What is the recommended approach for managing bone health in postmenopausal women over 50, particularly those with a history of fractures or risk factors for osteoporosis?

Bone Health Management in Women Over 50

Screening and Risk Assessment

All postmenopausal women aged 65 and older should undergo bone density testing, while women aged 50-64 require screening only if they have specific risk factors for osteoporosis. 1

For women aged 50-64, screen if any of the following are present:

• History of fragility fracture 2
• Family history of hip fracture in a parent 2
• Body weight less than 127 pounds (58 kg) 2
• Current smoking 2
• Medications causing bone loss (especially glucocorticoids) 2

Treatment Thresholds Based on Risk Stratification

Initiate pharmacologic therapy immediately for any woman over 50 with a history of fragility fracture, regardless of bone density, as this represents high fracture risk that warrants treatment independent of other calculations. 2

For women without prior fracture:

• Calculate 10-year fracture risk using the WHO FRAX tool 2
• Treat if FRAX shows ≥20% risk of major osteoporotic fracture OR ≥3% risk of hip fracture 2, 3
• Treat if T-score is approaching -2.5 or severe osteopenia (T-score <-2.0) 2

First-Line Pharmacologic Treatment

Oral bisphosphonates are the mandatory first-line therapy, reducing hip fractures by 50% and vertebral fractures by 47-56% over 3 years, with the most favorable balance of efficacy, safety, and cost. 2, 3, 4

Specific bisphosphonate regimens:

• Alendronate 70 mg once weekly (oral) 2, 4
• Risedronate 35 mg once weekly (oral) 2, 4
• Zoledronic acid 5 mg IV annually for patients unable to tolerate oral formulations 2, 4

Essential Supplementation (Non-Negotiable)

All women over 50 receiving osteoporosis treatment must take calcium 1,200 mg daily and vitamin D 800 IU daily, as pharmacologic therapy is significantly less effective without adequate supplementation. 2, 3, 4

• Target serum vitamin D level ≥20 ng/mL 2
• These supplements are required even for women not on pharmacologic therapy if they have osteopenia or osteoporosis 3

Treatment Duration and Monitoring Strategy

Treat with bisphosphonates for an initial 5-year period without monitoring bone density during treatment, as monitoring provides no clinical benefit. 2, 3, 4

After 5 years:

• Reassess fracture risk to determine if continued therapy is warranted 2, 3, 4
• Consider drug discontinuation only in patients at low risk for fracture 3, 4

Mandatory Lifestyle Modifications

All women over 50 with bone health concerns require:

• Weight-bearing exercise and resistance training 2, 3, 4
• Smoking cessation 2, 3
• Limit alcohol intake 2, 3
• Fall prevention strategies 2, 3
• Maintain healthy body weight 2

Secondary Causes Evaluation

All women diagnosed with osteopenia or osteoporosis require workup for secondary causes of bone loss, including vitamin D deficiency, hypogonadism, glucocorticoid exposure, malabsorption disorders, hyperparathyroidism, hyperthyroidism, and alcohol abuse. 2

Second-Line Treatment Option

For women who cannot tolerate bisphosphonates or have contraindications, denosumab 60 mg subcutaneously every 6 months is the recommended alternative. 2, 3, 4, 5

Critical warning: Never discontinue denosumab abruptly without transitioning to bisphosphonate therapy, as abrupt discontinuation is associated with multiple vertebral fractures. 2, 3

Agents to Avoid

Strongly avoid menopausal estrogen therapy, estrogen plus progestogen therapy, or raloxifene for osteoporosis treatment due to unfavorable benefit-harm balance. 2, 4

• Teriparatide and romosozumab are reserved for very high-risk osteoporosis only, not as first-line therapy 2, 6
• Teriparatide use should not exceed 2 years during a patient's lifetime due to osteosarcoma risk observed in animal studies 6

Safety Profile

High-certainty evidence shows bisphosphonates cause no difference in serious adverse events compared to placebo at 3+ years. 2, 3, 4

Common mild adverse effects include:

• Upper GI symptoms 2
• Influenza-like symptoms, myalgias, arthralgias, headaches 2

Rare serious adverse effects (risk increases with prolonged use):

• Osteonecrosis of the jaw (0.01% to 0.3% incidence) 4
• Atypical femoral fractures 2, 4

Cost Considerations

Prescribe generic bisphosphonates whenever possible rather than expensive brand-name medications or newer agents, as they are significantly more cost-effective while maintaining equivalent efficacy. 3, 4