ORIGINAL CONTRIBUTION
Treatment and Prevention Practices in Postmenopausal Women After Bone Mineral
Density Screening at a Community-Based Osteoporosis Project
Christine I. Rohr, DO
John M. Clements, MPA
Arup Sarkar, MD
Objective: To determine the use of treatment and prevention
practices in postmenopausal women who have received the
results of an osteoporosis screening.
Methods: Telephone survey to follow-up with women who
underwent dual-energy x-ray absorptiometry scanning at a
community-wide osteoporosis screening project. Participants
categorized by their scan results as having normal bone min-
eral density or low bone mineral density were asked about their
osteoporosis treatment and prevention practices since receiving
their scan results.
Results: Two hundred nineteen women were interviewed.
Calcium supplement use increased significantly in both groups
(P=.002). There was no significant difference in the number of
women using alendronate sodium, calcitonin, and selective
estrogen receptor modulators before and after screening. Both
groups reported increases in exercise levels and dairy intake,
but the difference was not statistically significant.
Conclusions: Our results indicate that the use of over-the-
counter calcium supplements increases after osteoporosis
screening. However, the use of treatments that require a physi-
cian prescription does not increase after screening regardless
of the patient’s bone mineral density status.
J Am Osteopath Assoc. 2006;106:396–401
http://www.jaoa.org/content/vol106/issue7/
T he availability and declining cost of reliable bone mineral
density (BMD) tests, such as dual-energy x-ray absorp-
tiometry (DEXA), has enhanced the ability of primary care
physicians to screen for and diagnose osteoporosis and
osteopenia. Promising medical treatments for patients with
low BMD provide further incentive to carry out BMD
From the Departments of Medical Education (Rohr, Clements); Research
(Clements); and Family Medicine (Sarkar), Synergy Medical Education Alliance,
Saginaw, Mich.
This study was presented as a poster presentation at the American Public
Health Association’s 131st Annual Meeting in San Francisco, Calif, on November
19, 2003.
Address correspondence to John M. Clements, MPA, Director of Research
and Educational Programs, Synergy Medical Education Alliance, 1000
Houghton Ave, Saginaw, MI 48602-5303.
E-mail: jclements@synergymedical.org
396 • JAOA • Vol 106 • No 7 • July 2006
screening in the populations most at risk.1–8
Osteoporosis screening in the older female population
through community centers, living facilities, and health fairs
is an effective tool in identifying low BMD in women at high
risk for osteoporosis and osteopenia.9 To gain the maximum
advantage from such screening programs, patients must be
made aware of the importance of following up a diagnosis of
low BMD with their primary care physicians to determine
the best treatment and prevention options. In addition, the
primary care physician should initiate a treatment plan
involving appropriate recommendations for lifestyle modifi-
cation and/or pharmacologic intervention.
Previous studies have been at odds as to whether a diag-
nosis of low BMD is an effective incentive for patients to follow
up with their primary care physicians for treatment guide-
lines. In a review of studies examining clinical practices in
osteoporosis treatment, Siris et al10 reported that physicians in
general are not evaluating patients with fractures for osteo-
porosis, nor are they prescribing calcium, vitamin D, or phar-
macologic therapy to reduce future risk of fracture. The authors
further reported that only 5% to 39% of patients with frac-
tures received appropriate screening and treatment for osteo-
porosis despite clinical guidelines supporting the use of
therapy.10 Noncompliance with recommendations after den-
sitometry can make widespread screening ineffective and inef-
ficient.10 We hypothesize that a large number of women who
have received a diagnosis of either osteoporosis or osteopenia
do not receive the follow-up care or guidance needed to pre-
vent fractures.
The purpose of our study was to determine what, if any,
action was taken by patients after being screened for osteo-
porosis.
Methods
We undertook a telephone-based follow-up survey of post-
menopausal women who had participated in a large com-
munity-based osteoporosis screening project that was con-
ducted by our group.9 Subjects were from the general public
and self-referred when the screening was made available at
local senior centers, living facilities, and health fairs. The orig-
inal study was conducted to increase access to BMD testing in
the elderly population. Bone mineral density testing and coun-
Rohr et al • Original Contribution

seling on osteoporosis and osteopenia were provided to 635
female residents of senior facilities from January through
December 1999. Screening was conducted using DEXA.
Patients were assessed for risk, screened for BMD, and referred
for follow-up care. In addition to diagnostic assessment,
patients received lifestyle counseling, recommendations for
calcium intake, and recommendations for follow-up with their
primary care physicians for treatment or prevention practices.
Between August and November 2001, we conducted a
follow-up study of the community-based screening project,
approved by the institutional review board of Synergy Med-
ical Education Alliance (Saginaw, Mich). We contacted subjects
by telephone to obtain current information on their progress
since the screening. The present study focused on the post-
menopausal women who were found to have either normal or
low BMD based on the following t score classifications of low
BMD from the World Health Organization11:

