What is the recommended treatment for osteopenia in women under 65?

Treatment of Osteopenia in Women Under 65

For women under 65 with osteopenia, first-line treatment should focus on lifestyle modifications including calcium (1,000-1,200mg daily), vitamin D (800-1,000 IU daily), and regular weight-bearing exercise, with pharmacological therapy reserved for those at high fracture risk based on FRAX assessment. 1

Risk Assessment and Diagnosis

• Osteopenia is defined as a bone mineral density (BMD) T-score between -1.0 and -2.5 2
• Despite lower individual fracture risk compared to osteoporosis, most fractures occur in osteopenic individuals due to their greater numbers 2
• Risk assessment should include:
  • BMD measurement (preferably femoral neck by dual-energy x-ray absorptiometry)
  • FRAX score calculation to determine 10-year fracture probability
  • Assessment of additional risk factors (low body weight, family history, smoking, alcohol use)

Treatment Algorithm

1. Lifestyle Modifications (All Patients)

• Calcium intake: 1,000-1,200mg daily (diet plus supplements) 1
• Vitamin D: 800-1,000 IU daily, targeting serum level ≥20 ng/ml 1
• Exercise: Weight-bearing or resistance training for at least 30 minutes, 3 days per week 1
• Smoking cessation and limited alcohol consumption 1, 3

2. Pharmacological Therapy (Based on Risk Assessment)

High Fracture Risk Patients (Consider Treatment)

• FRAX score ≥20% for major osteoporotic fracture or ≥3% for hip fracture 1
• Prior fragility fracture
• Additional significant risk factors

First-Line Pharmacological Options:

• Oral bisphosphonates (preferred first-line for high-risk patients) 1
  • Alendronate: Reduces hip fracture risk by 36% (RR 0.64; 95% CI, 0.50 to 0.82) 1
  • Consider weekly formulations to improve adherence

For Very High-Risk Patients:

• Anabolic agents (teriparatide, abaloparatide, romosozumab) for patients with:
  • Recent fractures
  • T-score ≤ -3.5
  • FRAX ≥30% for major osteoporotic fracture or ≥4.5% for hip fracture 1
  • Limited to 2 years of treatment for teriparatide/abaloparatide or 12 months for romosozumab 1

Monitoring and Follow-up

• BMD testing every 2-3 years for patients on treatment 1
• FRAX reassessment every 1-2 years 1
• Monitor treatment adherence (30-50% of patients don't take medication correctly) 1

Important Considerations

• The American College of Physicians does not recommend routine osteoporosis screening in women younger than 60 years of age who are not at increased risk 4
• Women 60-64 years with risk factors may benefit from screening comparable to routine screening in older women 4
• Low body weight (<70 kg) is the single best predictor of low bone mineral density 4
• African-American women generally have higher bone mineral density than white women at the same age 4

Common Pitfalls to Avoid

1. Overtreatment: Not all women with osteopenia require pharmacological therapy; treatment decisions should be based on comprehensive fracture risk assessment, not BMD alone 2

2. Undertreatment: Failing to identify high-risk individuals who would benefit from intervention despite having "only" osteopenia 2

3. Poor adherence: Consider barriers to medication compliance and choose formulations that promote adherence 1

4. Inadequate calcium/vitamin D: Ensure sufficient intake before initiating pharmacological therapy 1, 5

5. Lack of follow-up: Regular monitoring is essential to assess treatment efficacy and adherence 1