DXA Screening News

Posted on Sep 6, 2011 in Patient Care | 0 comments

Which Women Are the Best Candidates for Bone Density Testing and Treatment?

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A study published in the journal Menopause suggests that 41% of women who underwent dual-energy x-ray absorptiometry (DXA) screening for osteoporosis did not need to be tested,[1] based on criteria published by the North American Menopause Society (NAMS).[2] These guidelines mirror other national screening guidelines, including those from the American College of Obstetricians and Gynecologists, the National Osteoporosis Foundation (NOF), and the United States Preventive Services Task Force.[3-5]

According to the 2006 NAMS guidelines, women with the following characteristics should undergo DXA:

• All women age 65 and older, regardless of clinical risk factors
• Postmenopausal women with medical causes of bone loss regardless of age
• Postmenopausal women age 50 and older with additional risk factors (such as fracture, thinness, smoking, alcohol use, family history)
• Postmenopausal women with a fracture from a fall from standing height

In 2010, the NAMS guidelines were updated to include women with rheumatoid arthritis and those who drink more than two alcoholic drinks per day.[6]

The study was designed to assess whether a cohort of women sent for DXA screening met the screening criteria, how many were receiving preventive measures at the time of screening, and how many were being treated independent of whether they met treatment guidelines.

Researchers reviewed data from 615 postmenopausal women (age older than 49 years) who were sent for DXA screening between January 1, 2007 and March 1, 2009 at four radiology centers in Hartford, Connecticut. Risk factors for osteoporosis, demographic information, and current DXA results were recorded. The NAMS 2006 Osteoporosis Position Statement was used as the criteria for screening and therapeutic intervention guidelines.

Using the NAMS 2006 guidelines for screening and treatment, 41% of the women who underwent DXA testing did not meet the screening criteria. In addition, many of these women were not practicing preventive measures such as taking calcium (25.5%) or vitamin D (31%) or exercising for at least one-half hour per week (60%).

The Results in Context

The reasons for the inappropriate screenings are not clear, but may be due to an individual woman’s request or a lack of awareness of the guidelines by their healthcare providers. While the bone scan is simple and noninvasive, it can cost $200 to $300 and can lead to women being treated unnecessarily with medications that can carry serious, though uncommon, risks such as stroke, breast cancer, heart disease, or osteonecrosis of the jaw.

While the current findings suggest that many women undergo osteoporosis screening when they don’t need it, the authors also point to a problem of both under- and overtreatment. Among women who were screened and met NAMS guidelines for osteoporosis treatment, 16% were not taking calcium, 19% were not taking vitamin D, 53% were not exercising at least two hours per week, and 35% were not receiving any therapy at all. The authors are not clear on the reasons for under treatment, although they speculate that women may decline treatment when it is offered. Of particular note is that of women without any indication for treatment, 18% were treated with bisphosphonates, raloxifene, or calcitonin. While these medications are considered safe for short-term treatment, there is a paucity of data regarding their use over the long term.

It’s hard to know exactly how much weight to put behind this study. The study is limited by its design—most of the women were white and from a single geographic area; therefore, it’s not clear whether the results would be the same nationwide. However, the study design is very rigorous and probably understates the results.

The authors of the study call for more research to better determine why some women are screened when they don’t meet guidelines and why others are not treated even though they do. In addition, they urge women to be more aware of the screening guidelines, to understand why the screening is being recommended, and to become comfortable asking questions.

The NOF estimates that approximately half of postmenopausal women will suffer an osteoporosis-related fracture at some point. To help prevent bone loss with age, experts recommend getting a well-balanced diet with enough calcium and vitamin D, in particular, as well as regular exercise.

 

Jill Shuman, MS, ELS
Published on September 6, 2011

References

1. Schnatz PF, Marakovits KA, Dubois M, O’Sullivan DM. Osteoporosis screening and treatment guidelines: are they being followed? [published online ahead of print July 8, 2011]. Menopause. doi:10.1097/gme.0b013e318215101a.
2. North American Menopause Society. Management of osteoporosis in postmenopausal women: 2006 position statement of The North American Menopause Society. Menopause. 2006;13(3):340-367.
3. American College of Obstetricians and Gynecologists, Women’s Health Care Physicians. ACOG practice bulletin. Clinical management guidelines for obstetrician-gynecologists. Number 50, January 2003. Obstet Gynecol. 2004;103(1):203-216.
4. National Osteoporosis Foundation. Clinician’s Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2010. http://www.nof.org/professionals/clinical-guidelines.
5. Nelson HD, Haney EM, Chou R, et al. Screening for Osteoporosis: Systematic Review to Update the 2002 U.S. Preventive Services Task Force Recommendation. Evidence Synthesis No. 77. AHRQ Pub No. 10-05145-EF-1. Rockville, MD: Agency for Healthcare Research and Quality; 2010.
6. Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause. 2010;17(1):25-54.