<\/p>\n
By the U.S. Preventive Services Task Force (USPSTF)*<\/a><\/p>\n Address correspondence to: Chair, U.S. Preventive Services Task <\/a>*This statement summarizes the current U.S. Recommendation and Rationale statements present the current USPSTF The USPSTF recommendations are independent of the U.S. Government. They do Summary The U.S. Preventive Services Task Force (USPSTF) recommends that women aged The USPSTF found good evidence that the risk for osteoporosis and fracture The USPSTF makes no recommendation for or against routine osteoporosis The USPSTF found fair evidence that screening women at lower risk for Return Return One-half of all postmenopausal women will have an osteoporosis-related The prevalence of osteoporosis in Mexican-American women is similar to the The USPSTF examined two components of screening:<\/p>\n Predicting Risk for Osteoporosis or Fracture<\/strong><\/p>\n The USPSTF evaluated both individual risk factors and prescreening assessment Specific instruments to assess risk for low bone density or fractures Among eight studies of prediction instruments for fracture risk, most had Measurements of Bone Density<\/strong><\/p>\n To date, bone density measured at the femoral neck by DXA is the best In a study of over 200,000 women in a primary care setting, women diagnosed No controlled studies have evaluated the effect of screening on fractures or Available trials that reported fracture outcomes have examined the efficacy There are no direct comparisons of alendronate and estrogen or raloxifene The benefits of treating osteoporosis are larger in women at higher risk for These results suggest that treatment will produce larger benefits in women There is little evidence regarding which patients are likely to benefit from To estimate the benefits of routine screening for women in different age In all age groups, the number needed to screen to prevent fractures is lower There are several potential harms of screening, although the empirical data In the alendronate treatment trials, gastrointestinal side effects occurred Return In 1998, the National Osteoporosis Foundation, in collaboration with other Return The USPSTF grades its recommendations according to one of five A.<\/strong> The USPSTF strongly recommends that clinicians routinely provide <\/a>B.<\/strong> The USPSTF recommends that clinicians routinely <\/a>C.<\/strong> The USPSTF makes no recommendation for or against D.<\/strong> The USPSTF recommends against routinely providing [the service] to I.<\/strong> The USPSTF concludes that the evidence is insufficient to recommend Return <\/a><\/p>\n The USPSTF grades the quality of the overall evidence for a service on a Good:<\/strong> Evidence includes consistent results from well-designed, Fair:<\/strong> Evidence is sufficient to determine effects on health outcomes, Poor:<\/strong> Evidence is insufficient to assess the effects on health Return <\/a>1. U.S. Preventive Services Task Force. Guide to <\/a>2. Nelson HD, Helfand M, Woolf SH, et al. Screening <\/a>3. Nelson HD, Helfand M. Screening for <\/a>4. Cadarette SM, Jaglal SB, Kreiger N, et al. <\/a>5. Cadarette SM, Jaglal SB, Murray T, et al. <\/a>6. Melton LJ 3rd, Kan SH, Frye MA, et al. <\/a>7. Barrett JA, Baron JA, Karagas MR, et al. <\/a>8. Kanis JA. Assessment of fracture risk and its <\/a>9. Melton LJ 3rd. How many women have osteoporosis <\/a>10. Looker AC, Wahner HW, Dunn WL, et al. Updated <\/a>11. Lydick E, Cook K, Turpin J, et al. Development <\/a>12. Siris ES, Miller PD, Barrett-Connor E, et al. <\/a>13. Nelson HD, Helfand M. Hormone Replacement <\/a>14. Burger H, de Laet CE, Weel AE, et al. Added <\/a>15. Bouxsein ML, Radloff