USPSTF Recommendations: Screening for Osteoporosis to Prevent Fractures

SUMMARY:  

The USPSTF released recommendations update for osteoporosis screening to prevent fractures (2025).  The following guidelines are based upon an assessment of benefits vs harms and does not include cost analysis.

• USPSTF Recommendations
• Clinical risk factors in postmenopausal women <65 years of age
• Clinical risk assessment tools
• DXA Scan
• Additional Related USPSTF Recommendations
• Screening Intervals

USPSTF Recommendations

Women ≥ 65 years and older 

• The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures (B recommendation)
  • Offer or provide this service
  • There is high certainty that the net benefit is substantial

Women <65 years and postmenopausal  

• The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women who are at increased risk estimated by clinical risk assessment (B recommendation)
  • Offer or provide this service
  • There is high certainty that the net benefit is substantial 
• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men (I statement)
  • Evidence is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined

KEY POINTS:  

Screening Test for Osteoporosis

• Screening for osteoporosis to prevent fractures consists of a central DXA bone mineral density (BMD), with or without fracture risk assessment
• Osteoporosis definition
  • Bone density at the hip or lumbar spine that is 2.5 standard deviations or lower (T score ≤–2.5) than the mean BMD measured at that site for a reference population of young healthy White women (WHO definition)
  • Over time, T score ≤–2.5 has become the reference standard for persons of all racial and ethnic groups, and for males and females

Postmenopausal Women <65 Years of Age

Two Step-Approach  

• If ≥1 clinical risk factor, “a reasonable approach” is to use a clinical risk assessment tool (see below)  
• Clinical risk factors include  
  • Parental history of hip fracture 
  • Smoking 
  • Excessive alcohol consumption 
  • Low body weight
  • Medications (e.g., glucocorticoids)
  • Chronic diseases (e.g., rheumatoid arthritis) 
• Incorporate results of clinical assessment tool to aid clinical decision making regarding screening 

Clinical risk assessment tools 

•  The following tools perform similarly, have thresholds for screening and are moderately accurate at predicting osteoporosis 
  • Osteoporosis Risk Assessment Instrument (ORAI) 
  • Osteoporosis Self-Assessment Tool (OST) 
• FRAX tool (University of Sheffield) 
  • Assesses a person’s 10-year risk of fracture 
  • Includes questions about previous DXA results but not required to assess risk 
  • No threshold for screening
  • USPSTF notes that average risk 65 year old White female has a hip fracture risk of 1.3% and 10-year risk of MOF (major osteoporotic fracture: hip, spine, wrist, or shoulder) of 9.3% based on FRAX | USPSTF does not intent these numbers to be used as a threshold but rather as an aid to inform decision making regarding further screening

Note: The USPSTF addresses the above tools but should not be considered a comprehensive list 

DXA Scan 

• Central DXA scan (dual-energy x-ray absorptiometry “is the established standard for the diagnosis of osteoporosis”
  • Measures BMD at the total hip and lumbar spine 
  • Used for most professional treatment guidelines (based on entry criteria for study enrollment)

…this review only reports evidence for central DXA—the bone measurement test most commonly used to screen for osteoporosis

• ACOG also considers DXA as the “preferred” modality for BMD measurement

Additional Related USPSTF Recommendations 

• Preventing falls 
  • The USPSTF recommends exercise interventions to prevent falls in community-dwelling adults 65 years and older at increased risk of falls  
  • The USPSTF recommends that clinicians individualize the decision to offer multifactorial interventions to prevent falls to community-dwelling adults 65 years or older who are at increased risk for falls | Existing evidence indicates that the overall net benefit of routinely offering multifactorial interventions to prevent falls is small 
• Preventing fractures  
  • USPSTF recommends against supplementation with 400 IU or less of vitamin D and 1000 mg or less of calcium in postmenopausal women to prevent fractures 
  • The USPSTF found insufficient evidence on supplementation with higher doses of vitamin D and calcium, alone or combined, to prevent fractures in postmenopausal women, or at any dose in men and premenopausal women

Screening Intervals 

• Screening intervals of 4 to 8 years did not result in additional accuracy in predicting fractures
• USPSTF does not recommend a specific screening interval but does not that transition to osteoporosis is more likely over shorter intervals for individuals who are older and have lower baseline T scores  

Learn More – Primary Sources:  

US Preventive Services Task Force Recommendation Statement:  Screening for Osteoporosis to Prevent Fractures

FRAX® Fracture Risk Assessment Tool

Osteoporosis Self Assessment Tool (OST)

Osteoporosis Risk Assessment Instrument (ORAI)

ACOG Clinical Practice Guideline 1: Osteoporosis Prevention, Screening and Diagnosis

United States Preventive Services Taskforce Recommendation: Falls Prevention in Community-Dwelling Older Adults: Interventions 

United States Preventive Services Taskforce Recommendation: Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults