Osteoporosis screening

Menopause: The Journal of The North American Menopause SocietyVol. 18, No. 10, pp. 1072/1078DOI: 10.1097/gme.0b013e318215101a* 2011 by The North American Menopause Society

Osteoporosis screening and treatment guidelines: are theybeing followed?

Peter F. Schnatz, DO, FACOG, FACP, NCMP,1,2,3,4 Kimberly A. Marakovits, BA,1,5

Melissa DuBois, MD,1 and David M. OSullivan, PhD1

AbstractObjective: The objective of this study was to examine a cohort of women sent for dual-energy x-ray absorpti-

ometry (DXA) screening to see whether they met the criteria for bone density testing. In addition, we sought todetermine whether they were receiving appropriate interventions, based on published guidelines.

Methods: Between January 1, 2007, and March 1, 2009, inclusive, postmenopausal women (age 949 y) who weresent for DXA bone density screening were offered enrollment into the study. Risk factors for osteoporosis, demo-graphic information, and current DXA results were recorded. The 2006 Osteoporosis Position Statement of The NorthAmerican Menopause Society was used for screening and therapeutic intervention guidelines.

Results: Among the 615 women with data, the mean (SD) age was 61.5 (8.3) years. Using the 2006 guidelines ofThe North American Menopause Society, 41.3% (253 of 612) of the women who had DXA testing did not meetthe criteria for such screening. Of these women, 25.5% (157 of 615) were not taking calcium, 31.1% (191 of 614)were not taking vitamin D, and 59.8% (343 of 574) were not exercising at least half an hour per week. Of the womenwith any of the approved indications for treatment, 15.7% (16 of 102) were not taking calcium, 18.6% (19 of 102)were not taking vitamin D, 52.7% (49 of 93) were not exercising at least 2 hours per week, and 35.3% (36 of 102)were not receiving therapy. In contrast, of those women without an indication for treatment, 17.8% (83 of 467) werereceiving bisphosphonate, raloxifene, or calcitonin therapy.

Conclusions: A large number of women are not properly screened or treated for osteoporosis. Inappropriatescreening may also lead to improper management of osteoporosis and its associated complications.

Key Words: Osteoporosis Y Screening and treatment guidelines Y Menopause Y Bone health Y Calcium andvitamin D.

With the number of postmenopausal women increas-ing, osteoporosis is becoming an increasingly com-mon disorder. Osteoporosis is defined as low bone

mineral density (BMD) andmicroarchitectural deterioration thatleads to skeletal fragility and an increased risk of fracture.1

to treat postmenopausal women appropriately for osteoporosis(Table 1). A retrospective study examining the prevalenceof osteoporosis therapy found that fewer than half of womenwith chest x-ray evidence of a previous vertebral fracturereceive subsequent pharmacologic intervention for osteo-porosis.9 Physicians must have appropriate knowledge ofthe guidelines to allow for comprehensive screening and treat-ment of potential osteoporosis patients even before a patientpresents with osteoporosis-related symptoms. Although therisk of osteoporotic fracture clearly increases as bone massdecreases, the National Osteoporosis Risk Assessment data10

show that the absolute number of women who sustain frac-tures is highest in women with low bone mass (T scoresbetween j1 andj2.5). It may seem logical to respond to thiswith more aggressive screening and intervention in womenwith low bone mass, but this response is not appropriatebecause of the large number of women with T scores in thelow bone mass range. Most of these women with low bonemass will never develop fractures, and treating all of themwould be impractical and inappropriate. The natural question,therefore, is how to identify the women with low bone masswho are at greatest risk of sustaining fractures. NAMS iscontinuously revising and updating the guidelines for pre-dicting fracture risk. According to the 2006 NAMS positionstatement on the management of osteoporosis,3 women metthe criteria for pharmacologic management if they had Tscores between j2 and j2.5, concurrent with specific riskfactors (Table 2). The new 2010 position statement4 is even

more complete, incorporating the FRAX model for fracturerisk assessment11 and relying on multiple, well-establishedrisk factors to identify women with low bone mass whorequire treatment. The objective of this study was to examinea cohort of women sent for DXA screening to determinewhether they met the current criteria for bone density testing,how many of them were receiving appropriate preventivemeasures, and how many were being treated independent ofwhether they met treatment guidelines.

