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Many interesting articles and blog posts about osteoporosis have come out in the past few weeks. I’ve been “collecting” them and highly recommend the following:
All very thought-provoking. In my practice, I read DXA scans weekly and see consultations for osteoporosis and osteopenia management. I have noticed that I have been reading DXA scans ordered on younger women. Note the following recommendation from the US Dept of Health and Human Services site:
The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures.
There is good evidence that the risk for osteoporosis and fracture increases with age and other factors; bone density measurements accurately predict the risk for fractures in the short-term; treating asymptomatic women with osteoporosis reduces their risk for fracture. The USPSTF concludes that the benefits of screening and treatment are of at least moderate magnitude for women at increased risk by virtue of age or presence of other risk factors.
There is insufficient evidence to recommend for or against routine osteoporosis screening in postmenopausal women who are younger than 60 or in women aged 60-64 who are not at increased risk for osteoporotic fractures.
Despite these recommendations, many women seem to start their DXA screening around the time of menopause and continue to get scans every 2 years indefinitely. Why start at perimenopause or menopause when this is not the recommendation? I can only guess that it may have something to do with the pervasive marketing of osteoporosis medications and/or a belief that any test provides information and that must be helpful. Why every 2 years? That is the minimum interval many insurers will pay for the test. Note that there is no guideline as to frequency, like for mammography or pap smears. Subsequent DXA scans are recommended when the result would change clinical management. This forces us to think and is perhaps one area where checklists are not helpful. Women and their physicians should not think of the DXA as an every 2 year test to be done without considering the implications of the results. This may be part of the issue behind the above discussion regarding “osteopenia.” To take the debate a step further, are follow up scans needed in the first few years after a woman has started taking an osteoporosis medication? Likely not, according to this article from BMJ. The authors concluded that,
Monitoring bone mineral density in postmenopausal women in the first three years after starting treatment with a potent bisphosphonate is unnecessary and may be misleading. Routine monitoring should be avoided in this early period after bisphosphonate treatment is commenced.
I also recommend reading the accompanying editorial. The goal of identifying risk factors, screening for osteoporosis and using these medications is to prevent the morbidity and mortality from osteoporotic fractures. The challenge lies, as it does with all tests and treatments, is to use them appropriately and for good reason.