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Osteoporosis screening guidelines fail to identify fracture risk in younger postmenopausal women

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December 12, 2018

Current osteoporosis screening and treatment guidelines in the United States and Canada have low sensitivity for identifying younger postmenopausal women who subsequently experience major osteoporotic fracture, according to findings published in the Journal of Bone and Mineral Research.

Carolyn J. Crandall

The U.S Preventive Services Task Force screening guide for osteoporosis recommends the use of a formal clinical risk assessment tool for postmenopausal women aged 50 to 64 years to identify candidates for bone mineral density testing, whereas the Canadian strategy recommends BMD testing in women with specific clinical risk factors, Carolyn J. Crandall, MD, MS, professor of medicine in the division of internal medicine at the David Geffen School of Medicine at UCLA, and colleagues wrote in the study background. The National Osteoporosis Foundation uses the Fracture Risk Assessment Tool (FRAX) to guide treatment decisions, but only for women with a BMD T-score between –1 and –2.5. Osteoporosis Canada, in contrast, endorses a simplified tool derived from FRAX as the preferred national risk assessment system for women aged 50 years or older who meet guidelines for BMD testing.

“We are in need of new osteoporosis screening and treatment algorithms, particularly in young postmenopausal women,” Crandall told Endocrine Today. “The current U.S. and Canadian screening and treatment strategies that we tested are not performing well in identifying women aged 50 to 64 years who are at the highest risk for fracture.”

Researchers analyzed data from a subset of postmenopausal women participating in the Women’s Health Initiative study who also participated in the WHI Bone Density Substudy (n = 117,707). Participants underwent hip and anteroposterior lumbar spine DXA measurements at enrollment. Fractures were self-reported on annual and semiannual questionnaires. FRAX-predicted 10-year absolute risks for major osteoporotic fracture and hip fracture were calculated for each participant. Mean baseline age for the cohort was 62 years, and mean BMI was 27.8 kg/m²; 31.5% had fallen at least once in the year before baseline.

The researchers observed that, among women aged 50 to 64 years who experienced a major osteoporotic fracture during the 10-year follow-up, the USPSTF screening strategy would have identified 7% of women aged 50 to 54 years and 50% of women aged 60 to 64 years for BMD testing at baseline.

In contrast, the Canadian screening strategy would have identified 54% of women aged 50 to 54 years and 61% of women aged 60 to 64 years for BMD testing at baseline.


Among women aged 50 to 64 years who experienced a major osteoporotic fracture during follow-up, specificity of the USPSTF for identifying BMD testing candidates was “consistently higher” vs. the Canadian strategy, according to the researchers. The positive predictive value of both screening strategies was low, at 16% for the USPSTF and 14% for the Canadian strategy, and was lowest for women aged 50 to 54 years.

In identifying women with incident major osteoporotic fracture as treatment candidates, the National Osteoporosis Foundation treatment strategy identified a larger proportion of women for drug treatment (16%) vs. the Canadian treatment strategy (3%; P < .001). In assessing all women aged at least 50 years who experienced a major osteoporotic fracture during follow-up, researchers found that the National Osteoporosis Foundation strategy had a higher sensitivity for identifying such women as treatment candidates at baseline; however, the sensitivity was low for both strategies, at 50% for the National Osteoporosis Foundation and 25% for the Canadian strategy.

“It is difficult to predict which women will fracture, particularly in younger women aged 50 to 64 years,” Crandall said. “Efforts should go toward refining our ability to identify which women will experience fracture so that our screening and treatment strategies can be improved.” – by Regina Schaffer

For more information:

Carolyn J. Crandall, MD, MS, can be reached at the David Geffen School of Medicine at UCLA, 10833 Le Conte Ave., Los Angeles, CA 90095; email:

Disclosures: The authors report no relevant financial disclosures.

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It has been said that all guidelines are wrong, but good ones are useful. Osteoporosis guidelines are no exception. They are wrong in the sense that there are many clinical circumstances with individual patients where the guidelines may not be appropriate. They are useful in that they provide a framework for care and a foundation for studies that evaluate the guidelines, with the goal of making them better with subsequent revisions. Such is the case with the report by Crandall and colleagues, which used the very large dataset from the Women’s Health Initiative study to compare U.S. and Canadian guidelines for screening and treatment of postmenopausal women. It was found that for “young” postmenopausal women (aged 50-64 years), the osteoporosis screening and treatment strategies for both countries performed poorly compared to older postmenopausal women (aged 65 years). Current guidelines appear to be missing a substantial number of young postmenopausal women, especially those aged 50 to 54 years, who go on to fracture and would have benefited from early screening and treatment.

The reasons for guideline underperformance in identifying at-risk, young postmenopausal women is unclear but may be related to a high rate of bone remodeling and accelerated bone loss that can occur in the early years of menopause in women not on estrogen therapy. This report may stimulate additional studies to confirm or refute these observations and ultimately lead to guideline revisions.

E. Michael Lewiecki, MD, FACP, FACE

Director, New Mexico Clinical Research and Osteoporosis Center
Director, Bone Health TeleECHO
University of New Mexico Health Sciences Center

Disclosure: Lewiecki reports he has received institutional grant or research support from Amgen, Mereo and PFEnex; has served on scientific advisory boards for Alexion, Amgen, Radius, Sandoz, Shire and Ultragenyx; and serves on speakers bureaus for Alexion, Radius and Shire. He is a board member of the National Osteoporosis Foundation, International Society for Clinical Densitometry and Osteoporosis Foundation of New Mexico.