normal BMD: ⭓1

osteopenia: ⬍⫺1 to ⬎ ⫺2.5

osteoporosis: ⭐ ⫺2.5
We categorized the women into two groups according to their
screening results: normal BMD and low BMD (ostopenia or
osteoporosis). Questions assessed whether the participants
had engaged in any osteoporosis treatment or prevention
practices since receiving the screening results, including use of
over-the-counter calcium supplements, physician-prescribed
medications (alendronate sodium, calcitonin, hormone replace-
ment therapy [HRT], and selective estrogen receptor modu-
lators), and dairy intake and exercise. We compared the data
from the initial screening project with the data collected during
the follow-up survey. (There were no baseline data on dairy
intake and exercise.) Data were analyzed using a Pearson ␹2
test to determine the significance of differences in nominal
data between proportions of two groups.
Results
A follow-up telephone survey was administered to 234 older
women (age range, 59-86 years; mean, 74.9 years) who par-
ticipated in the initial BMD screening program. We were able
to obtain status and follow-up information for 219 of the 234
women. The normal BMD group comprised 77 (35.2%)
women, and the low BMD group comprised 142 (64.8%)
women.
Women With Normal Bone Mineral Density
In the group with normal BMD, there was a statistically sig-
nificant increase in calcium supplement use (P=.002), from 28
(37%) taking calcium supplements before the screening to 47
(61.6%) taking them after the screening. The use of HRT
decreased, but the decrease was not significant (24 [30.7%]
before screening vs 17 [22.7%] after screening; P=.07). There was
Rohr et al • Original Contribution
ORIGINAL CONTRIBUTION
no significant difference in the number of women using alen-
dronate, calcitonin, and selective estrogen receptor modulators
before and after screening. With regard to exercise and dairy
intake, though we did not have baseline data for comparison,
as noted, 30 (39%) women reported an increase in exercise, and
12 (15.5%) reported an increase in dairy intake since the
screening (Figure 1).
Women With Low Bone Mineral Density
As in the group with normal BMD, there was a significant
increase in the use of calcium supplements in women with low
BMD (64 [45.4%] vs 111 [78.5%]; P=.001). The decrease in HRT
use in this group was statistically significant (30 [21%] vs 9
[6.3%]; P=.003). There was no significant difference in the
number of women using alendronate, calcitonin, and selective
estrogen receptor modulators before and after screening.
Finally, 44 (31%) women in this group reported an increase in
exercise, and 33 (23%) reported an increase in dairy intake
(Figure 2).
Results for Entire Cohort
Overall, there was a statistically significant increase in the use
of calcium supplementation (92 [42.1%] before screening vs 156
[71.3%] after screening; P<.001). The use of HRT decreased
significantly (P<.001) after screening, with just 25 (11.7%)
women using HRT compared with 52 (23.9%) before screening.
In addition, women with normal BMD were significantly
more likely to report HRT use than those with low BMD (17
[22.7%] vs 9 [6.3%]; P<.001). There was no significant difference
in the use of alendronate, calcitonin, and selective estrogen
receptor modulators before and after screening. Although we
did not have a baseline for comparison, 75 (34.4%) women
reported an increase in exercise, and 46 (21.1%) reported an
increase in dairy intake since the screening. There was no sig-
nificant difference in the reported increase in exercise or dietary
intake between the group with normal BMD and the group
with low BMD.
Comment
While use of HRT decreased in our cohort, the use of calcium
supplementation increased in both groups and was signifi-
cant for the entire cohort. During screening, nonprescription
calcium supplementation was recommended to all women
and emphasized to those at high risk. In addition, women
with low BMD were referred to their primary care physicians
for follow-up to begin prescription therapy; whether they took
this step and whether they received guidance and/or pre-
scriptions for therapy was not studied. There were no signif-
icant increases in the use of any therapy that needed a pre-
scription. Based on these results, it appears that the immediate
recommendation of nonprescription therapy is more effective
JAOA • Vol 106 • No 7 • July 2006 • 397
ORIGINAL CONTRIBUTION

Percentage

* *
Therapy

Figure 1. Women with normal bone mineral density (n=77). Patient compliance with recommended osteoporosis treat-
ment and preventive therapies. HRT indicates hormone replacement therapy; SERMs, selective estrogen receptor mod-
ulators. The asterisk [*] indicates that there were no baseline values for exercise and dairy intake.

