Osteoporosis: Who Should be Screened?

•Postmenopausal women younger than 65 years with at least one risk factor for osteoporosis (other than being white) or with a fracture

•All women age 65 and older regardless of their risk profile.(11)

By and large, screening is best done with tabletop measurements of bone density in both the hip and spine by dual-energy x-ray absorptiometry (DXA). Another screening tool, ie, ultrasonography of the heel, can be used for mass screening if DXA is not available. Although a low reading by ultrasonography and DXA of the finger or wrist is predictive of future fractures, the correlation is less precise than with DXA of the hip and spine.

Our patient presents with vertebral fractures and several other risk factors: advanced age, height loss, a recent fracture, family history of osteoporosis, estrogen deficiency, white race, low body weight, low level of physical activity, and vitamin D deficiency.(12) She is also at higher risk for falling because of instability exacerbated by her medications.(12,13)

However, nothing in her medical history suggests secondary osteoporosis, eg, due to glucocorticoid therapy, and her normal parathyroid hormone level rules out secondary hypoparathyroidism.

Case Continued
The patient undergoes bone density measurement with DXA. Her T score is -2.8 at the lumbar spine and -3.0 at the femoral neck.

Bone Mass and History Determine Severity
Bone density measurements can be taken of the spine, hip, or wrist; when values are available for more than one site, risk is determined by the lowest value.

Fracture risk approximately doubles for each standard deviation below the mean.(14,15)

Furthermore, once a patient sustains a fracture, she is five times more likely to sustain another fracture within a year than is a woman without a fracture (Figure 1).(16) In addition to previous fracture and low bone mineral density, the NORA study found that poor health status and mobility also contribute to fracture risk.(17)

Figure 1.

Our patient has severe osteoporosis: she has both a history of fracture and spine and hip bone densities more than 2.5 standard deviations below the mean for young women (Table 2).(2,11) Her low bone density, combined with multiple (more than five) risk factors for fracture, make her risk of hip fracture 10 times higher than for a woman with low bone mineral density but with no more than two risk factors.(18) Her life expectancy is also shortened-the odds for survival decrease with more vertebral or hip fractures.(19)

Therefore, she has a clear and urgent need for treatment to prevent additional fractures.

Cleveland Clinic Journal of Medicine
Volume 71, Number 10, October 2004

The author has indicated that he has received grant or research support from the Wyeth, Pfizer, Proctor and Gamble, Sanofi, NPS, and Alexis corporations and is on the speakers' bureaus of the Abbott, Merck, and Proctor and Gamble corporations. This paper discusses treatments that are experimental or are not approved by the US Food and Drug Administration for the use under discussion.