteoanabolic treatment may be appropriate.
  7. Age ≥70 and Medicare
    • Medicare currently funds an initial BMD study for people aged ≥70 years.
    • For people ≥70:
      • T-score ≥–1.5 → MBS-funded repeat every 5 years
      • T-score <–1.5 but >–2.5 → MBS-funded repeat every 2 years.
    • These are MBS eligibility intervals, not a requirement that every patient clinically needs repeat DXA at those intervals.
  8. Repeat DXA
    • There is no universal “normal q5y / osteopenia q2y / osteoporosis yearly” clinical rule.
    • Repeat DXA is generally performed ≥2 years apart when the result could change risk assessment or management.
    • If BMD is stable and fracture risk is low, intervals may be much longer.
    • Annual DXA may occasionally be appropriate where rapid bone loss is expected, such as glucocorticoid therapy, androgen deprivation therapy or aromatase inhibitor therapy.
  9. Fracture prevention
    • assess falls risk
    • resistance and balance exercise
    • adequate calcium, preferably through diet
    • correct vitamin D deficiency
    • stop smoking
    • limit alcohol
    • maintain adequate nutrition and healthy body weight.

The useful exam skeleton is:

  • >50 + risk factors → FRAX
  • FRAX MOF ≥10% → DXA
  • Disease / major medication risk → DXA directly
  • T-score ≤–2.5 → osteoporosis
  • T-score –1.5 to –2.5 + FRAX MOF ≥20% or hip ≥3% → treat
  • Minimal-trauma hip / vertebral fracture >50 → clinical osteoporosis
  • Very high risk → specialist

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