SE. Quantitative <\/a>16. Cranney A, Wells G, Willan A, et al. <\/a>17. Black DM, Cummings SR, Karpf DB, et al. <\/a>18. Adami S, Passeri M, Ortolani S, et al. Effects <\/a>19. Bone HG, Downs RW Jr, Tucci JR, et al. <\/a>20. Chesnut CH, 3rd, McClung MR, Ensrud KE, et al. <\/a>21. Hosking D, Chilvers CE, Christiansen C, et al. <\/a>22. Liberman UA, Weiss SR, Broll J, et al. Effect <\/a>23. McClung M, Clemmesen B, Daifotis A, et al. <\/a>24. Greenspan SL, Parker RA, Ferguson L, et al. <\/a>25. Pols HA, Felsenberg D, Hanley DA, et al. <\/a>26. Cummings SR, Black DM, Thompson DE, et al. <\/a>27. Bonnick S, Rosen C, Mako B, et al. Alendronate
\nForce; c\/o Project Director, USPSTF, Agency for Healthcare Research and Quality
\n(AHRQ); 540 Gaither Road; Rockville, MD 20850; E-mail: uspstf@ahrq.gov<\/a>.<\/p>\n
\nPreventive Services Task Force (USPSTF) recommendations on screening for
\nosteoporosis and the supporting scientific evidence, and it updates the 1996
\nrecommendations contained in the Guide to Clinical Preventive Services<\/em>,
\nsecond edition.1<\/a><\/sup>
\nExplanations of the ratings and of the strength of overall evidence are given in
\nAppendix
\nA<\/a> and Appendix
\nB<\/a>, respectively. The complete information on which this statement is based,
\nincluding evidence tables and references, is available in the accompanying
\narticle, “Screening
\nfor Osteoporosis: A Review of the Evidence for the U.S. Preventive Services Task
\nForce<\/a>“2<\/a><\/sup>
\nand in the Systematic Evidence Review3<\/a><\/sup>
\non this topic, which can be obtained through the USPSTF Web site (http:\/\/www.preventiveservices.ahrq.gov\/<\/a>)
\nand in print through the AHRQ Publications Clearinghouse (call 1-800-358-9295)
\nor E-mail ahrqpubs@ahrq.gov<\/a>.<\/p>\n
\n
\nrecommendations, the rationale for the recommendations, and the supporting
\nscientific evidence. These statements address preventive health services for use
\nin primary care clinical settings, including screening tests, counseling, and
\nchemoprevention<\/em>.<\/p>\n
\nnot represent the views of the Agency for Healthcare Research and Quality
\n(AHRQ), the U.S. Department of Health and Human Services, or the U.S. Public
\nHealth Service<\/em>.<\/p>\n
\n<\/a>Contents<\/h2>\n
\nof Recommendations<\/a>
\nClinical
\nConsiderations<\/a>
\nScientific
\nEvidence<\/a>
\nRecommendations
\nof Others<\/a>
\nAppendix
\nA. USPSTF Recommendations and Ratings<\/a>
\nAppendix
\nB. USPSTF Strength of Overall Evidence<\/a>
\nReferences
\nand Notes<\/a>
\nAcknowledgments<\/a>
\nReprints<\/a><\/p>\n<\/a>Summary of Recommendations<\/h2>\n
\n65 and older be screened routinely for osteoporosis. The USPSTF recommends that
\nroutine screening begin at age 60 for women at increased risk for osteoporotic
\nfractures (see “Clinical Considerations” for discussion of women at increased
\nrisk). B
\nrecommendation<\/a>.<\/strong><\/p>\n
\nincreases with age and other factors, that bone density measurements accurately
\npredict the risk for fractures in the short-term, and that treating asymptomatic
\nwomen with osteoporosis reduces their risk for fracture. The USPSTF concludes
\nthat the benefits of screening and treatment are of at least moderate magnitude
\nfor women at increased risk by virtue of age or presence of other risk
\nfactors<\/em>.<\/p>\n
\nscreening in postmenopausal women who are younger than 60 or in women aged 60-64
\nwho are not at increased risk for osteoporotic fractures. C
\nrecommendation<\/a>.<\/strong><\/p>\n
\nosteoporosis or fracture can identify additional women who may be eligible for
\ntreatment for osteoporosis, but it would prevent a small number of fractures.