in increasing compliance with treatment and prevention. A
question for additional studies is whether patients would be
more likely to use prescription therapy if prescriptions were
given as soon as screening results were obtained. If other pre-
vention or treatment strategies were as readily available to
the public without a physician prescription or physician over-
sight, we probably would have seen increases in their use as
well.
Participants reported a statistically significant decrease
in HRT use after receiving the results of their BMD scan even
though HRT as prevention or treatment for low BMD has
been shown to reduce bone loss and increase BMD in the
spine and hip, thereby reducing the risk of hip and spinal
fractures in postmenopausal women.12–14 It is important to
note that this study took place prior to changing guidelines on
HRT use, so it is unlikely that the decrease was a response to
new guidelines recommending the discontinuation of HRT.15
Although we did not explore the reasons for discontinuing
HRT, there are several areas for further study that could pro-
vide explanations for the decrease in HRT use that we
observed. These areas include determining whether subjects
understood the protective nature of HRT, whether they were
concerned about side effects of HRT, whether the level of
information that physicians provide to patients regarding the
importance of therapy is adequate, and whether patients felt
continued HRT use was necessary as they aged.
There was no statistically significant increase in the use of
prescription therapy, probably because the physicians partic-
ipating in the screening project relied on participants to make
appointments with their primary care physicians for follow-
up. Either the patients did not take this step or their physicians
did not adequately prescribe treatment.
There may be several reasons why patients do not engage
in treatment or prevention practices after receiving their
screening results. We did not investigate the financial status
of our patients, but it may be possible that some individuals
were not financially able to bear the costs of following up with
physicians or paying for prescriptions. It may be possible that
patients were not motivated to follow-up because they did
not understand the results of the screening or the importance
of therapy. This issue could be resolved by providing more
extensive patient education on osteoporosis. Finally, physi-

398 • JAOA • Vol 106 • No 7 • July 2006 Rohr et al • Original Contribution

 ORIGINAL CONTRIBUTION

Percentage

* *

Therapy

Figure 2. Women with low bone mineral density (n=142). Patient compliance with recommended osteoporosis treat-
ment and preventive therapies. HRT indicates hormone replacement therapy; SERMs, selective estrogen receptor mod-
ulators. The asterisk [*] indicates that there were no baseline values for exercise and dairy intake.

cians may not attend to cases of osteoporosis properly, an
often underdiagnosed and undertreated disease.10,16,17
The issue of compliance is one that needs to be addressed
both in physician practice and in patient behavior. Andrade et
al16 undertook a study to document the rate of patient treatment
following fracture and subsequent diagnosis of osteoporosis.
They reported that of 3492 women older than 60 years with a
fragility fracture, only 24% received treatment for osteoporosis
in the year following the fracture. In addition, they found that
increasing age was significantly associated with a decrease in
the recommendation and use of therapy.16 Another study
identifying treatment practices in patients with acute hip frac-
ture reported that only 3.5% of patients were treated for osteo-
porosis.17
Hsieh et al18 found that few women take measures to
prevent osteoporosis despite believing that it is a serious con-
dition. Ryan et al19 studied compliance with recommenda-
tions to use HRT in postmenopausal women following
screening for osteoporosis. Their results indicate that screening
leads to an immediate increase in HRT use among women
who are at high risk for osteoporosis. However, they also
found that 40% of women with low BMD were not using HRT
at an 8-month follow-up as recommended by their physicians.
The current controversy and recommendations on the use of
HRT may make HRT a less likely treatment for osteoporosis.
Ryan et al19 conclude that screening should not be widely rec-
ommended until improved compliance with recommenda-
tions is demonstrated.
Studies have also shown that screening increases com-
pliance. Torgenson et al20 studied the effect of an osteoporosis
screening program on HRT use. They found that screening for
low BMD in a sample of perimenopausal women significantly
increased their use of HRT. Papaioannou et al21 examined
decisions made by women at risk for osteoporosis-related
fractures who were educated about HRT and who were also
counseled about their BMD screening results. Their findings
indicate that a combination of education on HRT and BMD is
significantly associated with an increase in the use of HRT
and other osteoporosis preventive medications. Hsieh et al18
found that women who were actively worrying about devel-
oping osteoporosis were more likely to be engaged in pre-
ventive behavior. Fitt et al22 found that effective communica-

Rohr et al • Original Contribution JAOA • Vol 106 • No 7 • July 2006 • 399

ORIGINAL CONTRIBUTION

90

80 Before Screening

After Screening
70

60
Percentage

50

40

30

20

10

HRT Calcium Alendronate Calcitonin SERMs Exercise* Dairy*

Sodium
Therapy

Figure 3. Entire study population (N=219). Patient compliance with recommended osteoporosis treatment and pre-
ventive therapies. HRT indicates hormone replacement therapy; SERMs, selective estrogen receptor modulators. The
asterisk [*] indicates that there were no baseline values for exercise and dairy intake.

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