METHODS

The data for this study were collected with the approval andunder the supervision of the Hartford Hospital institutionalreview board.8 The analytical plan was reviewed and approvedby the Reading Hospital and Medical Center institutionalreview board. The data were collected in conjunction with thewomen presenting to one of four private radiology offices inthe greater Hartford, CT, area for DXA screening betweenJanuary 1, 2007, and March 9, 2009, inclusive.8 The currentanalysis reviewed these data to evaluate whether the referraland the subsequent treatment were appropriate according tothe 2006 NAMS criteria.3 All participants were women in themenopause age range, defined as having reached their 49thbirthday. Exclusion criteria included not having reached their49th birthday, not having the time to be informed about thestudy that day, not signing the Health Insurance Portability andAccountability Act consent form, and being unavailable forfollow-up. Each participant was then contacted by telephonefor verbal consent to be included in the study. Those givingconsents were asked about previous pregnancies and breast-feeding, along with family history, current medications, and

TABLE 1. NAMS 2010 guidelines for screening and treatmentof osteoporosis

NAMS 2010 indications for DXA screening4

BMD should be measured in the following populations:(1) Postmenopausal women with medical causes of bone loss,

regardless of agea

(2) Postmenopausal women 65 y or older, regardless of additionalrisk factors

(3) Postmenopausal (50 y and older) with at least one of the followingrisk factors:(A) Fragility fracture after menopauseb

(B) Thinness (bodyweight G127 lb [57.7 kg] or bodymass index G21 kg/m2)(C) History of hip fracture in a parent(D) Current smoker(E) Rheumatoid arthritis(F) Alcohol intake 92 units per dayc

NAMS 2010 treatment guidelines4

Osteoporosis drug therapy should be initiated in the following populations:(1) All postmenopausal women with an osteoporotic vertebral or

hip fracture(2) All postmenopausal women with a lumbar spine, femoral neck,

or total hip T score ej2.5(3) All postmenopausal women with a low bone mass (T score from

j1 to j2.5) and a 10-y hip fracture probability Q3% or 10-y majorosteoporotic-related fracture probability Q20%d

DXA, dual-energy x-ray absorptiometry; BMD, bone mineral density; NAMS,The North American Menopause Society.aSecondary causes of bone loss in this study include steroid use (past or cur-rent, every day for more than 6 mo), anticoagulant use (warfarin or heparin),anticonvulsant use, hyperparathyroidism, hyperthyroidism, or anorexia.bFractures other than those in the skull, facial bone, ankle, finger, and toe.cThe current study did not collect alcohol intake data.dData are based on the FRAX calculator.11

TABLE 2. NAMS 2006 guidelines for screening and treatmentof osteoporosis

NAMS 2006 indications for DXA screening3

BMD should be measured in the following populations:(1) Postmenopausal women with medical causes of bone loss,

regardless of agea

(2) Postmenopausal women 65 y or older, regardless of additionalrisk factors

(3) Postmenopausal women with at least one of the following fourrisk factors:(A) Fragility fracture after menopauseb

(B) Thinness (bodyweight G127 lb [57.7 kg] or bodymass index G21 kg/m2)(C) History of hip fracture in a parent(D) Current smoker

NAMS 2006 treatment guidelines3

Osteoporosis drug therapy should be initiated in the following populations:(1) Postmenopausal women with BMD values (hip or spine T score) ej2.5(2) Postmenopausal women with BMD values (hip or spine scores) between

j2 and j2.5 with at least one of the following risk factors:Thinness (body weight G127 lb or body mass index G21 kg/m2)Fragility fracture since menopauseHistory of a hip fracture in a parent

