Treatment of Osteopenia in Postmenopausal Women
For postmenopausal women with osteopenia and no significant medical history, pharmacologic treatment is NOT routinely recommended unless fracture risk assessment indicates high risk; instead, focus on calcium (1,000-1,200 mg/day), vitamin D (600-800 IU/day), and lifestyle modifications with monitoring. 1
Risk Stratification is Essential
Before deciding on treatment, you must calculate the 10-year fracture risk using the FRAX tool 1:
Pharmacologic treatment should be considered if FRAX shows:
- 10-year risk of major osteoporotic fracture ≥20%, OR
- 10-year risk of hip fracture ≥3% 1
Monitor without pharmacologic treatment if fracture risk is below these thresholds 1
Always treat pharmacologically if there is a history of low-trauma (fragility) fracture, even with osteopenia 1
Non-Pharmacologic Management (All Patients)
These interventions form the foundation and should be implemented in every postmenopausal woman with osteopenia 2, 3:
- Calcium supplementation: 1,000-1,200 mg daily (total from diet plus supplements) 1, 2
- Vitamin D supplementation: 600-800 IU daily, with serum 25-OH vitamin D levels ≥20 ng/mL 1, 2
- Weight-bearing exercise: Regular weight-bearing and resistance training exercises 3, 4
- Smoking cessation: Critical modifiable risk factor 3
- Alcohol limitation: Reduce excessive intake 3
- Fall prevention: Address home safety and balance 3
- Maintain healthy body weight: Avoid excessively low body weight 3
Pharmacologic Treatment (When Indicated by FRAX)
If fracture risk assessment warrants treatment, first-line therapy is oral bisphosphonates 1:
- Alendronate: 70 mg weekly or 10 mg daily 1
- Risedronate: 35 mg weekly or 5 mg daily 1
- Ibandronate: 150 mg monthly 1, 5
Alternative agents if bisphosphonates are not appropriate 1:
- Raloxifene (60 mg daily): Good option for younger postmenopausal women with lower fracture risk 1, 6
- Denosumab: For women with higher fracture risk who cannot tolerate bisphosphonates 1
- Teriparatide: Reserved for severe osteoporosis or treatment failures, not typically used for osteopenia 1, 6
Monitoring Strategy
- Repeat DXA scanning: Every 2-3 years depending on risk factors 1
- Annual clinical fracture risk assessment 1
- Check for vertebral fractures: Consider spine radiographs or vertebral fracture assessment if height loss occurs, as silent vertebral fractures are common (50% prevalence in some osteopenic populations) and would trigger treatment 1, 7
Critical Pitfalls to Avoid
- Do not automatically prescribe bisphosphonates for osteopenia alone without fracture risk assessment—this leads to overtreatment 1
- Do not use oral bisphosphonates in patients at increased risk of aspiration 1, 5
- Do not prescribe oral bisphosphonates to patients with esophageal abnormalities or inability to remain upright for 30 minutes 1
- Do not overlook secondary causes of bone loss: Screen for vitamin D deficiency, hypogonadism, hyperthyroidism, hyperparathyroidism, malabsorption, and medication effects (especially glucocorticoids) 1, 4
- Ensure adequate calcium and vitamin D before and during any pharmacologic treatment—medications are ineffective without this foundation 5, 6
Special Consideration for Vitamin D Deficiency
If 25-OH vitamin D levels are low, higher doses may be needed initially to replete stores before maintenance dosing 1. Check vitamin D levels if osteopenia is detected 1.