All women ages 65 and older and at-risk postmenopausal women under 65 should be screened for osteoporosis to prevent fractures, according to a final recommendation statement from the U.S. Preventive Services Task Force (USPSTF).
USPSTF said with “moderate certainty” that screening for osteoporosis to prevent osteoporotic fractures has a moderate net benefit in all women 65 and older and in postmenopausal women ages 40 to 64 who have at least one risk factor for osteoporosis (both grade B recommendations).
Evidence is still insufficient to assess the balance of benefits and harms of screening in men (I statement), said Wanda Nicholson, MD, MPH, MBA, of the Milken Institute of Public Health at George Washington University in Washington, D.C., and colleagues. “Clinicians should use their clinical judgment regarding whether to screen for osteoporosis” in men, the task force stated in JAMA.
The USPSTF recommendations are broadly consistent with those from 2018 — the last time the task force addressed the topic — and are meant for patients without known osteoporosis or a history of fragility fractures. The recommendations do not apply to patients with secondary osteoporosis due to underlying medical conditions or from use of medications linked to bone loss.
Data underpinning the recommendation statement included 145 unique studies assessed in a systematic evidence review, which showed that osteoporosis screening was associated with reduced hip fractures (pooled relative risk [RR] 0.83, 95% CI 0.73-0.93) and major osteoporotic fractures (pooled RR 0.94, 95% CI 0.88-0.99) compared with usual care. Absolute risk differences were five fewer hip fractures and six fewer major osteoporotic fractures per 1,000 participants screened.
While the recommendations are largely congruent with the USPSTF’s 2018 statement, there are some “subtle revisions” that “may result in substantive changes in screening of younger postmenopausal women in clinical practice,” said accompanying editorial authors Kristine Ensrud, MD, MPH, of the University of Minnesota in Minneapolis, and Carolyn Crandall, MD, MS, of the University of California Los Angeles.
“The 2018 statement recommended assessing risk of osteoporosis in these women using a formal clinical risk assessment tool, whereas the 2024 Recommendation Statement recommends screening those at increased risk for an osteoporotic fracture as estimated by clinical risk assessment,” the editorialists wrote.
“Additionally, the screening test for both younger and older postmenopausal women in the 2018 recommendation is specified broadly as bone measurement testing. By contrast, the 2024 statement is more specific and defines screening as central (hip or lumbar spine) dual-energy x-ray absorptiometry (DXA) bone mineral density (BMD) testing with or without fracture risk assessment,” they added.
When deciding which postmenopausal women under 65 to screen, the USPSTF recommended that clinicians first take stock of risk factors for osteoporosis — including low body weight, parental history of hip fracture, cigarette smoking, and excess alcohol consumption.
And then for women with at least one of those risk factors, clinicians should use a clinical risk assessment tool (without BMD assessment) to identify patients who warrant screening. These include the Fracture Risk Assessment Tool (FRAX) — the most studied tool — the Fracture Risk Calculator, and the Garvan Fracture Risk Calculator. Other risk assessment tools, like the Osteoporosis Risk Assessment Instrument and the Osteoporosis Self Assessment Tool (OST), generally require fewer risk inputs than tools designed to predict fracture risk, they added.
According to the USPSTF, “FRAX predicts the 10-year probability of hip fracture or [major osteoporotic fracture] for persons aged 40 to 90 years by using demographic and clinical factors alone or in combination with BMD measured at the femoral neck. Risks predicted by FRAX alone and by BMD alone are similar, but both are less accurate than risks predicted by FRAX plus BMD.”
Predicting fracture risk in postmenopausal women under 65 is “formidable,” said Ensrud and Crandall, and called it “surprising” that the USPSTF continues to suggest use of FRAX in its screening strategy for younger postmenopausal women given the tool’s “poor performance” in predicting osteoporosis fracture risk in this age group.
