What are the management options 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 and calcium/vitamin D supplementation, with pharmacologic therapy reserved for those at high risk of fracture based on FRAX score or risk factors. 1

Diagnostic Assessment

• DEXA scan is recommended for all women 65 years and older
• For postmenopausal women <65 years, 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

Non-Pharmacologic Management

Calcium and Vitamin D Supplementation

• Calcium intake: 1,200 mg daily for women 51 years and older 1
• Vitamin D intake: 600 IU daily for women 51-70 years; 800 IU daily for women >70 years 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

Pharmacologic Management

When to Consider Medication

Pharmacologic treatment should be considered in women with osteopenia who have:

• 10-year risk of major osteoporotic fracture ≥20% based on FRAX 1
• 10-year risk of hip fracture ≥3% based on FRAX 1
• History of low-trauma fracture 1
• Advanced osteopenia (T-score closer to -2.5) 1
• Age ≥65 years with severe osteopenia (T-score <-2.0) 1

Medication Options

First-Line Therapy

• Bisphosphonates (preferred initial therapy) 1
  • Alendronate: 5 mg daily or 35 mg weekly for prevention 1, 2
  • Risedronate: 5 mg daily, 35 mg weekly, 75 mg on two consecutive days monthly, or 150 mg monthly 1
  • Zoledronic acid: 5 mg IV every two years for prevention 1

Second-Line Therapy

• Denosumab for women who have contraindications to or experience adverse effects of bisphosphonates 1

Medications to Avoid

• Menopausal estrogen therapy or estrogen plus progestogen therapy should not be used for osteoporosis treatment 1
• Raloxifene should not be used for osteoporosis treatment 1

Duration of Therapy

• Consider stopping bisphosphonate treatment after 5 years unless strong indication for continuation exists 1
• Decision for drug discontinuation should be individualized based on:
  • Baseline fracture risk
  • Type of medication and its half-life in bone
  • Benefits and harms of discontinuation 1

Monitoring

• Bone density monitoring is not recommended during the initial 5-year treatment period 1

Special Considerations

Common Pitfalls to Avoid

1. Overtreatment: Not all women with osteopenia require pharmacologic therapy
2. Undertreatment: Failing to identify high-risk women who would benefit from medication
3. Inadequate calcium/vitamin D: Supplements are necessary when dietary intake is insufficient
4. Medication side effects: Bisphosphonates are associated with:
   • Gastrointestinal symptoms
   • Rare but serious risks of osteonecrosis of the jaw and atypical femoral fractures 1
   • Risk increases with longer treatment duration 1

Risk Assessment

• Use FRAX tool to calculate 10-year fracture risk
• Consider additional risk factors not captured by FRAX:
  • Fall history
  • Rate of bone loss
  • Medications affecting bone health

By following this algorithmic approach to management, clinicians can effectively reduce fracture risk in postmenopausal women with osteopenia while minimizing unnecessary medication exposure and potential adverse effects.