\nThe USPSTF concludes that the balance of benefits and harms of screening and
\ntreatment is too close to make a general recommendation for this age
\ngroup<\/em>.<\/p>\n
\nto Contents<\/a><\/p>\n<\/a>Clinical Considerations<\/h2>\n
\n
\nosteoporosis among women aged 60-64 who are at increased risk for osteoporosis
\nand fracture are comparable to those of routine screening in older women. The
\nexact risk factors that should trigger screening in this age group are
\ndifficult to specify based on evidence. Lower body weight (weight < 70 kg )
\nis the single best predictor of low bone mineral density.4<\/a>,<\/sup>5<\/a><\/sup>
\nLow weight and no current use of estrogen therapy are incorporated with age
\ninto the 3-item Osteoporosis Risk Assessment Instrument (ORAI).4<\/a>,<\/sup>5<\/a><\/sup>
\nThere is less evidence to support the use of other individual risk factors
\n(for example, smoking, weight loss, family history, decreased physical
\nactivity, alcohol or caffeine use, or low calcium and vitamin D intake) as a
\nbasis for identifying high-risk women younger than 65. At any given age,
\nAfrican-American women on average have higher bone mineral density (BMD) than
\nwhite women and are thus less likely to benefit from screening. Additional
\ncharacteristics of screening tools are discussed in the “Accuracy
\nand Reliability of Screening Tests<\/a>” section.<\/li>\n
\nsites, bone density measured at the femoral neck by dual-energy x-ray
\nabsorptiometry (DXA) is the best predictor of hip fracture and is comparable
\nto forearm measurements for predicting fractures at other sites. Other
\ntechnologies for measuring peripheral sites include quantitative
\nultrasonography (QUS), radiographic absorptiometry, single energy x-ray
\nabsorptiometry, peripheral dual-energy x-ray absorptiometry, and peripheral
\nquantitative computed tomography. Recent data suggest that peripheral bone
\ndensity testing in the primary care setting can also identify postmenopausal
\nwomen who have a higher risk for fracture over the short term (1 year).
\nFurther research is needed to determine the accuracy of peripheral bone
\ndensity testing in comparison with dual-energy x-ray absorptiometry (DXA). The
\nlikelihood of being diagnosed with osteoporosis varies greatly depending on
\nthe site and type of bone measurement test, the number of sites tested, the
\nbrand of densitometer used, and the relevance of the reference range.<\/li>\n
\nlargely on studies of bisphosphonates. Some women, however, may prefer other
\ntreatment options (for example, hormone replacement therapy, selective
\nestrogen receptor modulators, or calcitonin) based on personal preferences or
\nrisk factors. Clinicians should review with patients the relative benefits and
\nharms of available treatment options, and uncertainties about their efficacy
\nand safety, to facilitate an informed choice.<\/li>\n
\nBecause of limitations in the precision of testing, a minimum of 2 years may
\nbe needed to reliably measure a change in bone mineral density; however,
\nlonger intervals may be adequate for repeated screening to identify new cases
\nof osteoporosis. Yield of repeated screening will be higher in older women,
\nthose with lower BMD at baseline, and those with other risk factors for
\nfracture.<\/li>\n
\nfew data on osteoporosis treatment in women older than 85. Patients who
\nreceive a diagnosis of osteoporosis fall outside the context of screening but
\nmay require additional testing for diagnostic purposes or to monitor response
\nto treatment.<\/li>\n<\/ul>\n
\nto Contents<\/a><\/p>\n<\/a>Scientific Evidence<\/h2>\n
Epidemiology and Clinical Consequences<\/h3>\n
\nfracture during their lives, including 25 percent who will develop a vertebral
\ndeformity6<\/a><\/sup>
\nand 15 percent who will suffer a hip fracture.7<\/a><\/sup>
\nRisk for fracture increases steadily as bone density declines, with no
\nthreshold. The commonly used definition of osteoporosis, derived from the World
\nHealth Organization (WHO) recommendations for epidemiologic studies, defines a
\nBMD more than 2.5 standard deviations (SD) below the mean for a young healthy
\nadult woman as osteoporosis, and a BMD between 1 and 2.5 SD below the mean as
\nosteopenia. Based on the WHO criteria and DXA measurements at the femoral neck,
\npopulation-based studies estimate that 41 percent of white women older than 50
\nhave osteopenia.8<\/a><\/sup>
\nWhen bone density is measured at the hip, spine, and wrist, 15 percent of white
\nwomen aged 50-59 and 70 percent of white women older than 80 have osteoporosis
\nby WHO criteria at at least one site.9<\/a><\/sup><\/p>\n
\nprevalence in white women. While rates of osteoporosis in African-American women
\nare approximately one-half those of the other groups, they are still substantial
\n(8 percent among women older than 50). Including all races, an estimated 14
\nmillion women older than 50 have osteopenia, and over 5 million have
