II. Indications: Osteoporosis Screening
- All women over age 65 years
- Consider in all men over age 70 years
- Postmenopausal women 60 to 65 years with 1 risk below
- Fracture after age 45 years
- Hip Fracture in a parent
- Tobacco Abuse
- Body Mass Index <22
- Extended gluococorticoid use (>3 months)
- Indications in Men over age 50 and Postmenopausal Women at any age
- Nontraumatic Fracture (esp. hip, Vertebrae, wrist)
- Incidental finding of Osteopenia on plain XRay
- Glucocorticoid use (e.g. Prednisone 5 mg per day for >3 months)
- Hypogonadism
- Hyperparathyroidism
- Multiple Osteoporosis Risk Factors (see below)
- See Osteoporosis Secondary Causes
- Risk Calculators
III. Risk Factors: WHO Model for Fracture Risk (10 year risk)
- Age over 65 in women and over 70 in men
- Female gender
- Personal history of Fracture
- Parental history of Hip Fracture
- Femoral neck Bone Mineral Density (based on DEXA Scan)
- Glucocorticoid use (e.g. Prednisone >5 mg/day for >3 months)
- Current Tobacco Abuse
- Heavy Alcohol use (3 or more drinks per day)
- Body Mass Index <22 kg/m2
- Resources
IV. Risk factors: Osteoporosis
- See Osteoporosis Secondary Causes
- Natural Progression
- Increasing age (over age 65 in women or over age 70 in men)
- Female gender
- Constitutional
- White (fair-skinned) or Asian origin
- Black and Hispanic patients have lower rates
- Low body weight or small stature
- Weight below 58 kilograms (127 pounds) in adults
- Body Mass Index (BMI) <20-22 kg/m2
- Height Loss
- White (fair-skinned) or Asian origin
-
Family History
- Parental history of Hip Fracture
- Osteoporosis
- Kyphosis
- Pathologic Fracture
- Lack of Bone loading or Exercise
- Sedentary
- Physical Disability interfering with weight-bearing
- Early Hypogonadism
- Premature Ovarian Failure (e.g. Female Athlete Triad)
- Orchiectomy for Prostate Cancer in men
- Lifestyle
- No longer considered a risk factor
- High phosphate (soda) does not cause Osteoporosis
- Other factors
- Diabetes Mellitus
- Nulliparity
V. Causes: Secondary
VI. Diagnosis
- Keep High level of suspicion in both men and women
- Inquire at routine clinic visits
- Look for spine deformity, pain, and immobility
- Loss of total height measurement
- Women: >4 cm height loss since age 25 years
- Men: >6 cm height loss since age 25 years
- Some use 1.5 inch height loss for criteria
- Evaluation
- Prompts thoracic and Lumbar Spine XRay
- Evaluate for Vertebral Compression Fracture
VII. Imaging
- XRays taken for other reasons
- XRays show changes after 40-50% skeletal mass loss
-
DEXA Scan (single most important BMD testing)
- Can be followed as often as every 2 years
- See DEXA Scan for indications
- Qualitative Ultrasound of Calcaneus
VIII. Labs: Initial at diagnosis (evaluating for Osteoporosis Secondary Causes)
- Complete Blood Count
- Alkaline Phosphatase increased
- Hepatic Aminotransferase levels (AST, ALT) increased
- Hepatic disease
- Serum Albumin decreased
-
Serum Creatinine increased
- Renal disease
- Ionized Serum Calcium
- Increased Calcium
- Hyperparathyroidism
- Cancer
- Decreased Calcium
- Vitamin D Deficiency
- Malabsorption
- Increased Calcium
- Thyroid Stimulating Hormone (TSH) decreased
-
Hypogonadism
- Men: Total Serum Testosterone
- Women: Estradiol
- Consider in pre- or peri-menopausal women
- Unnecessary in post-menopausal women
IX. Labs: High risk for Secondary Cause
-
Hypercalciuria
- 24 hour Urine Calcium excretion >250 mg
-
Vitamin D Deficiency
- Serum 1,25-Hydroxy Vitamin D decreased
-
Hyperparathyroidism
- Intact Parathyroid Hormone (PTH) increased
- Cushing's Disease
- Multiple Myeloma evaluation
-
Hemochromatosis
- Serum Iron increased
- Ferritin level increased
-
Celiac Sprue
- Tissue transglutaminase and Endomysial antibodies
X. References
- (2021) Obstet Gynecol 138(3):494-506 +PMID: 34412075 [PubMed]
- Jeremiah (2015) Am Fam Physician 92(4): 261-8 [PubMed]
- Kanis (1994) J Bone Miner Res 8:1227-34 [PubMed]
- Kleerekoper (1998) Postgrad Med 103(4):45-68 [PubMed]
- Kroger (1998) Ann Med 30:278-87 [PubMed]
- Rosen (1998) Postgrad Med 104(4):101-14 [PubMed]
- Tosteson (2008) Osteoporos Int 19(4):437-47 [PubMed]
- Weber (1998) Endocrinol Metab Clin North Am 27(2):325 [PubMed]