What is the management approach for osteopenia in postmenopausal women?

Management of Osteopenia in Postmenopausal Women

For postmenopausal women with osteopenia (T-score between -1.0 and -2.5), management should focus on lifestyle modifications, calcium and vitamin D supplementation, with pharmacologic therapy reserved for those at high fracture risk based on FRAX score assessment (≥20% for major osteoporotic fracture or ≥3% for hip fracture). 1

Diagnostic Assessment

• DEXA scanning is recommended for all women 65 years and older
• For postmenopausal women younger than 65, DEXA is indicated if they have:
  • History of fragility fracture
  • Weight less than 127 lb (58 kg)
  • Medications or diseases causing bone loss
  • Parental history of hip fracture 1

Risk Assessment for Treatment Decisions

For women with osteopenia (T-score between -1.0 and -2.5):

• Calculate 10-year fracture risk using FRAX tool
• Consider pharmacologic treatment if:
  • 10-year risk of major osteoporotic fracture ≥20%, OR
  • 10-year risk of hip fracture ≥3%, OR
  • History of low-trauma fracture 1
• Women with severe osteopenia (T-score closer to -2.5) benefit more from treatment than those with mild osteopenia (T-score closer to -1.0) 1

Non-Pharmacologic Management

Calcium and Vitamin D

• Calcium recommendations:
  • Ages 51-70: 1,200 mg daily
  • Ages 71+: 1,200 mg daily 1
• Vitamin D recommendations:
  • Ages 51-70: 600 IU daily
  • Ages 71+: 800 IU daily 1
• Target serum vitamin D level: ≥20 ng/mL (50 nmol/L) 1

Lifestyle Modifications

• Regular weight-bearing and resistance exercise
• Smoking cessation
• Limiting alcohol intake
• Fall prevention strategies
• Maintaining healthy body weight 1

Pharmacologic Management

For women with osteopenia at high fracture risk:

First-Line Therapy

• Bisphosphonates (based on patient preference):
  • Alendronate: 5 mg daily or 35 mg weekly (prevention)
  • Risedronate: 5 mg daily, 35 mg weekly, 75 mg on two consecutive days monthly, or 150 mg monthly 1
  • Consider limiting bisphosphonate treatment to 5 years due to potential long-term adverse effects 1

Second-Line Therapy

• Denosumab: Consider for women who have contraindications to or cannot tolerate bisphosphonates 1

Alternative Options

• Raloxifene: May be considered for younger postmenopausal women, particularly those at higher risk for breast cancer 1
• Teriparatide: Generally reserved for women with severe osteoporosis or previous fractures 1

Special Considerations

• Avoid menopausal estrogen therapy or estrogen plus progestogen therapy for osteoporosis treatment 1
• For women initially treated with anabolic agents, an antiresorptive agent should be offered after discontinuation to preserve bone gains 1
• Monitor for adverse effects of bisphosphonates, including rare but serious complications such as osteonecrosis of the jaw and atypical femoral fractures 1
• Generic medications should be prescribed when possible to improve affordability and adherence 1

Follow-Up

• Reassess fracture risk periodically
• Consider repeat DEXA scan after 2 years to monitor treatment response
• For women on bisphosphonates, consider drug holiday after 5 years of therapy based on individual risk assessment 1

This management approach prioritizes prevention of fractures and their associated morbidity and mortality while balancing the benefits and risks of pharmacologic intervention in women with osteopenia.