\nosteoporosis.10<\/a><\/sup>
\nThe actuarial risk of a 65-year-old white woman sustaining a fracture by age 90
\nis 16 percent for the hip, 9 percent for distal forearm, and 5 percent for
\nproximal humerus.9<\/a><\/sup>
\nSixteen percent of postmenopausal women have osteoporosis of the lumbar
\nspine.11<\/a><\/sup><\/p>\n<\/a>Accuracy and Reliability of Screening Tests<\/h3>\n
\n
\nidentifying women at risk for osteoporosis or fracture.<\/li>\n
\nidentifying women at risk for fracture who can benefit from osteoporosis
\ntreatment.<\/li>\n<\/ul>\n
\ntools that incorporate two or more of the risk factors. Risk for osteoporosis
\nincreases steadily and substantially with age. Relative to women aged 50-54, the
\nodds of having osteoporosis were 5.9-fold higher in women aged 65-69 and
\n14.3-fold higher in women aged 75-79, in a study of over 200,000 postmenopausal
\nwomen.12<\/a><\/sup>
\nLow body weight or body-mass index (BMI) and not using estrogen replacement were
\nalso consistently associated with osteoporosis but to a lesser degree than age.
\nOther risk factors for fracture or low bone density found in some, but not all,
\nstudies include white or Asian ethnicity, history of fracture, family history of
\nosteoporotic fracture, history of falls, low levels of physical activity,
\nsmoking, excessive alcohol or caffeine use, low calcium or vitamin D intake, and
\nthe use of various medications.<\/p>\n
\ngenerally have moderate-to-high sensitivity and low specificity. The best
\nvalidated instruments include the 3-item ORAI and the 6-item Simple Calculated
\nOsteoporosis Risk Estimation tool (SCORE). The ORAI uses age, weight, and
\ncurrent use of hormone replacement therapy to identify women at risk for
\nosteoporosis and has a sensitivity of 94 percent and specificity of 41
\npercent.4<\/a><\/sup>
\nThe SCORE has a sensitivity of 91 percent and specificity of 40 percent in one
\nvalidation population (n = 259), but it has much lower specificity in an older
\npopulation.11<\/a><\/sup><\/p>\n
\nonly modest sensitivity and specificity. The best performing model for hip
\nfracture outcomes included age, gender, height, use of a walking aid, current
\nsmoking, and weight and had a sensitivity of 70 percent with specificity of 84
\npercent.13<\/a><\/sup><\/p>\n
\npredictor of hip fracture and is comparable to forearm measurements for
\npredicting fractures at other sites. Recent prospective studies have evaluated
\nQUS measurements at the heel.14<\/a>,<\/sup>15<\/a><\/sup>
\nWhile QUS measurements are not highly correlated with DXA measurements, a result
\nin the osteoporotic range on either test is associated with an increased
\nshort-term probability of hip fracture. Several other radiologic methods that
\nmeasure bone density at peripheral sites2<\/a><\/sup>
\n(including sites in the hand, heel, wrist, and forearm) include single photon
\nabsorptiometry, quantitative computed tomography, single-energy x-ray
\nabsorptiometry, and peripheral quantitative computed tomography.<\/p>\n
\nwith osteoporosis by peripheral bone density measurements were 4 times more
\nlikely to have fractures than women with normal bone density over the subsequent
\nyear. The likelihood of being diagnosed with osteoporosis varies greatly
\ndepending on the site and type of bone measurement test, the number of sites
\ntested, the brand of densitometer, and the relevance of the reference range.<\/p>\nEffectiveness of Early Treatment<\/h3>\n
\nfracture-related morbidity. The Task Force reviewed the evidence to determine
\nwhether treatment for osteoporosis or low bone density in asymptomatic patients
\nreduced fractures.<\/p>\n
\nof bisphosphonates (alendronate and risendronate), estrogen, and selective
\nestrogen receptor modulators (raloxifene) and calcitonin. A meta-analysis16<\/a><\/sup>
\nof 11 randomized trials17-27<\/a><\/sup>
\ninvolving a total of 12,855 women, found that alendronate significantly reduced
\nvertebral fractures (RR, 0.52; 95 percent CI, 0.43-0.65), forearm fractures (RR,
\n0.48; 0.29-0.78), hip fractures (RR, 0.63; 0.43-0.92), and other nonvertebral
\nfractures (RR, 0.51; 0.38-0.69). There were nonsignificant trends toward
\nreduction in hip fractures. No randomized trial of treatment for osteoporosis
\nhas demonstrated an impact on mortality. One trial in women aged 70-79 with very
\nlow bone density (T-score less than -3) reported that risendronate reduced the
\nrisk for hip fracture (RR, 0.60; 95 percent CI, 0.40-0.90).28<\/a><\/sup><\/p>\n
\nthat report fracture outcomes. Estrogen, either alone or with progestin,
\nconsistently improves bone density in randomized trials. The effects of estrogen
\nand the selective estrogen receptor modulators on fractures are reviewed in more
\ndetail in a separate report.13<\/a><\/sup>
\nOnly a few small randomized clinical trials of estrogen indicate mixed results
\nfor fracture outcomes, but these studies are methodologically limited.