(3) Postmenopausal women with an osteoporotic vertebral fracture

DXA, dual-energy x-ray absorptiometry; BMD, bone mineral density; NAMS,The North American Menopause Society.aSecondary causes of bone loss in this study include steroid use (past or cur-rent, every day for more than 6 mo), anticoagulant use (warfarin or heparin),anticonvulsant use, hyperparathyroidism, hyperthyroidism, or anorexia.bFractures other than those in the skull, facial bone, ankle, finger, and toe.

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OSTEOPOROSIS GUIDELINES

Copyright 2011 The North American Menopause Society. Unauthorized reproduction of this article is prohibited.

their personal medical history. The questionnaire also obtainedinformation about race/ethnicity, date of birth, and osteoporosisrisk factors. Included in the risk factor assessment were ques-tions consistent with both the FRAX questionnaire11 and asimilar risk calculator.12

Secondary causes of bone loss, or those resulting frommedical conditions or interventions, included steroid use (pastor current, taken every day for more than 6 mo), anticoagulantuse (warfarin or heparin), anticonvulsant use, hyperparathy-roidism, hyperthyroidism, and anorexia nervosa. Consistentwith the NAMS criteria in the 2006 position statement,3 asidefrom age and secondary causes of bone loss, informationabout the four highest risk factors of fracture were obtainedand included fragility fractures after menopause, thinness(defined as body weight G127 lb [57.7 kg] or BMI G21 kg/m2),history of a hip fracture in a parent, and current smoking(Table 2). Rheumatoid arthritis was also queried and used forthe NAMS 2010 criteria (Table 1).4 In addition, renal failurewas tracked as a potentially high-risk medical condition. Eachwomans exercise history was elicited, along with informationon whether she needed to use her arms to stand up from a chair.An appropriate amount of exercise was defined as 2 hours ormore per week. This was a conservative definition, based onthe American Heart Associations recommendation to engagein moderate exercise for at least 150 minutes per week.13

Standard FRAX definitions11 were used to define the 10-yearhip fracture probability as 3% or greater and the 10-yearmajor osteoporosis-related fracture probability as 20% orgreater.11 A major osteoporotic fracture, according to theFRAX model, includes a clinical spine, forearm, hip, orshoulder fracture. Medications for osteoporosis specificallyqueried included hormone therapy (HT), a bisphosphonate,raloxifene, and calcitonin. Parathyroid hormone was not aspecific medication listed in the survey because it was notbeing used in the patient populations studied at the time thesurvey was approved. However, there was an opportunity forpatients to mention other medications being used, includingparathyroid hormone. Additional medications tracked includedcalcium, vitamin D, tamoxifen, leuprolide (Lupron), and Depo-Provera injections.

This review used the data described previously to determinewhether the women referred for DXA met the 2006 NAMScriteria for screening and treatment.3 Women met the criteriafor a BMD study via DXA scan if they were at least 65 yearsof age, were menopausal (age 949 y) with a medical causefor bone loss (as defined previously), or were menopausalwith at least one of the four highest risk factors (as definedpreviously). Women met the criteria for osteoporosis treat-ment if they were menopausal and had a hip or spine T scoreof j2.5 or less, if they presented with an osteoporotic verte-bral fracture, or if they had a hip or spine T score between j2and j2.5 with one of the following risk factors: thinness(weight G127 lb or BMI G21 kg/m2), fragility fracture sincemenopause, or a history of a hip fracture in a parent (Table 2).The definition of fracture for the current study was consistentwith the current guidelines. All participants who responded

positively to having a previous fracture were questioned fur-ther to determine the origin of the fracture. The history of aprevious fracture was excluded if the break was caused bytrauma or was considered to be a nonYosteoporosis-relatedfracture (face, skull, ankle, finger, or toe fracture). Much ofthis information was collected through the survey; however,osteoporosis data, DXA results, body weight, and height wereall confirmed at the time of each womans bone densityscreening. Standard definitions for osteoporosis were used asfollows: osteoporosis in those with a T score of j2.5 or less,low bone mass (or osteopenia) in those with a T score betweenj2.5 and j1.0, and normal bone density in those with a Tscore of j1.0 or greater.14