“Use of a simple time-efficient tool such as the OST appears to be a preferable strategy, although tools designed to identify osteoporosis also perform poorly in long-term fracture prediction in younger postmenopausal women,” Ensrud and Crandall suggested.
Discussing the change from screening via bone measurement testing to central DXA BMD, Nicholson and fellow task force members noted that “centrally measured DXA correlates with bone strength and clinical fracture outcomes and uses low doses of radiation. Fracture risk at a specific site is best predicted if bone density is measured at that site.”
“It is important that they did not recommend using the radius for screening,” said Susan Marie Ott, MD, of the University of Washington in Seattle, in another accompanying editorial in JAMA Network Open. She pointed out that some other organizations have recently suggested treating patients on the basis of findings of a T-score lower than -2.5 at any location, including the distal radius.
The USPSTF fell short of recommending a specific screening interval. While screening intervals tended to vary across studies reviewed, transition to osteoporosis typically occurred quicker for individuals with lower baseline T scores and older age, the task force said.
If screening indicates the patient requires treatment, the USPSTF listed the following approved drugs for treatment and prevention: bisphosphonates, denosumab, romosozumab (Evenity), parathyroid hormone, raloxifene, calcitonin, and estrogen (with or without progesterone). Clinicians should keep in mind that any treatment recommendations based on risk assessment tools that used fixed fracture risk treatment thresholds not specific to race and ethnicity may be less likely to identify Asian, Black, and Hispanic patients as high risk, making them potentially less likely to be treated compared with white patients of the same age, BMD, and clinical risk profile. Similarly, risk models that don’t take into consideration comorbidities like diabetes may underestimate risk.
When it comes to treatment, “it may be reasonable to avoid strict application of risk assessment tool treatment thresholds at the individual level to account for additional risks (e.g., fall risk) not considered in risk assessment tools like FRAX,” the task force explained.
Kristen Monaco is a senior staff writer, focusing on endocrinology, psychiatry, and nephrology news. Based out of the New York City office, she’s worked at the company since 2015.
Disclosures
The USPSTF is an independent, voluntary body. The US Congress mandates that the Agency for Healthcare Research and Quality (AHRQ) support the operations of the USPSTF.Task Force members members received travel reimbursement and an honorarium for participating in USPSTF meetings. Nicholson had no other disclosures. One co-author reported serving as chair for the Women’s Preventive Services Initiative Multidisciplinary Steering Committee and serving as chair on the American College of Obstetricians and Gynecologist Practice Advisory Committee, and another reported grants from National Institute on Aging. No other disclosures were reported.The systematic review was funded under contract from the AHRQ, HHS to support the USPSTF. Kahwati had no additional disclosures. Co-authors reported additional support from a National Research Service Award training grant from AHRQ, by a National Research Service Award grant from the Health Resources and Services Administration, and the National Institutes of Health’s National Center for Advancing Translational Sciences.Editorialists Ensrud and Crandall reported receiving an honorarium from the American College of Physicians; in addition Crandall reported receiving grants from the National Institutes of Health.Ott reported no disclosures.
Primary Source
JAMA
Source Reference: US Preventive Services Task Force “Screening for osteoporosis to prevent fractures: US Preventive Services Task Force recommendation statement” JAMA 2025; DOI: 10.1001/jama.2024.27154.
Secondary Source
JAMA
Source Reference: Kahwati LC, et al “Screening for osteoporosis to prevent fractures: a systematic evidence review for the US Preventive Services Task Force” JAMA 2025; DOI: 10.1001/jama.2024.21653.
Additional Source
JAMA
Source Reference: Ensrud KE, Crandall CJ “Fracture risk assessment as a component of osteoporosis screening — easier said than done” JAMA 2025; DOI: 10.1001/jama.2024.27416.
Additional Source
JAMA Network Open
Source Reference: Ott SM “Research that could broaden the scope of bone density screening” JAMA Netw Open 2025; DOI: 10.1001/jamanetworkopen.2024.60746.
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