\nObservational studies report a 25-30 percent reduction in the risk for hip
\nfracture with estrogen use. A good-quality study of raloxifene reported a
\nreduced risk for vertebral fractures (RR, 0.59; 95 percent CI,
\n0.50-0.70).29<\/a><\/sup><\/p>\n
\nfracture than in women at lower risk. The Fracture Intervention Trial (FIT) was
\nconducted with 2 different groups of participants: 2,027 high-risk women who had
\nT-scores of -1.6 or lower and pre-existing vertebral fractures, and 4,432 women
\nwith comparable T-scores but no pre-existing vertebral fracture. Over 3 years of
\ntreatment in high-risk women, alendronate reduced the risk for hip fracture (1.1
\npercent vs. 2.2 percent in the placebo group; relative hazard [RH], 0.49
\n[0.23-.099]) and the risk for any clinical fracture (18.2 percent vs. 13.6
\npercent; RH, 0.72 [0.58-0.90]). Among women with no pre-existing fracture, only
\nthe subgroup of patients who had a T-score less than -2.5 had a significant
\nreduction in all clinical fractures from treatment, from 19.6 percent to 13.1
\npercent (RR, 0.64; 0.50-0.82). Alendronate had no effect on fractures among
\nlower risk women who had T-scores between -1.6 and -2.5.<\/p>\n
\nwith more risk factors for fracture, such as those who are older, have very low
\nbone density, or have pre-existing vertebral fractures. FIT, as well as other
\ntherapy trials, enrolled highly selected patients thus limiting the
\ngeneralizability of their results to asymptomatic women detected in a typical
\nprimary care setting.<\/p>\n
\nscreening and treatment. It is not known whether women who have a similar
\noverall risk for fracture, but different bone densities, will benefit similarly
\nfrom treatment. This uncertainty is clinically important because the lack of
\naccepted criteria for initiating treatment remains a problem.<\/p>\n
\ngroups, the USPSTF used estimates from recent studies to project the number of
\nfractures that would be prevented over 5 years from screening and treatment of a
\nhypothetical cohort of 10,000 postmenopausal women.2<\/a><\/sup>
\nFor women aged 55-59, more than 4,000 would need to be screened to prevent 1 hip
\nfracture and more than 1,300 to prevent 1 vertebral fracture. For women older
\nthan 60, the number needed to screen to prevent 1 hip fracture is 1,856 for
\nwomen aged 60-64, 731 for women aged 65-69, and 143 for women aged 75-79. The
\nbenefits of screening improve substantially in older women because osteoporosis
\nis both more prevalent and more likely to lead to a fracture in older women.<\/p>\n
\nin women with important risk factors than it is in women who do not have risk
\nfactors. For women aged 60-64 who have a risk factor that increases the risk of
\nosteoporosis by 100 percent and fracture by 70 percent, the number needed to
\nscreen is 1,092 and the number need to treat is 72 to prevent 1 hip fracture.