These data were analyzed to determine whether the patientswere receiving the appropriate interventions, such as refer-ral for DXA, treatment with calcium and vitamin D, orosteoporosis-specific medical therapy. Data also were exam-ined to ascertain whether the patients were adhering to rec-ommended lifestyle precautions like exercise.

RESULTS

Among the 615 women, the mean (SD) age was 61.5 (8.3)years (range, 49.4-95.1 y). Because this was a populationbeing sent for DXA screening, it was not surprising that manywomen had risk factors for osteoporosis. These risk factorsincluded thinness (BMI G21 kg/m2 or weight G127 lb), prev-alent in 19.7% (121 of 615) of the women; history of hipfracture in a parent, 13.9% (85 of 611); and currently being asmoker, 7.2% (44 of 615; Table 3 shows the complete dem-ographic information). A total of 11.2% (69 of 614) of thesewomen were using HT, 21.5% (124 of 578) were taking abisphosphonate, 3.3% (20 of 614) were using raloxifene, 0.7%(4 of 614) were taking calcitonin, and nobody was using para-thyroid hormone.

Accounting for all risk factors and using the 2006 NAMSguidelines, 41.3% (253 of 612) of the women who had DXAtesting did not meet the criteria for such screening (Fig. 1).According to the NAMS 2010 screening guidelines, 40%(245 of 612) of these women did not meet the criteria. Of the232 patients who did not meet the criteria for a DXA bonescan with evaluable data (13 patients did not provide a reasonfor obtaining the DXA scan), the reasons they reported forbeing sent for screening included age (63.8%; 148 women), aprevious bone fracture (0.9%; 2 women), family history ofa bone fracture (8.2%; 19 women), low body weight (0.9%;2 women), unspecified risk factors (22.4%; 52 women), andnumerous other reasons (20.7%; 48 women).

Of the 615 women sent for DXA screening, 25.5% (157 of615) were not taking calcium, 31.1% (191 of 614) were nottaking vitamin D, and 52.9% (303 of 573) were not exercisingat least 2 hours per week (Fig. 2). Even among the womenwith a previous fracture, 13.3% (2 of 15) were not takingcalcium and/or vitamin D, 46.2% (6 of 13) were not exercisingat least 2 hours per week, and 33.3% (5 of 15) were notreceiving treatment (HT, a bisphosphonate, raloxifene, orcalcitonin). Of the 15 patients receiving drug treatment, 20%

1074 Menopause, Vol. 18, No. 10, 2011 * 2011 The North American Menopause Society

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(3 of 15) were receiving two agents for therapy. Of the womenwith a T score ofj2.5 or less, 12.9% (9 of 70) were not takingcalcium, 15.7% (11 of 70) were not taking vitamin D, 55.6%(35 of 63) were not exercising at least 2 hours per week, and27.1% (19 of 70) were not using pharmacologic therapy(HT, a bisphosphonate, raloxifene, or calcitonin).

Of the women with low T scores (between j2 and j2.5),in addition to having risk factors such as thinness, history of

a fragility fracture, or parental hip fracture (ie, women whomet the criteria for treatment based on the 2006 NAMSguidelines), many were not being treated appropriately. Thisincluded a total of 20.5% (8 of 39) who were not taking cal-cium, 23.1% (9 of 39) who were not taking vitamin D, 52.8%(19 of 36) who were not exercising at least 2 hours per week,and 46.2% (18 of 39) who were not receiving therapy (HT, abisphosphonate, raloxifene, or calcitonin).

