Osteoporosis Screening in Primary Care: A Quick NP Guide

Osteoporosis is usually silent until a fracture happens, and by then you've missed the window. The whole job in primary care is knowing who to screen and how to read the result. Here's a no-fluff workflow you can use in clinic.

Who needs screening

Women

• Age 65 and older: screen all women with a DEXA scan.
• Under 65: screen if they have risk factors such as low body weight, smoking, family history of fracture, early menopause, or chronic glucocorticoid use.

Men

• Routine screening is not universally recommended.
• Consider DEXA for men 70 and older, or younger if high risk (steroids, hypogonadism, chronic illness, low-trauma fracture).

Reading the DEXA

DEXA gives you a T-score, which compares the patient to a young healthy adult, and a Z-score, which compares them to age-matched peers.

• Normal: T-score -1.0 or higher.
• Osteopenia: T-score -1.0 to -2.5.
• Osteoporosis: T-score -2.5 or lower.

One thing not to skip: check the Z-score. If it's low (under -2.0), that points to a secondary cause, not just age-related bone loss.

How often to repeat screening

• Normal bone density or mild osteopenia: every 5 to 10 years.
• Moderate osteopenia: every 2 to 3 years.
• Osteoporosis or on therapy: every 2 years, sooner if clinically indicated.

Don't miss secondary causes

Before you label it "just osteoporosis," think about:

• Endocrine: hyperthyroidism, hyperparathyroidism, Cushing's.
• Nutritional: vitamin D deficiency, malabsorption, celiac disease.
• Medications: chronic steroids, aromatase inhibitors, anticonvulsants, SSRIs.
• Other: CKD, chronic liver disease, rheumatoid arthritis.

Tools to refine risk

• FRAX calculates 10-year fracture risk for hip and major osteoporotic fracture.
• It helps you decide whether a patient with osteopenia still needs treatment.
• FRAX works best in patients aged 40 to 90 who are not already on osteoporosis therapy.

Frequently asked questions

What T-score means osteoporosis?
A T-score of -2.5 or lower. The -1.0 to -2.5 range is osteopenia, and -1.0 or higher is normal.

Why check the Z-score if the T-score already gives the diagnosis?
A low Z-score (under -2.0) flags a secondary cause like thyroid disease, vitamin D deficiency, or long-term steroids. That changes your workup.

When do I use FRAX?
When a patient lands in the osteopenia range and you're deciding whether to treat. It works best for ages 40 to 90 and patients not already on therapy.

Osteoporosis screening comes down to screening the right people, reading both scores, and ruling out a secondary cause before you treat. From here it's a short step to osteoporosis treatment, and it helps to be clear on osteopenia vs osteoporosis first. If you want the T-score cutoffs on one page in clinic, the Clinical Desk Reference ($37 quick-reference) keeps them handy.

Education only. Use clinical judgment and your local guidelines.

Written by Allison Sowders, MSN, APRN, FNP-BC, a practicing primary care nurse practitioner and founder of Nurse Practitioner Mentor. Reviewed July 2026.