A personal story
Determining risk for osteoporosis and current screening guidelines
I’m going to use the story of my family to highlight the complexities involved in trying to figure out one’s risk for osteoporosis, and the barriers to obtaining early intervention to truly prevent this disease. Current screening guidelines for bone density screening and fracture prevention in women (USPSTF) recommends routine screening for all women at age 65, with consideration for earlier screening in those at ‘additional risk’. Risk factors for osteoporosis include White race, low body weight (below 127 lbs), early/premature menopause, cigarette smoking, a history of corticosteroid use, and a parental history of osteoporotic fracture.
I am White. At the time of menopause, I had no other significant risk factors and no family history of osteoporosis.
So, no problem waiting until age 65 to get screened, right? I was a lifelong weight bearing exerciser and tried to pay attention to my calcium intake in my reproductive years because I really do not like to drink milk.
New clues and concerns about personal bone status
Then came a series of clues and concerns that led me to believe my personal bone status was not as favorable as it seemed.
In my 40’s I noted that my paternal grandmother was losing height (she was then in her early 80’s) and brought her to see a colleague regarding whether or not she should receive a relatively new antiresorptive bone treatment, alendronate (Fosamax) to treat what was likely evolving osteoporosis. My endocrinology colleague advised her against it after balancing the risks of initiating a relatively new drug with the longer-term risk of fracture over the duration of my grandmother’s remaining life. My grandmother lived to age 99—well beyond the average female life span (which would have been age 79 for a woman her age at the time) and her last years were spent wheelchair bound due to vertebral compression.
In my 40’s and early 50’s I enrolled in several research studies that coincidentally included bone density determinations. Prior to menopause, my bone density was terrific—more than 1 standard deviation above the mean. This means that my t score was +1 or higher at my spine and hip. All good, and evidence that my healthy lifestyle was paying off. Then, in my 50’s, a few years after menopause, my bone density had dropped precipitously, with t scores dropping below -1, more than one standard deviation below the mean.
What had happened?
In the years between my drop from favorable to not-so-favorable bone density, the Study of Women’s Health Across the Nation showed that women lose up to 10% of their skeletal mass over the years spanning about 2 years before and up to 3 years after their final menstrual period. I had not taken hormone therapy consistently during those years, and I had sustained a bone density decrease that was beyond the average. And it had been completely missed. Could I be at higher risk than I believed and what the statistics seemed to indicate?
More family bone-related changes
Meanwhile, my grandmother continued to shrink. But no parental fractures, and no other risk factors for me emerged. So my risk remained low based on the risk factor modeling that existed at the time (and still exists).
The next issue that arose that spurred me to action was the discovery that my mother had developed significant osteoporosis, with t scores of -2.5 or lower at both her spine and her hip. My mother declined treatment and decided to manage her bone density with calcium/vitamin D and a walking program. Unlike my mother, I was sufficiently worried by my worsening family history to meet with a colleague who was a bone specialist. We made a joint decision to start a course of alendronate (Fosamax), which I took for 5 years. Fosamax is inexpensive, relatively easy to take (one tablet weekly), and stopped my bone loss. It has the additional advantage of having enduring benefit beyond the 5 years of use. Unfortunately, it has fallen out of favor because of the very rare but very serious complication of osteonecrosis of the jaw and ‘adynamic’ fractures of the femur seen in the early days of longer-term use of the drug. The practice of taking a drug ‘holiday’ after 5 years has greatly reduced the risks of these rare adverse events.
Since that time, we have learned more important things in my family that have changed the calculus of risk for low bone density and fracture:
- One of my two sisters has developed osteoporosis. She has chosen to avoid any pharmacologic treatment and is working on exercise, calcium and vitamin D intake, and other lifestyle treatments.
- My mother had a femur fracture after a fall and then sustained two vertebral fractures after separate falling events.
A different perspective on risk
So, what’s my point? If I knew then what I know now, I would have clearly been identified as a much higher risk person for osteoporosis than what the usual formulas indicate. I have also learned that people in my family live to relatively old ages (my other grandmother died at age 97 and my mother passed away just shy of her 92nd birthday partly due to complications from further bone fractures), and this gives us more years of osteoporosis related disability to look forward to if we do not tend to our bone health. And most importantly, it raises the question of how many more of my patients and other women out there have the same kind of family history and won’t learn about their risk for this disease until they get their screening bone density test at age 65 and suddenly discover that they have osteoporosis?
A call for change in screening for osteoporosis
The concept of screening for osteoporosis at age 65 is out of date. It was derived in a world where there were few bone sparing drugs for women other than hormone therapy, and in a world where the precipitous loss of bone mass over the menopause transition was not fully appreciated. Thus, at the time these guidelines were derived, the approach to osteoporosis was one of disease management, and not one of prevention.
It is high time that this approach is changed. A new and exciting study performed in New Zealand and reported in the New England Journal of Medicine last year1 studied 1054 women aged 50-60 over 10 years’ time. All were required to have bone density that was at the mean or lower, but above the osteoporosis threshold (a t score between 0 and -2.5). Women were randomly assigned to receive a bisphosphonate drug, zoledronic acid (a cousin of alendronate, given intravenously instead of as a weekly pill) at the beginning of the study and again at 5 years in some of the women, and some of the women received a placebo infusion twice. It’s important to note that these were women with average or below average bone density, none of whom would have been detected using current screening guidelines. Use of even one of the two doses of zoledronic acid cut the risk of X-ray determined fractures almost in half. This remarkable study indicates that there may well be a true population benefit for more widespread use of bone sparing agents in the prevention of osteoporosis and fracture.
So what can women do while we wait for these guidelines to be reevaluated?
We know that the biggest loss of bone mass occurs during the menopause transition, and we also know that bone loss does not occur due to changes in reproductive hormones before then. Therefore, moving screening back to this time of vulnerability for women would seem to make a lot more sense than waiting until age 65. Women with low bone mass may then have the option to take on a true preventive strategy that would involve the use of non- pharmacologic strategies or agents that reduce bone resorption (this could be hormone therapy or one of the many safe and effective bone drugs that are now on the market).
The barrier to adopting this strategy in a more widespread fashion is getting the bone density assessment to begin with. Health insurers are motivated to adhere to the USPSTF guidelines and most will not reimburse a patient for a bone density screening test. However, it is usually possible to get them for a relatively low cost (about $150 at private pay radiology offices). The appropriate test is a dual energy X-ray absorptiometry (DEXA) and the important sites on the body to measure are the lumbar spine, the hip, and the femoral neck.
It is high time to stop waiting for the bad news that one has already developed a challenging disease that will be life limiting for many and to develop a coherent preventive strategy that will allow women to avoid the pain, disability, and threat to life that osteoporosis poses. It is too late for my grandmother and my mother, but it’s not too late for my daughter to know her risks and be prepared.
- Bolland MJ, Nisa Z, Mellar A, Gasteiger C, Pinel V, Mihov B, Bastin S, Grey A, Reid IR, Gamble G, Horne A. Fracture prevention with infrequent zoledronate in women 50 to 60 years of age. New Engl J Med 2025; 392: 239-248.