TABLE 3. Demographic variables

Variable Total sample

Those withindication for

DXA

Those withoutindication for

DXA P

Those withindication fortreatment

Those withoutindication fortreatment P

Age at DXA,a y 61.4 (8.3) 359 (64.3 T 9.2) 253 (57.5 T 4.1) G0.001 102 (64.6 T 9.7) 513 (60.8 T 7.8) G0.001BMIa 26.9 (5.6) 359 (25.7 T 5.4) 253 (28.5 T 5.5) G0.001 102 (23.5 T 3.9) 513 (27.5 T 5.6) G0.001Race/ethnicity,b number of patients (%)Hispanic 4 (0.7) 3 (75.0) 1 (25.0) 0.498 0 (0.0) 4 (100.0) 0.365White 564 (94.6) 328 (58.5) 233 (41.5) 0.805 95 (16.8) 469 (83.2) 0.780African American 10 (1.7) 3 (30.0) 7 (70.0) 0.067 0 (0.0) 10 (100.0) 0.150Asian 7 (1.2) 6 (85.7) 1 (14.3) 0.140 4 (57.1) 3 (42.9) 0.004Native American 1 (0.2) 0 (0.0) 1 (100.0) 0.236 0 (0.0) 1 (100.0) 0.651Other 10 (1.7) 6 (60.0) 4 (40.0) 0.915 2 (20.0) 8 (80.0) 0.795

Smoking status, n (%)Past 259 (42.1) 164 (63.8) 93 (36.2) 0.028 45 (17.4) 214 (82.6) 0.654Current 44 (7.2) 44 (100.0) 0 (0.0) G0.001 8 (18.2) 36 (81.8) 0.768

HT use, n (%)Ever 323 (52.6) 203 (62.8) 120 (37.2) 0.030 54 (16.7) 269 (83.3) 0.941Current 69 (11.2) 41 (59.4) 28 (40.6) 0.905 11 (15.9) 58 (84.1) 0.874

Bisphosphonate use, n (%) 124 (21.5) 92 (74.2) 32 (25.8) G0.001 51 (41.1) 73 (58.9) G0.001Hx of steroid use, n (%) 33 (5.4) 33 (100.0) 0 (0.0) G0.001 8 (24.2) 25 (75.8) 0.226Hx of anticoagulant use, n (%) 8 (1.3) 8 (100.0) 0 (0.0) 0.017 4 (50.0) 4 (50.0) 0.011Hx of anticonvulsant use, n (%) 20 (3.3) 20 (100.0) 0 (0.0) G0.001 1 (5.0) 19 (95.0) 0.156Hyperparathyroidism, n (%) 7 (1.1) 7 (100.0) 0 (0.0) 0.025 1 (14.3) 6 (85.7) 0.869Hyperthyroidism, n (%) 20 (3.3) 20 (100.0) 0 (0.0) G0.001 4 (20.0) 16 (80.0) 0.676Anorexia, n (%) 3 (0.5) 3 (100.0) 0 (0.0) 0.145 1 (33.3) 2 (66.7) 0.434Wt G127 lb or BMI G21 kg/m2, n (%) 121 (19.7) 121 (100.0) 0 (0.0) G0.001 52 (43.0) 69 (57.0) G0.001Hx of a hip Fx in a parent, n (%) 85 (13.9) 85 (100.0) 0 (0.0) G0.001 21 (24.7) 64 (75.3) 0.022Hx of a previous atraumatic Fx, n (%) 15 (2.4) 15 (100.0) 0 (0.0) G0.001 15 (100.0) 0 (0.0) G0.001Exercise 92 h/wk, n (%) 270 (47.1) 160 (59.3) 110 (40.7) 0.611 44 (16.3) 226 (83.7) 0.742

P values in boldface indicate statistically significant differences at P G 0.05.Percentages may not add up to 100 because of rounding errors.DXA, dual-energy x-ray absorptiometry; HT, hormone therapy; BMI, body mass index; Hx, history; Wt, weight; Fx, fracture.aData are expressed either as mean (SD) or as n (mean T SD).bOf the 615 women in this study, these race/ethnicity numbers add up to only 596 because there were 19 who indicated multiple race/ethnicities that were excluded.

