••• CHAPTER 65^ ACOG Screening Guidelines Since 2007^659
❍ When should bone density screening be initiated?
- Begin at the age of 65.
- Postmenopausal women younger than 65 years with other risk factors for fracture.
- FRAX can be used in women younger than 65 years to determine which women should have a DXA scan;
women with a FRAX 10-year risk of major osteoporotic fracture of 9.3% can be referred for DXA because that
is the risk of fracture found in a 65-year-old Caucasian woman with no risk factors.
❍ What factors are considered high risk for fracture in postmenopausal women <65?
- Medical history of a fragility fracture.
- Body weight <127 lb.
- Medical causes of bone loss (medications or diseases).
- Parental medical history of hip fracture.
- Current smoker.
- Alcoholism.
- Rheumatoid arthritis.
❍ Is BMD monitoring necessary for patients taking depot medroxyprogesterone acetate (DMPA)?
No because partial or full recovery of BMD occurs at the spine and at least partial recovery occurs at the hip after
discontinuation of DMPA. The short-term loss of BMD associated with DMPA is recovered and unlikely to place
an adolescent or adult woman at risk of fracture during use or in later years.
❍ How often should DXA scan be repeated if a woman older than 65 years does not have osteoporosis?
If FRAX does not indicate a high risk of fracture:
- Interval screening every 15 years for a woman older than 65 years with a normal BMD or mild bone loss
(T-score ≥–1.5). - Interval screening every 5 years for a T-score from –1.5 to –1.99.
- Interval screening annually for a T-score between –2.0 and –2.49.
❍ When should treatment for osteoporosis be recommended?
- Women who have a BMD T-score of <–2.5.
- Women in the low bone mass with a high-risk FRAX assessment (a 10-year risk of major osteoporotic fracture
≥20% or a risk of hip fracture ≥3%). - Women who have had a low-trauma fracture (especially of the vertebra or hip) are candidates for treatment even
in the absence of DXA diagnosed osteoporosis.
❍ How is treatment effect monitored?
- After treatment initiation, one DXA scan 1 year or 2 years later can be used to assess the effect of treatment.
- If BMD is stable or improved, the DXA does not usually need to be repeated in the absence of new risk factors.
- Testing should not be undertaken before 2 years after initiation of treatment because it often takes 18–24 months
to document a clinically meaningful change.