\nThese numbers are comparable to those of women aged 65-69 without risk
\nfactors.2<\/a><\/sup>
\nThese estimates rely on many assumptions that may not apply for specific
\npopulations.<\/p>\nPotential Adverse Effects of Screening and Treatment<\/h3>\n
\nfor them are few. Women who undergo screening with bone density tests are more
\nlikely to begin hormone replacement therapy than women who do not. However,
\nwomen who were diagnosed with osteoporosis after screening reported increased
\nfears and anxiety in one study. Other potential harms may arise from
\ninaccuracies and misinterpretations of bone density tests. Clinicians may have
\ndifficulty in using test results to provide accurate information to the patients
\nbecause techniques used to measure bone density vary, test results are reported
\nas T-scores, and information on how to integrate bone density results with other
\nclinical predictors has not been clearly defined.2<\/a><\/sup><\/p>\n
\nin about 25 percent of patients taking alendronate, but this was usually not
\nhigher (or only slightly higher) than the rate for placebo. Higher rates were
\nobserved among Medicare enrollees taking alendronate. In the FIT-II trial, the
\nrates of ulcer disease were higher in the alendronate treatment group, with 2.2
\npercent developing ulcer disease, as opposed to 1.2 percent in the placebo group
\n(P<\/em><0.05).30<\/a><\/sup>
\nThe long-term adverse effects of alendronate are unknown. Harms of hormone
\nreplacement therapy include venous thromboembolic events, endometrial cancer,
\nand cholecystitis, all with relative risks of approximately 2.0.12<\/a><\/sup>
\nBoth raloxifene and tamoxifen are associated with thromboembolic events, leg
\ncramps, and hot flashes.2<\/a><\/sup><\/p>\n
\nto Contents<\/a><\/p>\n<\/a>Recommendations of Others<\/h2>\n
\nprofessional organizations, issued screening guidelines recommending bone
\ndensity testing for all women aged 65 or older and younger postmenopausal women
\nwho have had a fracture or who have one or more risk factors for
\nosteoporosis.31<\/a><\/sup>
\nCollaborating groups included the American Academy of Orthopaedic Surgeons, the
\nAmerican College of Obstetricians and Gynecologists, the American Geriatrics
\nSociety, the American College of Radiology, the American College of
\nRheumatology, the American Academy of Physical Medicine and Rehabilitation, the
\nAmerican Association of Clinical Endocrinologists, the Endocrine Society, and
\nthe American Society of Bone and Mineral Research. The American Association of
\nClinical Endocrinologists released revised guidelines in 2001.32<\/a><\/sup>
\nA 2000 Consensus Development Conference sponsored by the U.S. National
\nInstitutes of Health concluded that the value of universal osteoporosis
\nscreening was not yet established.33<\/a><\/sup>
\nThe conference panel recommended an individualized approach to screening, noting
\nthat bone density measurement is appropriate when it will aid the patient’s
\ndecision to institute treatment. The Canadian Task Force on Preventive Health
\nCare is currently revising its recommendations on screening for osteoporosis.<\/p>\n
\nto Contents<\/a><\/p>\n<\/a>Appendix A. USPSTF Recommendations and Ratings<\/h2>\n
\nclassifications (A, B, C, D, or I), reflecting the strength of evidence and
\nmagnitude of net benefit (benefits minus harms):<\/p>\n
\n[the service] to eligible patients. The USPSTF found good evidence that [the
\nservice] improves important health outcomes and concludes that benefits
\nsubstantially outweigh harms<\/em>.<\/p>\n
\nprovide [the service] to eligible patients. The USPSTF found at least fair
\nevidence that [the service] improves important health outcomes and concludes
\nthat benefits outweigh harms<\/em>.<\/p>\n
\nroutine provision of [the service]. The USPSTF found at least fair evidence
\nthat [the service] can improve health outcomes but concludes that the balance of
\nbenefits and harms is too close to justify a general recommendation<\/em>.<\/p>\n