FIG. 1. The percentage of women, among the women studied, who received dual-energy x-ray absorptiometry screening but did not have an indicationfor the test based on the 20063 and 20104 position statements of The North American Menopause Society (NAMS).

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In the group of women with any of the approved indicationsfor treatment (according to the 2006 NAMS guidelines),15.7% (16 of 102) were not taking calcium, 18.6% (19 of 102)were not taking vitamin D, 52.7% (49 of 93) were not exer-cising at least 2 hours per week, and 35.3% (36 of 102) werenot using pharmacologic therapy (HT, a bisphosphonate,raloxifene, or calcitonin). Of those receiving therapy, 7.3%(7 of 96) were receiving two agents.

Of the women who did not meet the criteria for treatment(no osteoporotic fracture with a T score greater than j2 or aT score between j2 and j2.5 without thinness, a fragilityfracture, or a parental hip fracture), many were not properlymanaged. A total of 28.5% (141 of 495) were not receivingcalcium, 33.8% (167 of 494) were not receiving vitamin D,and 52.9% (254 of 480) were not exercising at least 2 hoursper week. In addition, of those women without an indicationfor treatment, 17.8% (83 of 467) were receiving a bisphos-phonate, raloxifene, or calcitonin.

DISCUSSION

Organizational task force statements and committee opin-ions attempt to guide physicians in the appropriate utilizationof technology and management guidelines. The current datasuggest that, according to NAMS guidelines, many womenare not appropriately screened for low bone mass and osteo-porosis. The realization that guidelines are not being met,therefore, raises the questions of why and what the potentialimplications may be.

The reason why approximately two of every five womenare inappropriately screened is not well understood. A poten-tial reason is pressure from concerned patients. In todays liti-gious society, physicians may be quick to yield to a requestfor testing that a patient thinks is important. On the otherhand, physicians may simply be ill-informed. We know fromprevious data that women are often not appropriately screenedfor osteoporosis. Even women with radiologic evidence of

vertebral fractures infrequently receive appropriate treatment,9

presumably because many physicians do not consider the riskof osteoporosis. Some physicians may not recognize theimportance of screening and fail to send patients for bonedensity testing when necessary. However, once practitionersare aware of the importance, they may start sending too manypatients for testing without using the approved guidelines fordecision making.

Overutilization of DXA testing is certainly of concern be-cause some patients who do not meet the criteria for screeningare tested and yield abnormal DXA results. This may causeunnecessary psychologic stress and worry to a patient who hasno need for concern, as well as excessive treatment of con-ditions that may not need therapy. Results from this researchsuggest that many women sent for DXA scans receive treatmentinappropriately. Misplaced patient concerns may lead tounnecessary follow-up visits and testing, as well as excesshealthcare spending.

In this population, in which there was enough concern tosend women for expensive DXA testing, up to one third of thewomen were not receiving vitamin D or calcium, and approx-imately two thirds were not exercising the recommendedamount. In addition, approximately one in three women with anapproved indication for therapy was not being properly treated.Some of these women may have received recommendationsto do so, meaning that the patients lack of proper treatmentcould be caused by the patients own nonadherence. Whetherthe reason for inadequate treatment falls on the doctor or onthe patient, the fact remains that many patients are not receiv-ing risk-reducing preventive measures or pharmacologic in-tervention. Supplemental therapy may not be necessary forwomen whose dietary intake of calcium and vitamin D is ade-quate. The Institute of Medicine of the National Academiesrecently reported that most women are receiving appropriateamounts of these nutrients in their diets and that vitamin Ddeficiency has been overestimated.15,16 The fact remains,

FIG. 2. The percentage of women, among the women sent for dual-energy x-ray absorptiometry screenings, not following or receiving the standardrecommendations among the various subgroups within the study cohort (all women, those with a previous fracture, those with a T score ofj2.5 or less,and those meeting the 2006 guidelines of The North American Menopause Society [NAMS]).


