Osteoporosis: the 2025 USPSTF screening statement and how the ACP graded drug treatment in 2023

In February 2025, the US Preventive Services Task Force (USPSTF) issued a B recommendation for osteoporosis screening in women 65 years or older and in younger postmenopausal women at increased fracture risk on clinical assessment ^[1]. In the same statement, the USPSTF judged the evidence insufficient to weigh the benefits and harms of screening in men, an I statement ^[1]. The American College of Physicians (ACP) living guideline on drug treatment, first published in 2023, received its second update alert on 8 September 2026 ^[2].

What did the 2025 statement cover, and what followed in 2026?

The 2025 USPSTF statement covered adults 40 years or older without known osteoporosis or a previous fragility fracture ^[1]. The USPSTF assigned moderate certainty of moderate net benefit to screening in both groups of women ^[1]. The treatment grades below are those of the 2023 ACP guideline and network meta-analysis; Update Alert 2 of each followed on 8 September 2026 ^[2][3].

What does screening achieve?

In the USPSTF evidence review by Kahwati and colleagues, screening in older, higher-risk women was associated with fewer hip fractures than usual care (pooled relative risk [RR] 0.83; 95% CI 0.73 to 0.93; 3 trials; 42,009 participants) ^[4]. The same review reported a pooled RR of 0.94 (95% CI 0.88 to 0.99) for major osteoporotic fracture; absolute differences for hip and major osteoporotic fracture were 5 to 6 fewer fractures per 1,000 screened ^[4]. Most risk assessment instruments had an area under the curve between 0.60 and 0.80 for predicting major osteoporotic or hip fracture, which is poor to modest discrimination ^[4]. The Kahwati review found no trials of screening with bone density alone, or of screening in men or younger women ^[4]. For postmenopausal women younger than 65 years, the USPSTF found adequate evidence that screening detects osteoporosis and fracture risk and convincing evidence that treatment gives moderate benefit ^[1].

What do the drug classes show, and how did the ACP grade them?

In the Kahwati review, bisphosphonates were associated with a lower hip fracture risk than placebo, although the upper confidence limit reached 1.00, the point of no effect (pooled RR 0.67; 95% CI 0.45 to 1.00; 6 trials; 12,055 participants) ^[4]. In the 2023 ACP network meta-analysis by Ayers and colleagues, bisphosphonates and the RANK ligand inhibitor lowered hip, vertebral and other clinical fractures in postmenopausal women with osteoporosis, with moderate to high certainty ^[5]. The Ayers analysis found that parathyroid hormone and parathyroid hormone-related peptide analogues lowered vertebral fractures but raised withdrawals due to adverse events ^[5]. According to Ayers and colleagues, selective estrogen receptor modulators taken for 36 months or more lowered radiographic vertebral fractures but not clinical fractures ^[5].

The 2023 ACP guideline graded its recommendations with the GRADE system as follows ^[6]:

• Bisphosphonates as initial drug therapy: strong recommendation with high-certainty evidence in postmenopausal women with primary osteoporosis, conditional with low-certainty evidence in men ^[6].
• RANK ligand inhibitor as second-line therapy when bisphosphonates are contraindicated or not tolerated: conditional, moderate certainty in women and low certainty in men ^[6].
• Sclerostin inhibitor or recombinant parathyroid hormone, followed by a bisphosphonate: conditional, limited to women at very high fracture risk ^[6].
• Low bone mass in women over 65: an individualized decision on bisphosphonate therapy, conditional with low-certainty evidence ^[6].

Where is the evidence uncertain?

The Kahwati review found no statistically significant difference in adverse events between bisphosphonates or the RANK ligand inhibitor and placebo ^[4]. Ayers and colleagues reported that few trials enrolled men, people with low bone mass or Black participants, and few examined sequential therapy or treatment beyond 3 years ^[5]. In the Ayers review, bisphosphonate use for 36 months or more may raise the risk of atypical femoral fracture and osteonecrosis of the jaw, although absolute risks were low ^[5].

At the point of care: what to check

• Sex, age and menopausal status against the 2025 USPSTF screening populations ^[1].
• A clinical fracture-risk estimate for postmenopausal women under 65 ^[1].
• Fracture-risk tier, since the 2023 ACP recommendation for a sclerostin inhibitor or recombinant parathyroid hormone followed by a bisphosphonate covers only very high risk ^[6].
• Bisphosphonate duration of 36 months or more, which may raise atypical femoral fracture and osteonecrosis of the jaw risk, although absolute risks were low ^[5].
• Whether the trial populations (few men, few Black participants, few treated beyond 3 years) resemble the patient ^[5].
• Whether a bisphosphonate is contraindicated or not tolerated, the 2023 ACP condition for a RANK ligand inhibitor as second-line therapy ^[6].