\nasymptomatic patients. The USPSTF found at least fair evidence that [the
\nservice] is ineffective or that harms outweigh benefits<\/em>.<\/p>\n
\nfor or against routinely providing [the service]. Evidence that [the service]
\nis effective is lacking, of poor quality, or conflicting and the balance of
\nbenefits and harms cannot be determined<\/em>.<\/p>\n
\nto Contents<\/a><\/p>\nAppendix B. USPSTF Strength of Overall Evidence<\/h2>\n
\n3-point scale (good, fair, or poor):<\/p>\n
\nwell-conducted studies in representative populations that directly assess
\neffects on health outcomes.<\/p>\n
\nbut the strength of the evidence is limited by the number, quality, or
\nconsistency of the individual studies; generalizability to routine practice; or
\nindirect nature of the evidence on health outcomes.<\/p>\n
\noutcomes because of limited number or power of studies, important flaws in their
\ndesign or conduct, gaps in the chain of evidence, or lack of information on
\nimportant health outcomes.<\/p>\n
\nto Contents<\/a><\/p>\n<\/a>References<\/h2>\n
\nClinical Preventive Services<\/em>, second ed.. Washington, DC: Office of Disease
\nPrevention and Health Promotion; 1996.<\/p>\n
\nfor postmenopausal osteoporosis: A review of the evidence for the US Preventive
\nServices Task Force. Ann Intern Med<\/em> 2002;137:529-41. (Available on the
\nAHRQ Web site at http:\/\/www.preventiveservices.ahrq.gov\/<\/a>).<\/p>\n
\nPostmenopausal Osteoporosis. Systematic Evidence Review No. 17. (Prepared by the
\nOregon Health & Science University Evidence-based Practice Center under
\nContract No. 290-97-0018.) Rockville, MD: Agency for Healthcare Research and
\nQuality, Research and Quality, 2002. (Available on the AHRQ Web site at: http:\/\/www.ahcpr.gov\/clinic\/serfiles.htm<\/a>)<\/p>\n
\nDevelopment and validation of the Osteoporosis Risk Assessment Instrument to
\nfacilitate selection of women for bone densitometry. Can Med Assoc J<\/em>
\n2000;162:1289-94.<\/p>\n
\nEvaluation of decision rules for referring women for bone densitometry by
\ndual-energy x-ray absorptiometry. JAMA<\/em> 2001;286(1):57-63.<\/p>\n
\nEpidemiology of vertebral fractures in women. Am J Epidemiol<\/em>
\n1989;129:1000-11.<\/p>\n
\nFracture risk in the US Medicare population. J Clin Epidemiol<\/em>
\n1999;52:243-9.<\/p>\n
\napplication to screening for postmenopausal osteoporosis: synopsis of a WHO
\nreport. Osteoporos Int<\/em> 1994;4:368-81.<\/p>\n
\nnow? J Bone Miner Res<\/em> 1995;10:175-7.<\/p>\n
\ndata on proximal femur bone mineral levels of US adults. Osteoporos Int<\/em>
\n1998;8:468-89.<\/p>\n
\nand validation of a simple questionnaire to facilitate identification of women
\nlikely to have low bone density. Am J Manag Care<\/em> 1998;4:37-48.<\/p>\n
\nIdentification and fracture outcomes of undiagnosed low bone mineral density in
\npostmenopausal women: Results from the National Osteoporosis Risk Assessment.
\nJAMA<\/em> 2001;286:2815-22.<\/p>\n
\nTherapy and Osteoporosis. Systematic Evidence Review No 12. (Prepared by the
\nOregon Health & Science University Evidence-based Practice Center under
\nContract No. 290-97-0018.) Rockville, MD: Agency for Healthcare Research and
\nQuality 2002. (Available only on the AHRQ Web site at http:\/\/www.ahcpr.gov\/clinic\/serfiles.htm<\/a>)<\/p>\n
\nvalue of bone mineral density in hip fracture risk scores. Bone<\/em>
\n1999;25:369-74.<\/p>\n
\nultrasound of the calcaneus reflects the mechanical properties of calcaneal
\ntrabecular bone. J Bone Miner Res<\/em> 1997;12:839-46.<\/p>\n
\nMeta-analysis of alendronate for the treatment of postmenopausal women.
\nEndocr Rev<\/em> 2002; 23: 517-23.<\/p>\n
\nRandomised trial of effect of alendronate on risk of fracture in women with
\nexisting vertebral fractures. Fracture Intervention Trial Research Group.
\nLancet<\/em> 1996:1535-41.<\/p>\n
\nof oral alendronate and intranasal salmon calcitonin on bone mass and
\nbiochemical markers of bone turnover in postmenopausal women with osteoporosis.
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