. 2023 May 8;195(18):E639–E649. doi: 10.1503/cmaj.221219

Table 1:

Recommendations on screening to prevent fragility fractures

Organization	Recommendation
Society of Obstetricians and Gynaecologists of Canada, 2022⁸⁹	All adults aged ≥ 65 yr should be screened for increased fracture risk by clinical evaluation and BMD assessment. Community-based screening in older females may be effective in reducing the incidence of hip fracture (conditional, moderate). In postmenopausal females < 65 yr, evaluate fracture risk clinically without BMD assessment (FRAX without BMD). A BMD assessment should be considered for patients with diseases or drugs associated with an increased risk of fracture or in the presence of a previous fragility fracture (conditional, low). If the FRAX score for MOF without BMD is > 10%, a BMD assessment should also be considered.
National Osteoporosis Guideline Group UK, 2022¹⁵	A FRAX assessment should be performed in any postmenopausal female, or male aged ≥ 50 yr, with a clinical risk factor for fragility fracture, to guide BMD measurement and prompt timely referral or drug treatment or both, where indicated (strong recommendation). Males and females with intermediate fracture risk (i.e., between the upper and lower assessment thresholds) should be referred for BMD measurement, if practical. Thereafter, fracture probability should be reassessed using FRAX (strong recommendation). Vertebral fracture assessment is indicated in postmenopausal females, and males aged ≥ 50 yr, if there is a history of ≥ 4 cm height loss, kyphosis, recent or current long-term oral glucocorticoid therapy, a BMD T-score ≤ −2.5 at either the spine or hip, or in cases of acute-onset back pain with risk factors for osteoporosis (strong recommendation).
The Bone Health and Osteoporosis Foundation (formerly the National Osteoporosis Foundation) (USA), 2022²²	BMD testing should be performed in the following: Females aged ≥ 65 yr and men aged ≥ 70 yr Postmenopausal females and males aged 50–69 yr, based on risk profile Postmenopausal females and males aged ≥ 50 yr with history of adult-age fracture DXA facilities that employ accepted quality assurance measures The same facility and on the same densitometry device for each test whenever possible To detect subclinical vertebral fractures, vertebral fracture imaging (radiograph or DXA vertebral fracture assessment) should be performed in the following: Females aged ≥ 65 yr if T-score is ≤ −1.0 at the femoral neck Females aged ≥ 70 yr and males aged ≥ 80 yr if T-score is ≤ −1.0 at the lumbar spine, total hip or femoral neck Males aged 70–79 yr if T-score is ≤ −1.5 at the lumbar spine, total hip or femoral neck Postmenopausal females and males aged ≥ 50 yr with specific risk factors
The American College of Obstetricians and Gynecologists, 2021⁹⁰	Screening for osteoporosis is recommended in postmenopausal patients ≥ 65 yr with BMD testing to prevent osteoporotic fractures (strong recommendation, high-quality evidence). Screening for osteoporosis with BMD testing is recommended to prevent osteoporotic fractures in postmenopausal patients < 65 yr who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (strong recommendation, high-quality evidence).
Scottish Intercollegiate Guidelines Network, 2021 update of 2015 report⁸⁷	People aged ≥ 50 yr with a history of fragility fractures should be offered DXA scanning to evaluate the need for anti-osteoporosis therapy. Fracture risk assessment should be carried out, preferably using QFracture, before DXA in patients with clinical risk factors for osteoporosis and in whom anti-osteoporosis treatment is being considered. Measurement of BMD by DXA at the spine and hip should be carried out after fracture risk assessment in patients in whom anti-osteoporosis treatment is being considered. Population-based screening for fracture risk and an offer of treatment for those at high risk of fracture is not recommended as a means of reducing MOFs.
American Association of Clinical Endocrinologists and American College of Endocrinology, 2020²⁹	Postmenopausal osteoporosis guidelines: Evaluate all postmenopausal females aged ≥ 50 yr for osteoporosis risk (grade B; BEL 1, downgraded owing to gaps in evidence). A detailed history, physical examination and clinical fracture risk assessment with FRAX or other fracture risk assessment tool should be included in the initial evaluation for osteoporosis (grade B; BEL 1). AACE recommends BMD testing for females aged ≥ 65 yr and younger postmenopausal females at increased risk for bone loss and fracture, based on analysis of fracture risk.
UK National Screening Committee, 2019⁸⁸	Screening for osteoporosis is not recommended in postmenopausal females.
US Preventive Services Task Force, 2018⁸⁵	Screening for osteoporosis with bone measurement testing is recommended to prevent osteoporotic fractures in females aged ≥ 65 yr (B recommendation). Screening for osteoporosis with bone measurement testing is recommended to prevent osteoporotic fractures in postmenopausal females aged < 65 yr at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool (B recommendation). The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in males (I statement).
National Institute for Health and Care Excellence, 2017⁸⁶	Assessment of fracture risk should be considered: In all females aged ≥ 65 yr and all males aged ≥ 75 yr In females aged < 65 yr and males aged < 75 yr in the presence of risk factors Either FRAX (without a BMD value if a DXA scan has not previously been undertaken) or QFracture, within the tools’ allowed age ranges, should be used to estimate 10-yr predicted absolute fracture risk when assessing risk of fracture. Above the upper age limits defined by the tools, people should be considered to be at high risk. BMD should not be routinely measured to assess fracture risk without previous assessment using FRAX (without a BMD value) or QFracture. After risk assessment with FRAX (without a BMD value) or QFracture, measuring BMD with DXA should be considered in people whose fracture risk is in the region of an intervention threshold for a proposed treatment, and absolute risk recalculated using FRAX with the BMD value.
American College of Radiology, 2016⁹¹	BMD screening should be carried out for: All females aged ≥ 65 yr and males aged ≥ 70 yr (asymptomatic screening) Females aged < 65 yr who have additional risk for osteoporosis, based on medical history and other findings Females aged < 65 yr or males aged < 70 yr who have additional risk factors People of any age with bone mass osteopenia or fragility fractures on imaging studies such as radiographs, computed tomography or magnetic resonance imaging People aged ≥ 50 yr who develop a wrist, hip, spine or proximal humerus fracture with minimal or no trauma, excluding pathologic fractures People of any age who develop ≥ 1 insufficiency fractures People being considered for pharmacologic therapy for osteoporosis
Osteoporosis Canada, 2010¹² ^*	People aged ≥ 65 yr should have a BMD test. Menopausal females, and males aged 50–64 yr with clinical risk factors for fracture, should have a BMD test. Height should be measured annually, and the presence of vertebral fractures should be assessed (grade A). History of falls in the past year should be assessed. If there has been such a fall, a multifactorial risk assessment should be conducted, including the ability to get out of a chair without using arms (grade A).

Note: AACE = American Association of Clinical Endocrinologists, ACOG = American College of Obstetricians and Gynecologists, BEL = best evidence level, BMD = bone mineral density, DXA = dual-energy x-ray absorptiometry, FRAX = Fracture Risk Assessment Tool, MOF = major osteoporotic fracture, NSC = National Screening Committee, USPSTF = US Preventive Services Task Force.

The upcoming 2023 Osteoporosis Canada guideline was unavailable for review. However, a 2020 analysis supporting the upcoming guideline⁸⁴ suggested the following for males and females: “BMD testing is indicated at age 70 if no additional FRAX clinical risk factors are present, or at age 65 if one or more clinical risk factors exists.”