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GPAC: Guidelines and Protocols Advisory Committee Bone Density Measurement in Women Effective Date: May 1, 2005 Summary | Flow Sheet | Patient Guide | Full Guideline in PDF Recommendations and TopicsScopeThis guideline defines the medical necessity of bone mineral density (BMD) measurement using dual-energy x-ray absorptiometry (DXA or DEXA), and applies to adult women 19 years of age and older. Currently, 94% of DXA scans in British Columbia are performed on female patients. This guideline outlines age and risk factors that are indications for medically necessary BMD testing. While many of the same indications for BMD testing apply to men as well as women, it is not the intent at this time to address BMD testing in men. Currently, insufficient data exist on the relationship between bone mineral density and risk of fracture in men.1 Bone mineral density measurements are used to assess fracture risk. Osteoporotic fractures are very unusual in women under 50-55 years of age, even those with somewhat reduced bone density. Therefore, bone density measurements are rarely indicated in people under 50-55 years of age without evidence of considerable risk.2  RECOMMENDATION 1: ScreeningBone mineral density (BMD) measurement is not recommended as a screening procedure for women under 65 years of age, nor as part of routine evaluation around the time of menopause. RECOMMENDATION 2: Appropriate Indications for BMD Measurement Using DXABMD measurement should only be performed when:
BMD may be of value in assessing the risks and potential benefits of pharmacotherapy in women with risk factors for osteoporosis. Appropriate lifestyle modification should be recommended irrespective of BMD results. Table 1: Risk Factors for Osteoporosis (modified from 1)RECOMMENDATION 3: Trauma Fractures/Measured Loss of HeightWhere other disease has been ruled out, patients with low-trauma, (also known as fragility) fractures*, have osteoporosis and should be treated accordingly. BMD measurement is not required to confirm osteoporosis in such cases, but may be useful as a baseline against which to measure the effects of treatment in cases when it is contemplated. Patients with a significant measured loss of height amounting to at least 2 cm in one year, or 5 cm over a lifetime, (not resulting from other causes, including neoplasm or infection), can be assumed to have osteoporosis without BMD measurement. *The World Health Organization (WHO)5 defines fragility fracture as, "a fracture caused by injury that would be insufficient to fracture normal bone: the result of reduced compressive and/or torsional strength of bone." The Canadian guidelines for osteoporosis1 further suggests a fragility fracture may be defined as, "one that occurs as a result of minimal trauma, such as a fall from standing height or less, or no identifiable trauma." RECOMMENDATION 4: Inappropriate Indications for BMD MeasurementChronic Back pain: Only about one-third of low-trauma vertebral fractures cause symptoms. The pain of low trauma vertebral fractures, if it occurs, is usually of relatively acute onset. Therefore, without other risk factors for osteoporosis, BMD measurement is not indicated for long-standing back pain. Kyphosis: While dorsal kyphosis is often associated with vertebral fracturing, there are other causes of the condition. In the absence of other reasons to do densitometry, kyphosis is best first investigated by obtaining lateral thoracic spine x-rays (radiographs) to rule out anterior compression fractures Menopause: There is no indication for routine perimenopausal bone density measurement in the absence of risk factors. RECOMMENDATION 5: Follow-Up Bone Density MeasurementsFollow-up bone density measurements are not considered necessary prior to two years after the original measurement except:
The response to many of the drugs used to treat osteoporosis is characterized more by a reduction in fracture incidence than by an increase in bone density. Follow-up measurements of bone density should be interpreted with this fact in mind. RationaleMeasurement of bone density may be useful in specific clinical circumstances to assist in management decisions and therapeutic choices. Low trauma fractures in certain disease states and in the elderly, are causes for concern, but loss of bone mineral is only one of many risk factors for fracturing. Many individuals with low bone density do not progress to fracture and many with normal bone densities do suffer from fractures. Management decisions based on bone density alone, therefore, may lead to over-treatment or false reassurance, as well as detract from other important management issues such as diet, exercise and prevention of falls. However, if a patient’s decision to initiate or comply with therapy is dependent upon the results of bone density measurement, then such measurement may be appropriate. In assessing response to treatment, either an increasing or stable bone mineral density can be interpreted as a satisfactory treatment response. Reliable follow-up DXA measurements are best obtained using the same machine, in the same facility, at the same time of year. The rate of change of BMD with age or treatment is usually small (circa 0.5-1.0%); given the precision of the test, any changes except in specific circumstances, will not usually be detectable in less than 2 years. In recent years, the availability of quantitative ultrasound testing for osteoporosis has proliferated in nonaccredited facilities. The findings may not be reliable, tend to overestimate the presence of osteoporosis, and are unsatisfactory for use in follow-up.6 References
SponsorsThis guideline, revised by the Bone Density Working Group, subcommittee of Guidelines and Protocols Advisory Committee, supersedes the Protocol for Bone Density Measurement developed in 1999. This revision has been approved by the British Columbia Medical Association and adopted by the Medical Services Commission. Partial funding for this guideline was provided by the Health Canada Primary Health Care Transition Fund. Revised Date: April 1, 2007This guideline is based on scientific evidence current as of the effective date. The principles of the Guidelines and Protocols Advisory Committee are to:
DisclaimerThe Clinical Practice Guidelines (the "Guidelines") have been developed by the Guidelines and Protocols Advisory Committee on behalf of the Medical Services Commission. The Guidelines are intended to give an understanding of a clinical problem, and outline one or more preferred approaches to the investigation and management of the problem. The Guidelines are not intended as a substitute for the advice or professional judgment of a health care professional, nor are they intended to be the only approach to the management of clinical problems. PDF Format Some documents on this Web site are in PDF format and require a PDF reader. If you do not have Adobe Acrobat Reader Version 7.0 or the most recent version of another PDF reader, you can download Adobe Acrobat Reader by clicking on the 'Get Acrobat Reader' icon.
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