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however, that many women who are at the highest risk offracturing are not receiving the recommended treatment. Alongwith the new osteoporosis recommendations and strategies toeducate both medical communities and the general public,osteoporosis management would benefit from future researchexploring novel and effective ways of modifying risk-basedscreening and interventions.

Based on the risk factors and testing results, approximatelyone in six women who did not meet the criteria for treatmentwas receiving antiresorptive therapy for osteoporosis. Thispractice raises concern about long-term therapy using anti-resorptive agents. Although these medications are consideredto be safe for short-term use, long-term data are lacking.4

Furthermore, the risks are not yet known to younger womenreceiving antiresorptive treatment inappropriately who willsubsequently meet the treatment criteria and need bisphos-phonate therapy for diagnosed bone loss.

Approximately 1 in 13 women who had an indication fortreatment was receiving at least two antiresorptive agents.Although the results of scientific studies suggest that thecombination of two antiresorptive agents may slightly in-crease BMD, the general recommendation is to avoid usingtwo antiresorptive agents simultaneously. There is a concernthat the advantage of any small increase in bone density maybe offset by an oversuppression of bone turnover, which couldlead to poor bone quality and a paradoxical increase in the riskof a fracture.4 Although therapy using an anabolic agent, suchas parathyroid hormone, and an antiresorptive agent may bereasonable in rare situations, the fact that more than 7% ofpatients are taking dual antiresorptive agents suggests thatphysicians may not be aware of this concern.

Limitations of the study include the retrospective nature ofdata collection, which has inherent biases, and the possibilitythat some of the data points may have been affected by par-ticipant recall bias (although weight, DXA results, and someof the demographic variables were verified) and that thefindings may not necessarily be generalizable to the pop-ulation because most participants were white (94.2%) andwere sampled from the greater Hartford, CT, region. In addi-tion, the age used for menopause (949 y) was slightly underthe average menopause age of 51 years. This determinationwas intended to err on the side of meeting the screening andtreatment criteria based on the NAMS guidelines. Using astricter definition of menopause may have resulted in findingsskewed toward a higher percentage of patients being inap-propriately screened and treated. Because some of the reportedfindings may underestimate the reality of inadequate osteo-porosis screening, the results of this study may be even moreconcerning and further highlight the importance of educationon screening and treatment guidelines. In addition, some ofthe women listed as Bon treatment[ may have been receivingHT for other indications, hence overestimating the percentageof participants being appropriately treated. Despite the inher-ent limitations of the study design, the detailed definitionsused for data collection and the thorough personalized admin-istration of the questionnaire reinforce the accuracy of the data.

The main hospital, which generated the referrals for theradiology testing sites, did not have guidelines for DXA test-ing or osteoporosis treatment aside from national standardsand recommendations. Although some physicians may followrecommendations other than the NAMS guidelines, all of thestandard guidelines and recommendations are quite similarand, hence, unlikely to yield major differences in care. Al-though the provider types referring patients were not trackedfor this study, the basic premise should be to understand thetesting guidelines when making a referral. Additional data areneeded to understand why current guidelines and recom-mendations are not followed. From these data, it may bepossible to test certain interventions to determine whetherchanges toward more appropriate screening and therapeuticinterventions can be achieved. Until then, enhanced educa-tional initiatives and continuing medical educational readingwould help make providers aware of the appropriate guide-lines for osteoporosis management.

CONCLUSIONS

Many women are not screened or treated for osteoporosisproperly. Inappropriate screening could also lead to unneces-sary treatment. Healthcare providers must strive to educate themedical community and the nonmedical public about thecurrent screening and therapeutic intervention guidelines inmanaging osteoporosis.

