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PANCE® Question of the Day: Gynecology exam

Osmosis Team
May 15, 2024

Prepare for the PANCE with this question! Learn about osteoporosis screening using FRAX score. Understand when to assess fracture risk in postmenopausal women, even if they're younger than 65.

A 58-year-old woman presents to her gynecology PA for her yearly well-check. She has no current complaints. Her last colonoscopy was five years ago, mammogram six months ago, and HPV/Pap co-test three years ago: all were normal. She has a smoking history of 15 pack years and quit 20 years ago. Her family history is significant for Parkinson disease in her father. She no longer has menstrual periods. Temperature is 37.0°C (98.6°F), pulse is 62/min, respiratory rate is 16/min, blood pressure is 120/78 mmHg, oxygen saturation is 98% on room air, and BMI is 24. Physical examination is unremarkable. Calculated FRAX score is 13% and Framingham risk score is 7%. Which of the following is the next best step in management?  

A. DEXA scan

B. HPV/Pap co-test 

C. Mammography  

D. Colonoscopy 

E. Low-dose chest CT 

Scroll down for the correct answer!

The correct answer to today's PANCE® Question is...

A. DEXA scan 

Before we get to the Main Explanation, let's look at the incorrect answer explanations. Skip to the bottom if you want to see the correct answer right away!

Incorrect answer explanations

B. HPV/Pap co-test 

Incorrect: HPV/Pap co-testing is recommended every five years for women aged 30-65 years. This patient is currently up-to-date on her cervical cancer screening.  

C. Mammography  

Incorrect: Mammography is recommended either annually or biennially depending on the guideline used. The decision regarding screening frequency should include shared decision making with the patient. This patient had a normal mammogram six months ago and would not be due for another mammogram at this time regardless of the guideline used.  

D. Colonoscopy 

Incorrect: The interval for colorectal cancer screening with colonoscopy is 10 years. This patient is up-to-date on colorectal cancer screening. 

E. Low-dose chest CT 

Incorrect: Lung cancer screening using low-dose chest CT is recommended for adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. This patient does not meet the pack-year duration or the time since quitting to have lung cancer screening done. 

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Main Explanation

This postmenopausal patient with a history of smoking has a FRAX score over 8.4% and should be offered osteoporosis screening with a DEXA scan. Normally, osteoporosis screening does not start in biological females until age 65; however, patients who are younger than 65 with increased risk of fractures should have their risk measured by a clinical risk assessment tool, such as FRAX. Patients should begin screening if their score is > 8.4%. 

Osteoporosis screening is an important part of the well-patient assessment. The goal of the FRAX clinical assessment tool is to risk-stratify how likely a patient is to have a major osteoporotic fracture in the next 10 years. Values above 8.4% indicate that the patient has a higher risk than the reference cohort (White women 65 years of age and older), and the patient should not wait until 65 to be screened. Factors taken into account when calculating the FRAX score include previous fracture history, parental fracture history, low body weight, smoking, glucocorticoid use, rheumatoid arthritis, secondary osteoporosis, alcohol consumption, and prior bone mineral density score of the femoral neck, if available. Follow-up intervals for the DEXA scan are dependent on the findings of the initial test as well as patient risk factors, but most screening guidelines recommend that a DEXA scan should not be repeated more frequently than every two years. 

Major Takeaway

Osteoporosis screening with a DEXA scan should be performed in biological females over the age of 65 and those younger than 65 if their FRAX score is > 8.4%.  

References:

Viswanathan M, Reddy S, Berkman N, et al. Screening to Prevent Osteoporotic Fractures: An Evidence Review for the U.S. Preventive Services Task Force [Internet]. Rockville (MD): Agency for Healthcare Research and Quality (US); 2018 Jun. (Evidence Synthesis, No. 162.) Table 1, Recommendations About Screening and Treatment of Osteoporosis From Various Professional and Health Organizations. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532080/table/table1/ 

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