Practitioners who see their patient year in and year out may need a prompt for them to evaluate a freshly menopausal woman for osteoporosis with a DXA bone density test. Early menopause is the ideal time to evaluate the highest risk group, white women.
Many white women carry the genetic osteoporosis complex that is triggered by the loss of estrogen characteristic of menopause. Bone density survey data show that 50% of white women entering menopause are osteopenic and 7% are osteoporotic. Bone loss rates increase at menopause from an average of 0.5% annually in the 40s to 1-2% per annum during the 50s. That is the average rate. The rate of loss seen in the women among this group destined to develop osteoporosis is higher. By the time these white women reach their 60s, 18% will be osteoporosis and most will experience spine, hip, or peripheral fractures during their lifetime.
All our US FDA indicated drugs have been extensively tested and shown to be safe and effective for treating osteoporosis and preventing fractures. These drugs are designed and indicated for use by postmenopausal women, not women before menopause. Since white women experience 2.5 x more fractures from osteoporosis than other women or men, logic dictates that a screening recommendation like this should focus on them. Other women and men can also be screened on a case-by-case basis but it is not economically justified or medically necessary in my view as a routine practice. Screening DXA is indicated when everyone turns 60 years old.
Screening guidelines by the highly authoritative non-profit voluntary health organization, who more than anyone else represents the interests of people with osteoporosis in the U.S., the National Osteoporosis Foundation publishes the following guidelines for bone density screening.
The National Osteoporosis Foundation Bone Density Testing Recommendations
NOF recommends that you have a bone density test if:
- You are a woman age 65 or older
- You are a man age 70 or older
- You break a bone after age 50
- You are a woman of menopausal age with risk factors
- You are a postmenopausal woman under age 65 with risk factors
- You are a man age 50-69 with risk factors
A bone density test may also be necessary if you have any of the following:
- An X-ray of your spine showing a break or bone loss in your spine
- Back pain with a possible break in your spine
- Height loss of ½ inch or more within one year
- Total height loss of 1½ inches from your original height
White women are in a case by themselves when it comes to risk for osteoporosis and fractures. I see many healthy white postmenopausal women with florid osteoporosis that have no other health issues and no significant risk factors. Most of those with the osteoporosis genetic complex will have a family history of osteoporosis; a risk factor for the disease that probably would qualify them for a test using the NOF criteria.
The data clearly shows that white women whose ancient ancestors hail from Northern Europe are a special class as far as I am concerned. They have fracture rates 250% higher than other women or men and their fractures begin about a decade sooner than seen with age related osteoporosis that affects all people about the same. It is inappropriate to apply screening guidelines to them that fail to appreciate their elevated and early risk compared to other women or men.
I suggest primary care practitioners make it a standing practice to do a screening DXA bone density test on all white women as soon after menopause as practical in order to characterize their current bone health state and be empowered with data now to plan what the next best step to take.
Data show that you will find 7% of those tested among the postmenopausal white group will already be in the osteoporotic range and are candidates for evaluation for secondary causes of bone loss and treatment. Half of those tested will be in the osteopenic range. Of that group, those with T-scores below –2 are in the low bone density category and deserve special attention. These women in the low bone density group should also be evaluated for secondary causes of osteoporosis but are not candidates for drug therapy. This group should be monitored every 2 years with DXA and follow good general health dietary and exercise practices. Special attention to vitamin D nutrition is important in these women.
Women found to have low-grade osteopenia, a T-score between 1- and –2, no evaluation or treatment is indicated in my opinion. The normative T-score at age 50 for all white women is –1, this is why I can say with such confidence that 50% with be below –1. Obviously 50% will also be above –1 or have normal bone density. Those with normal bone density at menopause will probably not develop osteoporosis. As with all patients, ensuring good vitamin D nutrition is essential for human health. I recommend a second screening bone density test again in 5 years on both the low-grade osteopenic group and the normal bone density patients.