Getting a Leg Up With Bone Density Testing

Newly updated guidelines can help women decide when to have a bone density tested to determine their risk of fracture and perhaps get treatment that can lessen it. But the new guidelines may further discourage already reluctant men from doing the same.

The guidelines, issued by the U.S. Preventive Services Task Force, suggest that all women 65 and older undergo bone density screening, a brief, noninvasive, safe and inexpensive test covered by Medicare. It is called a DEXA scan. For women past menopause who are younger than 65, the guidelines say a scan may be appropriate depending on their risk factors for osteoporosis.

But for men, the task force said “current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures.”

Not all experts on bone health agree. As I wrote in this column in October 2016, although men get “about half as many osteoporotic fractures as women, when a man breaks his hip because of osteoporosis, he is more likely than a woman similarly afflicted to be permanently disabled and twice as likely to die within a year.”

And thanks to the decline in smoking and progress in treating heart disease, many more men are now living long enough to experience a debilitating and perhaps deadly osteoporotic fracture. As Dr. Robert A. Adler, an endocrinologist at the Veterans Affairs Medical Center in Richmond, Virginia, has written, it is time to stop thinking of osteoporosis as just “a lady’s disease.”

With age, virtually everyone loses bone density, a process that typically starts at age 30 and accelerates rapidly in women past menopause who do not take supplemental estrogen. In men, who enter adulthood with thicker, stronger bones, bone loss in midlife is more gradual but often becomes medically significant after age 70.

“Osteoporosis causes bones to weaken and potentially break, which can lead to chronic pain, disability, loss of independence and even death,” the task force noted. Osteoporotic fractures are very common and extremely expensive. Nearly 44 million women and men 50 and older — more than half the people in that age bracket — have low bone density that increases their chances of breaking a bone from a minor accident, like tripping on the sidewalk or over the cat.

These so-called fragility, or low-trauma, fractures drain an estimated $20 billion a year from the U.S. economy, up from $17 billion in 2005, with a continued rise in the rate and cost predicted as the population ages. Men account for 29 percent of these fractures and 25 percent of the cost, according to a 2007 report in the Journal of Bone Mineral Research.

Insurance coverage for bone density tests, both government and private, is typically based on the advice rendered by the Preventive Services Task Force, so it is helpful to know what the group recommends. But it can also help to know when it may be wise to circumvent these guidelines.

Few question the value of bone density screening for women 65 and older, with timely repetitions of the exam determined by the initial results. The test is painless and noninvasive, and involves a level of radiation 50 times lower than that of a mammogram, Dr. Margaret L. Gourlay, research associate professor of family medicine at the University of North Carolina, told me. There is also solid evidence that treatment with a bone-preserving or bone-building drug is beneficial when a bone density test reveals a level of bone loss defined as osteoporosis in the spine or a hip.

“Bone density testing also has a place for women younger than 65,” Gourlay said. The question is, for which women and how often should it be done? The task force concluded that the need for an initial test is best determined by first examining a woman’s risk factors, a process that Gourlay said could consume half the time of a typical doctor visit.

There are three such screening tools currently available.

The most popular and most time-consuming risk assessment tool is called FRAX. It involves a list of about a dozen factors that can influence a person’s risk of osteoporosis, and estimates the chances of a major osteoporotic fracture occurring in the next 10 years. The factors include age, sex, weight, height, previous fracture, parental fracture history, smoking, alcohol consumption and the use of steroids. If the FRAX assessment deems a woman’s risk is 3 percent or higher for a hip fracture or 20 percent or higher for a fracture on the forearm, shoulder or spine, she is likely to be urged to get a bone density test if she is 40 or older.

Another somewhat simpler risk assessment is called SCORE. It calculates risk based on race, rheumatoid arthritis, fracture history, age, estrogen use and weight. And a third, called OST, involves only age and weight and may be as good or better than more complicated risk tools. In an editorial accompanying the task force report, Gourlay wrote that “multiple observational studies have demonstrated that age and weight are as strongly associated with osteoporosis and fracture outcomes as more complicated risk tools.”

Dr. Jane A. Cauley, epidemiologist at the University of Pittsburgh who also wrote an editorial about the task force report, said in an interview that in the Women’s Health Initiative Study of women ages 50 through 64, the OST tool identified 80 percent of women who had a bone density reading in the osteoporotic range. In contrast, she said, the SCORE tool identified 74 percent of such women, but both OST and SCORE did a better job than FRAX.

So, ladies, if you are past menopause and thin, consider getting your bone density checked. The lower your weight, the less benefit weight-bearing activities like walking will have on the strength of your bones. Also, women who lose weight by dieting lose bone along with fat and may consider getting checked for bone density, Gourlay suggested.

Cauley said she was “disappointed” that the task force issued no recommendations for testing men. “Men age 70 and older who have a high probability of an osteoporotic fracture based on any one of the assessment tools should get a bone density scan,” she said. “One in 5 men will experience an osteoporotic fracture, and bone density screening is warranted if the risk is relatively high given that there is a good screening method and effective treatment for bone loss.”