What's new in osteoporosis screening and fracture prevention?

In the two years since publication of the latest American Family Physician review article on osteoporosis, new guidelines and research studies have enhanced management of this common condition. In early 2025, the U.S. Preventive Services Task Force (USPSTF) updated its recommendations on screening for osteoporosis. Although on the surface these are unchanged from the 2018 version—recommending screening in all women 65 years or older and postmenopausal women younger than 65 years at increased risk for an osteoporotic fracture and finding insufficient evidence to screen men—an accompanying editorial noted a small, but significant, difference.

Previously, the USPSTF defined increased risk by a threshold on the Fracture Risk Assessment Tool (FRAX) that corresponded to the 10-year fracture risk of an average 65-year-old White woman. However, evidence indicates that the predictive value of FRAX without bone mineral density is poor and inferior to simpler tools such as the Osteoporosis Self-Assessment Tool and the Osteoporosis Risk Assessment Instrument. In its updated recommendations, the USPSTF recommends only a “clinical risk assessment” and notes that if FRAX is used, it “does not intend that these 10-year risk levels be used as mechanistic thresholds” to decide who should undergo dual-energy absorptiometry screening.

A recent analysis of the performance of the Osteoporosis Self-Assessment Tool, Osteoporosis Risk Assessment Instrument, and the Osteoporosis Assessment of Risk tools in a subgroup of Women’s Health Initiative participants 50 to 64 years of age found that each had “fair to moderate discrimination” in identifying osteoporosis, with areas under the receiver operating characteristic curve of 0.633 to 0.663, with 1.0 being perfect and 0.5 being no better than chance.

Not only is it difficult to clinically predict osteoporosis risk, fragility fractures can occur in patients without osteoporosis. In January 2025, researchers published a randomized, placebo-controlled trial of an alternative strategy for reducing fractures: treating women in early menopause with antiresorptive therapy regardless of bone mineral density. There were 1,054 women 50 to 60 years of age with bone mineral density T-scores at the lumbar spine or hip from 0 to -2.5 at baseline assigned to one of three groups: zoledronate intravenous infusion at baseline and repeated at 5 years; zoledronate infusion at baseline, placebo at 5 years; and placebo infusions at baseline and at 5 years. After 10 years, new fractures had occurred in 11.1% of the placebo-placebo group, 6.6% of the zoledronate-placebo group, and 6.3% of the two dose zoledronate group. The relative risk of fractures in the two-dose zoledronate compared with the placebo-placebo group was 0.72, with a number needed to treat of 25 to prevent one fracture. The comparative benefits and cost effectiveness of this prevention strategy vs fracture risk assessment and treating women at increased risk remains to be seen.

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This post first appeared on the AFP Community Blog.