Acknowledgments: We thank Taghogho Agarin, MD; MarianneMuchura, MD; Charnetta Smith, MD; Jessica Abrantes; AlisonRomegialli; David Cunningham; Sarah Dobrowolski; and BarbaraLevarge, MD, for their help in patient recruitment and data collection.We thank J. David Schnatz, MD, for his assistance with manuscriptreview and editing.

REFERENCES

1. NIH Consensus Development Panel on Osteoporosis Prevention, Diag-nosis, and Therapy. JAMA 2001;285:785-795.

2. Javaid MC, Cooper C. Prenatal and childhood influences on osteopo-rosis. Best Pract Res Clin Endocrinol Metab 2002;16:349-367.

3. The North American Menopause Society. Management of osteoporo-sis in postmenopausal women: 2006 position statement of The NorthAmerican Menopause Society. Menopause 2006;13:340-367.

4. The North American Menopause Society. Management of osteoporo-sis in postmenopausal women: 2010 position statement of The NorthAmerican Menopause Society. Menopause 2010;17:25-54.

5. Looker AN, Orwoll ES, Johnson CC, et al. Prevalence of low femoralbone density in older U.S. adults from NHANES III. J Bone Miner Res1997;12:1761-1768.

6. U.S. Department of Health and Human Services, Public Health Service,Office of the Surgeon General, Rockville, MD. Bone health and osteo-porosis: a report of the Surgeon General 2004. Available at: http://www.surgeongeneral.gov/library/bonehealth/Executive_Summary.htmlAccessed February 2, 2011.

7. Raisz LG. Screening for osteoporosis. N Engl J Med 2005;353:164-171.8. Schnatz PF, Barker KG, Marakovits KA, OSullivan DM. The effects of

age at first pregnancy and breastfeeding on the development of post-menopausal osteoporosis. Menopause 2010;17:1161-1166.

9. Kroth PJ, Murray MD, McDonald CJ. Undertreatment of osteoporosis inwomen based on detection of vertebral compression fractures on chestradiography. Am J Geriatr Pharmacother 2004;2:112-118.

10. Siris ES, Chen YT, Abbott TA, et al. Bone mineral density thresholds for

Menopause, Vol. 18, No. 10, 2011 1077



pharmacological interventions to prevent fractures. Arch Intern Med 2004;164:1108-1112.

11. FRAX-WHO fracture risk assessment tool. Available at: http://www.shef.ac.uk/FRAX/. Accessed February 2, 2011.

12. Black DM, Steinbuch M, Palermo L, et al. An assessment tool for pre-dicting fracture risk in postmenopausal women. Osteoporosis Int 2001;12:519-528.

13. Mosca L, Benjamin EJ, Bezanson JL, et al. Effectiveness-based guidelinesfor the prevention of cardiovascular disease in women 2011 update: aguideline from the american heart association. Circulation 2011;123:1243-1262.

14. Geneva World Health Organization. WHO: Guidelines for preclinical

evaluation and clinical trials in osteoporosis. January 11, 1998. Available at:http://whqlibdoc.who.int/publications/1998/9241545224_eng.pdf. AccessedFebruary 2, 2011.

15. Ross AC, Taylor CL, Yaktine AL, Del Valle HB. Dietary ReferenceIntakes for Calcium and Vitamin D. Food and Nutrition Board, Instituteof Medicine of the National Academies. Available at: http://books.nap.edu/openbook.php?record_id=13050&page=R1. Accessed February 2, 2011.

16. Dietary Reference Intakes for Calcium and Vitamin D. November2010. Available at: http://www.iom.edu/~/media/Files/Report%20Files/2010/Dietary-Reference-Intakes-for-Calcium-and-Vitamin-D/Vitamin%20D%20and%20Calcium%202010%20Report%20Brief.pdf. AccessedFebruary 2, 2011.


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