Pharmacological Management of Osteoporosis in Postmenopausal Women

Publication Date: February 18, 2020
Last Updated: May 15, 2023

Objective

Objective

This patient summary means to discuss key recommendations from the Endocrine Society for the pharmacologic management of postmenopausal osteoporosis. This patient summary is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Overview

  • Osteoporosis describes softening of bone that increases the risk of fractures.
    • Vertebrae (spine bones) and the hip are the most frequently affected.
  • We will use the abbreviation BMD throughout this summary to refer to bone mineral density.
  • Osteoporosis develops when estrogen production decreases during menopause.
  • There are other causes, such as chronic use of cortisone-like medications, zero gravity, poor nutrition, certain hormonal treatments for cancer and being bedridden.
  • Symptoms rarely appear before a bone breaks.
  • Fracture risk is greatest during menopause and in the two years following an osteoporotic fracture.
  • This patient summary focuses on drug treatment of postmenopausal osteoporosis.

Diagnosis

Diagnosis

  • An initial assessment covers not only your general health and medical conditions but also your nutrition, family history, physical activity, alcohol and tobacco use.
  • A bone mineral density (BMD) test (DXA) is usually done.
  • X-rays may also be useful to aid in diagnosis.

Prevention

Prevention

  • Lifestyle improvements include optimal nutrition including calcium and vitamin D, regular physical activity, avoidance of harmful habits like alcohol and smoking, and measures to protect against falling.
    • These measures slow the progression of the condition but do not improve it.

Treatment

Treatment

  • Early drug treatment is recommended for all women at high risk of fractures.
  • Risk is determined by BMD and features of your personal medical history.
    • Risk is considered high if you have had a recent osteoporotic fracture.
  • Drug choices include:
    • A bisphosphonate (alendronate, risedronate, zoledronic acid, and ibandronate)
      • A bisphosphonate holiday for 1-5 or more years for patients not at high risk is often a good idea due to the long-term accumulation of the drug in bones.
    • Denosumab
      • Denosumab should be taken continuously and its results assessed after 5-10 years of continuous treatment.
      • Interrupting treatment is not recommended because of a rebound effect.
    • Teriparatide and abaloparatide
      • Two years of treatment with one of these drugs is recommended for very high-risk patients.
      • Other drugs should be substituted after two years.
    • Romosozumab
      • One year of romosozumab is an alternate for very high-risk patients, after which another class of drugs should be substituted.
    • Selective Estrogen Receptor Modulators (SERMs) (raloxifene or bazedoxifene)
      • SERMs are a second choice for patients with a low risk for blood clotting disorders and a high risk of breast cancer.
    • Menopausal Hormone Therapy and Tibolone
      • These agents have multiple effects and side effects. Consequently, there are numerous “for” and “against” conditions pertaining to their use.
    • Calcitonin
      • Nasal spray calcitonin is a third-choice drug when others are inappropriate for any of a variety of reasons.
    • Calcium and Vitamin D
      • Total daily intakes of calcium (1,000-1,200 mg) and vitamin D (400-800 IU) are beneficial for almost everyone.
Note: In addition to improving osteoporosis, each of these drugs has its own action profile. Your doctor will discuss each with you to select the best choice.
  • BMD measurements and fracture risk will be repeated every 1-3 years.
    • Changes in treatment will be based on these assessments.
  • You may be referred to a specialist if optimum results are not achieved.
  • Expect lifelong management.

Abbreviations

  • BMD: Bone Mineral Density
  • IU: International Unit(s)
  • SERM: Selective Estrogen Receptor Modulator

Source Citation

Dolores Shoback, Clifford J Rosen, Dennis M Black, Angela M Cheung, M Hassan Murad, Richard Eastell, Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Guideline Update, The Journal of Clinical Endocrinology & Metabolism, Volume 105, Issue 3, March 2020, Pages 587–594, https://doi.org/10.1210/clinem/dgaa048

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.