Postmenopausal Osteoporosis Management Guidelines

An Endocrine Society Guideline Update

What Is the Definition of Postmenopausal Osteoporosis?

Osteoporosis is defined as “a [silent] skeletal disorder characterized by compromised bone strength predisposing to an increased risk of fracture. Bone strength reflects the integration of two main features: bone density and bone quality”

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Who to Treat?

Guidelines recommend treating postmenopausal women at high risk of fractures, especially those who have experienced a recent fracture, with pharmacological therapies, as the benefits outweigh the risks.

Essential Points of Management

Treat high risk individuals - particularly those with previous fracture.

Consider bisphosphonates (alendronate, risedronate, zoledronic acid, and ibandronate) as the first line therapeutic choice for postmenopausal women at high risk of fracture.

Reassess fracture risk after patient has been on bisphosphonates for 3-5 years.

Following reassessment, prescribe a “bisphosphonate holiday” for women who are on bisphosphonates and are low-to-moderate risk of fracture.

In postmenopausal women with osteoporosis who are at high risk for osteoporotic fractures, Endocrine Society Guideline recommend using denosumab as an alternative initial treatment.

Consider anabolic therapy (teriparatide or abaloparatide) for women at very high risk of fractures, including those with multiple fractures.

In postmenopausal women with osteoporosis at high risk of fracture and with a low risk of deep vein thrombosis and for whom bisphosphonates or denosumab are not appropriate or with a high risk of breast cancer, guideline recommend raloxifene or bazedoxifene to reduce the risk of vertebral fractures.

In postmenopausal women at high risk of fracture and with those in whom bisphosphonates or denosumab are not appropriate, under 60 years of age or <10 years past menopause, at low risk of deep vein thrombosis, guideline suggest menopausal hormone therapy, using estrogen only in women with hysterectomy, to prevent all types of fractures.

All women undergoing treatment with osteoporosis therapies other than anabolic therapy should consume Calcium and Vitamin D in their diet or via supplements.

Calcium and Vitamin D Supplementation

In postmenopausal women with low bone mineral density and at high risk of fractures with osteoporosis, Endocrine Society guideline suggests that Calcium and Vitamin D be used as an adjunct to osteoporosis therapies.

In postmenopausal women at high risk of fracture with osteoporosis who cannot tolerate bisphosphonates, estrogen, selective estrogen response modulators, denosumab, tibolone, teriparatide, and abaloparatide, guideline recommend daily Calcium and Vitamin D supplementation to prevent hip fractures

Monitoring Treatment Outcome

In postmenopausal women with a low bone mineral density and at high risk of fractures who are being treated for osteoporosis, we suggest monitoring the bone mineral density by dual-energy X-ray absorptiometry at the spine and hip every 1 to 3 years to assess the response to treatment.