Bone Densitometry (DXA Scan) Referrals

All referrals for DXA at the Royal Wolverhampton NHS Trust (RWT) must be made using the locally approved RWT DXA referral form. Locally agreed variations of the form may be available on GP clinical systems, but these should not be modified. Completed forms can be emailed using the email address at the top of the referral form. Alternatively, completed referral forms can be posted to the address at the top of the referral form. If a pdf version of the referral form is required, please contact the department.

Referrers must clearly identify themselves, fully completing the ‘Referrer Information’ section of the referral form and providing their signature and registration number at the bottom of the form. Electronic signatures will be accepted following assurance that access to the system used to generate the signature is controlled, so only those entitled to refer under IR(ME)R regulations have access to the system and are clearly identified when referring.

The patient being referred for DXA should be clearly identified through full completion of the ‘Patient Details’ section of the referral form. All relevant clinical information should be provided to enable justification of DXA, where appropriate. Further information can be found on the reverse (page 2) of the DXA referral form.

In the event the referral needs to be amended or cancelled, an email, marked urgent, should be sent to the email address at the top of the referral form. For cancellations, the patient should also be informed to avoid the risk of the exposure going ahead when no longer required.

Suspicion of low bone density/increased fracture risk, normally based on at least one of the following risk factors/indications. The below list is not exhaustive – if you feel DXA will inform patient management, please consider referral but ensure sufficient information is provided to enable justification by the name IR(ME)R Practitioner

Adult (>40 years)

• Fragility Fracture (defined as a fracture occurring as a result of, or a force equivalent to, a fall from standing height or less – does not include the bones of the skull or small bones of the hands or feet)
• Parental Hip Fracture
• Radiological Osteopenia in patients where FRAX indicates BMD measurement, or treatment, if this is the sole indication.
• BMI <18.5 kg/m² or Anorexia Nervosa
• Oral Corticosteroids ≥3 months
• Untreated Premature Menopause <45 years
• Malabsorption / Coeliac
• Increased risk of falls
• Rheumatoid Arthritis
• Aromatase Inhibitor / Androgen deprivation therapy
• Disease, condition, or medication associated with low bone mass, bone loss or increased fracture risk.
• Monitor treatment in line with NOGG, local and disease-specific guidelines

Adults (<40 years)

• BMI <18.5 kg/m² and/or Anorexia Nervosa
• Aromatase Inhibitor / Androgen deprivation
• Prolonged Amenorrhea
• Screening or monitoring as indicated within disease specific guidance
• Other as confirmed with DXA IRMER Practitioner

Children and Adolescents (>6 years – <20 years)

• BMI <18.5 kg/m² and/or Anorexia Nervosa
• Vertebral Compression Fracture
• Primary Bone Disease
• Screening or monitoring as indicated within disease specific guidance
• Other as confirmed with DXA IRMER Practitioner

Transgender and Gender Non-conforming Individuals

Baseline BMD testing is indicated for Transgender and Gender Non-Conforming (TGNC) individuals if they have any of the following conditions:

• History of gonadectomy or therapy that lowers endogenous gonadal steroid levels prior to initiation of hormone therapy.
• Hypogonadism with no plan to take gender-affirming hormone therapy.
• Presence of other risks for bone loss or fragility fracture.

Follow-up BMD testing in TGNC individuals should be done when the results are likely to influence patient management. Examples include:

• Monitoring low bone mineral density, as defined by ISCD guidelines*
• Individuals taking treatment to suppress puberty, such as GnRH analogs.
• Non-adherence with or inadequate doses of gender-affirming hormone therapy.
• Plans to discontinue gender-affirming hormone therapy.
• Presence of other risks for bone loss or fragility fracture.

*Bone mineral density testing intervals should be individualised based on each patient’s clinical status: typically, every two years until BMD is stable or improved is appropriate, with longer intervals thereafter.

A referral will be rejected if it fulfils any of the following criteria:

• Pregnancy
• Insufficient/incomplete patient/referrer details
• Insufficient time since previous DXA scan (typically a minimum of 2 years is required to detect clinically meaningful changes in BMD.
• Insufficient/inappropriate risk factors
• Inappropriate Signature/Signatory Format
• Ratified or Modified Referral forms
• Patient weight exceeds scanner capacity
  • If appropriate, peripheral (seated forearm) DXA may be considered
• Patient mobility limits the ability to appropriately maintain the required positioning for BMD measurement.

We aim to send all reports out electronically within 3 weeks of the DXA scan appointment.  Reports will be sent to the referring health care professional and a copy electronically sent to the patient’s named GP.