Over 200 million women worldwide are affected by osteoporosis.1
However, fewer than 1 in 5 women with postmenopausal osteoporosis will be
evaluated.2-4
And fewer than 1 in 3 postmenopausal women with osteoporosis are treated.5-13
Obtain a DXA scan in all women ≥ 65 and women older than 50 who have clinical risk factors for
osteoporosis.14-17
Understanding clinical risk factors for osteoporosis and fracture risk can help in formulating
the best questions to ask your patients for accurate screening and diagnosis.14-18
Questions to consider asking your patients might be: Have you ever experienced a fracture? Has
anyone in your family? Have you had any recent falls? Do you have prolonged unusual back pain? A
yes, could indicate a vertebral fracture. Are you taking medications that increase bone loss
like glucocorticoids? Or are you taking medications that increase your risk of falling like
narcotic analgesics? Have you experienced significant weight loss? Do you consume alcohol or
tobacco? Are you getting adequate calcium and vitamin D in your diet? What is your level of
activity?18
In addition to asking these questions, on your clinical examination, look for
kyphosis14,17,18 or height loss14-18 which are signs of osteoporosis, or
difficulty performing the get up and go test which indicates risk for falls.19 Further, in
patients at risk, consider spine x-rays to identify unrecognized vertebral fractures and
consider adding "rule out vertebral fracture" to imaging orders.15,16
Bone mineral density alone does not explain all fragility fracture risk. In fact 60% of women
with fragility fractures have non-osteoporotic bone mineral density (T-score
>-2.5).14,20,21 Understanding clinical risk factors and BMD together improve fracture
risk prediction21 in these patients.
Determining a patient's fracture risk requires consideration of several clinical risk factors of
which a history of prior fracture, older age, and low bone mineral density are most important,
followed by other non-modifiable and modifiable risk factors.16,22-25
Some non-modifiable risk factors influencing a patient's fracture risk include: family history of
hip fracture or osteoporosis, female sex, Asian or white ethnicity, small frame, comorbid
conditions.16,23-25 While some modifiable risk factors include: estrogen deficiency,
fall-related risk factors and inadequate physical activity.16,23
There are several methods you can use to identify women over age 50 at high risk for fracture
that need treatment. Patients with a history of fracture at the hip or spine are at a high risk
for future fracture.16,26
Women over age 50 with bone mineral density T-scores below -2.5 are considered osteoporotic and
at high risk for future fracture.26
High risk patients are those women with FRAX 10-year probability of hip fracture ≥ 3%, or
10-year probability of major osteoporotic fracture ≥ 20%.26
Fragility fractures at the proximal humerus, pelvis, and in some cases wrist qualify patients as
high risk for future fracture, when occurring in combination with low bone mineral density at
the hip or spine.26 Please note that regional thresholds and criteria for treatment
eligibility may vary.
References
1. International Osteoporosis Foundation. Facts and statistics.
www.iofbonehealth.org/facts-statistics. Accessed February 13, 2018.
2. Boudreau DM, et al. J Am Geriatr Soc. 2017;65:1829-1835.
3. Fast Facts. Osteoporosis Canada. https://osteoporosis.ca/about-the-disease/fast-facts/.
4. Nguyen TV, et al. Med J Aust. 2004;180:S18-22.
5. Yusuf AA, et al. Arch Osteoporos. 2016;11:31.
6. Spångéus A, et al. Ann Rheum Dis. 2017;76(suppl2):72.
7. Sanfélix-Genovés J, et al. Osteoporos Int. 2013;24:1045-1055.
8. Hadji P, et al. Dtsch Arztebl Int. 2013;110(4):52-7.
9. Viprey M, et al. PLoS ONE. 2015;10(12):e0143842.
10. Bell JS, et al. Aust Fam Physician. 2012;41:110-118.
11. Eisman J, et al. J Bone Miner Res. 2004;19:1969-75.
12. Taiwanese Guidelines for Prevention and Treatment of Osteoporosis. Taiwanese Osteoporosis
Association, 2013.
13. Boytsov NN, et al. Am J Med Qual. 2017;32(6):644-654.
14. Camacho PM, et al. Endocr Pract. 2016;22(suppl 4):1-42.
15. Papaioannou A, et al. CMAJ. 2010;182:1864-1873.
16. Cosman F, et al. Osteoporos Int. 2014;25:2359-2381.
17. Kanis JA, et al. Osteoporos Int. 2013;24:23-57.
18. Orimo H, et al. Arch Osteoporos. 2012;7:3-20.
19. Vondracek SF, et al. Clin lnterv Aging. 2009;4:121-136.
20. Siris ES, el al. JAMA. 2001;286:2815-2822.
21. Siris ES, et al. Arch Intern Med. 2004;164:1108-1112.
22. Kanis JA, et al. Bone. 2004;35:375-382.
23. Kanis JA, et al. Lancet. 2002;359:1929-1936.
24. Eisman JA, et al. J Bone Miner Res. 2012;27:2039-2046.
25. US Department of Health and Human Services. Bone health and osteoporosis: a report of the
surgeon general. 2004. Rockville, MD.
26. Siris ES, et al. Osteoporos Int. 2014;25:1439-1443.