On June 13, 2012, the medical website Medscape posted an interview with the president of the American Academy of Family Physicians (AAFP) on AAFP’s involvement with the “Choosing Wisely” campaign. “Choosing Wisely,” according to the article, is an initiative of the American Board of Internal Medicine Foundation that has come up with evidence-based recommendations from 9 organizations about questionable medical tests and procedures. The organizations are mainstream medical groups like AAFP. The goal is to use these recommendations as the basis for discussions between doctors and patients.
According to the article, one of AAFP’s top five recommendations is that women should not be routinely screened for osteoporosis at the time of menopause. In fact, except for women who have high risk factors, screening should not begin until age sixty-five. The same recommendation was made by a Choosing Wisely group in 2011 and was also the judgment of the U.S. Preventive Services Task Force. This is in contrast to a common practice among physicians to order a DEXA screening test to measure bone mineral density (BMD) around the time of menopause and to prescribe medication for women who score low on the test beginning at this time
Here’s some background: The word “osteoporosis” at one time meant a medical condition in which bones are fragile and break easily; low bone mineral density was a risk factor for osteoporosis. However, low BMD also came to mean that a person had the disease itself rather than a risk factor for it. “Osteopenia” means that BMD is not as low as in osteoporosis but lower than a statistically-defined normal amount. One perspective by physicians and medical groups has been that since menopause and the transition to menopause are associated with declining BMD, it makes sense to test BMD at this time and to begin treating women, often with medication, if a screening test shows low bone density. Osteopenia as well as osteoporosis might be treated. A different perspective is that osteoporosis involves bone becoming so fragile that it fractures; BMD is only one of the factors that contribute to bone fragility; many factors (including lifestyle) contribute to bone strength and to whether a woman will break a bone. Further, since osteopenia is defined statistically, it may not really indicate a problem (as in Lake Wobegon, where everyone wanted their children to be above average).
What are factors indicating osteoporosis or risk of osteoporosis before age 65? Some of them are: if a bone fractures for what seems like no good reason (e.g., if you haven’t had a hard fall or something else like it); if you’ve lost height; if you’ve been prescribed steroids for long periods of time; if you have certain other diseases like thyroid problems. There are many other factors that statistically predict increase risk. FRAX is an online tool that can be used to estimate risk. However, it is based on things like sex, height, weight, and medical history and does not take lifestyle measures (whether you exercise, have ways to avoid falls, etc.) into account. Many websites have additional information (e.g., National Institutes of Health, National Women’s Health Network).
Some reasons behind recommending that women should not routinely be screened for osteoporosis until age 65 are: the rate of fracture does not go up until after age 65; there is little evidence that using medication helps women with osteopenia; the medications used to treat osteoporosis are good medicines for women who need them but carry risks, so women who don’t clearly need them or will benefit from them shouldn’t be using them. Thus, the Choosing Wisely initiative recommends that unless a woman has high risk factors to suspect osteoporosis, screening tests should not be ordered until a woman is 65.
