Screening for Osteoporosis to Prevent Fractures: Updated USPSTF Guidelines

Introduction: This document summarizes the 2025 US Preventive Services Task Force (USPSTF) guideline on screening for osteoporosis to prevent fragility fractures. Osteoporosis, characterized by low bone mass and decreased bone quality, can lead to fractures that impair independence, increase morbidity, and raise mortality. The revised guidance builds on evidence that screening in select populations reduces fracture risk. Although the Task Force finds moderate net benefit for screening certain groups, it concludes that evidence remains insufficient to assess benefits and harms in other segments.

Key Recommendations:

1. Population and Rationale:
   • Women 65 years or older: The USPSTF concludes with moderate certainty that screening for osteoporosis in this age group leads to moderate net benefit for preventing osteoporotic fractures.
   • Postmenopausal women younger than 65 years at increased risk: Screening is recommended if a formal risk assessment or clinical risk factors indicate elevated risk, as moderate certainty suggests moderate benefit.
   • Men: The current evidence is insufficient to establish the balance of benefits and harms of screening men without known osteoporosis or prior fragility fractures.
2. Screening Methods:
   • The USPSTF identifies central dual-energy x-ray absorptiometry (DXA) of the hip or lumbar spine as the key screening test.
   • In younger postmenopausal women, a two-step approach is suggested: (1) assess risk factors (e.g., low body weight, smoking, parental history of hip fracture); (2) apply a validated tool (e.g., Osteoporosis Risk Assessment Instrument [ORAI] or Osteoporosis Self-assessment Tool [OST]) to determine who should proceed to DXA.
   • Tools such as FRAX may be used with or without BMD input to estimate 10-year fracture probability, but clinicians should be aware that tool accuracy and calibration vary by age, race/ethnicity, and underlying data sources.
3. Screening Intervals:
   • Current data do not clearly define an optimal interval for repeated screening.
   • Some evidence suggests little added value in repeating BMD tests within four to eight years if initial results are normal or only mildly low.
4. Management Following a Positive Screening Result:
   • After osteoporosis is confirmed, patients should be counseled on modifiable risk factors (e.g., smoking cessation, fall prevention) and assessed for pharmacotherapy.
   • Approved treatments (e.g., bisphosphonates, denosumab) have demonstrated benefit in reducing vertebral, hip, and other major fractures.
5. Harms of Screening and Treatment:
   • Screening anxiety and overdiagnosis are minimal concerns, though data are limited.
   • Bisphosphonate use has not been associated with significant excess serious adverse events in short- to medium-term trials, but rare events (e.g., atypical femur fractures, osteonecrosis of the jaw) remain possible with long-term use.
   • Denosumab reduces multiple fracture outcomes, though discontinuation can lead to rebound bone loss and increased risk of vertebral fractures without follow-up management.
   • The USPSTF underscores that treatment decisions should be individualized, especially in diverse populations and those with complex comorbidities.

Conclusion: These updated recommendations highlight the importance of osteoporosis screening in women 65 years or older and in younger postmenopausal women at higher fracture risk. Early detection with central DXA, informed by clinical risk tools, can reduce fracture incidence and related burdens. Further research is needed to clarify optimal screening intervals, the role of screening in men, and long-term treatment strategies. In the meantime, clinicians should collaborate with patients to personalize screening and treatment plans, considering both clinical risks and patient preferences.

Reference:

• US Preventive Services Task Force. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. Published online January 14, 2025. DOI: http://doi.org/10.1001/jama.2024.27154
• Editorials:
  • Ensrud KE, Crandall CJ. Fracture Risk Assessment as a Component of Osteoporosis Screening—Easier Said Than Done. JAMA. Published online January 14, 2025. DOI: http://doi.org/10.1001/jama.2024.27416
  • Ott SM. Research That Could Broaden the Scope of Bone Density Screening. JAMA Netw Open. 2025;8(1):e2460746. DOI: http://doi.org/10.1001/jamanetworkopen.2024.60746
• Evidence Report:
  • Kahwati LC, Kistler CE, Booth G, et al. Screening for Osteoporosis to Prevent Fractures: A Systematic Evidence Review for the US Preventive Services Task Force. JAMA. Published online January 14, 2025. DOI: http://doi.org/10.1001/jama.2024.21653