Management of Postmenopausal Osteoporosis
Bisphosphonates should be used as first-line pharmacologic treatment for postmenopausal osteoporosis due to their favorable balance of benefits, harms, patient values and preferences, and cost compared to other medications. 1, 2
Initial Assessment and Diagnosis
- All women 65 years and older and postmenopausal women younger than 65 with risk factors should undergo dual-energy x-ray absorptiometry (DEXA) scanning 2
- Treatment is recommended for patients with a T-score of -2.5 or less or those with a history of low-trauma fracture 2
- For T-scores between -1.0 and -2.5, use the FRAX calculator to guide treatment decisions (recommended for 10-year risk of major osteoporotic fracture ≥20% or hip fracture risk ≥3%) 2
- Risk factors to assess include: age, prior fracture history, family history of fracture, low body mass index (<19 kg/m²), smoking, excess alcohol intake, inadequate exercise, and early maternal hip fracture 1, 2
Non-Pharmacologic Interventions
- Ensure adequate calcium intake of 1,200 mg daily for women over 50 years 2, 3
- Supplement with vitamin D3 (600-1,000 IU daily) for adults over 50 years to maintain serum levels of at least 20 ng/mL 2, 3
- Recommend regular weight-bearing and resistance exercise to maintain bone density 2, 4
- Advise smoking cessation and limiting alcohol consumption 1, 2
- Implement fall prevention strategies including vision assessment, medication review, and home safety evaluation 2
Pharmacologic Treatment Options
First-Line Therapy
- Oral bisphosphonates (alendronate, risedronate) are recommended as initial treatment due to their efficacy, safety profile, and lower cost 1, 2
- Bisphosphonates should be taken on an empty stomach in the morning, 0.5-2 hours before food and other medications, and at a different time than calcium supplements 1
- Consider stopping bisphosphonate treatment after 5 years unless there's a strong indication to continue, as long-term use may increase risk of osteonecrosis of the jaw and atypical femoral fractures 1, 2
Second-Line Therapy
- Denosumab is recommended for patients with contraindications to or adverse effects from bisphosphonates 1, 2
- After discontinuation of denosumab, patients should transition to an antiresorptive agent to prevent rapid bone loss 2
Other Options
- Raloxifene (60 mg daily) can be considered, particularly for younger postmenopausal women who also have high breast cancer risk, but should not be used in patients taking aromatase inhibitors 2, 3
- Teriparatide is typically reserved for patients with severe osteoporosis or those who have had fractures 2
- After discontinuation of anabolic agents like teriparatide, patients should transition to an antiresorptive agent to maintain bone gains 1, 2
Special Considerations
- For postmenopausal breast cancer survivors, obtain baseline DEXA scan and repeat every 2 years for women taking aromatase inhibitors 1
- Bisphosphonates or denosumab can prevent bone loss and/or treat established osteoporosis in cancer patients, but consider risk versus benefit of antiresorptive therapy 1
- Selective estrogen receptor modulators (SERMs) should not be used for osteoporosis prevention in women taking aromatase inhibitors 1
- Generic medications should be prescribed when possible to improve affordability and adherence 1, 2