Diagnosis and Treatment of Postmenopausal Osteoporosis

Patient Guideline Summary

Publication Date: March 2, 2020

Last Updated: March 3, 2023

Objective

This patient summary means to discuss key recommendations from the American Association of Clinical Endocrinologists and for diagnosis and treatment of postmenopausal osteoporosis.

Overview

Osteoporosis is a medical condition that softens bones, increasing their fragility.

Osteoporosis most often occurs in postmenopausal women since estrogen is a major promotor of bone growth.

Other causes of osteoporosis are type 1 diabetes, improper nutrition, metabolic disorders, liver disease, and medications like cortisone.

The first symptom is usually a fracture, often from a minor impact.

This patient summary focuses on the diagnosis and treatment of postmenopausal osteoporosis.

Diagnosis

All postmenopausal women aged ≥50 years should be evaluated for osteoporosis risk.
- The evaluation ordinarily includes:
  - a detailed history, physical exam, and clinical fracture risk assessment with the fracture risk assessment tool (FRAX®) or other fracture risk assessment.
  - an axial dual-energy X-ray absorptiometry (DXA) measurement (lumbar spine and hip or the distal third of the radius if indicated).
  - bone turnover markers
  - vitamin D levels.
  - a search for vertebral fractures
  - identifying other metabolic bone disorders and causes of secondary osteoporosis such as type 1 diabetes, glucocorticoids (cortisone), osteogenesis imperfecta, hyperthyroidism, hypogonadism, premature menopause, chronic malnutrition or malabsorption, and chronic liver disease.

Treatment

Assure an adequate dietary intake of calcium to a total intake (including diet plus supplement, if needed) of 1,200 mg per day for women aged ≥50 years.
Supplement vitamin D3, if needed, with a daily dose of 1,000 to 2,000 international units (IU).
Stop smoking.
Limit alcohol.
Engage in regular weight-bearing, balance, and resistance exercises.
Minimize the risk of falls.
- Physical therapy can greatly improve function and reduce the chance of falling.

Medications
- Oral agents include alendronate, denosumab, risedronate, and zoledronate.
- The injectable agents abaloparatide, denosumab, romosozumab, teriparatide, and zoledronate should be considered for patients unable to use oral therapy.
- Ibandronate or raloxifene may be appropriate initial therapy in some cases for patients requiring drugs with spine-specific activity.
- Sequential changes in medications are preferred to use of more than one drug at a time.
- A bisphosphonate holiday after 3–10 years of treatment may be recommended under certain conditions.

Vertebroplasty and kyphoplasty (surgical procedures to repair vertebral fractures or collapse) are not recommended as initial treatment.
Referral to an osteoporosis specialist, a clinical endocrinologist, or a fracture liaison team is recommended for unsatisfactory treatment results.

Monitoring

The lumbar spine, total hip, or femoral neck bone studies should be repeated every 1 to 2 years until the bone mineral density is stable or increasing.
- Due to lack of standardization, using the same DXA facility is preferred.
Bone turnover markers (BTMs) and bone formation markers may also be used to monitor treatment progress.
Two or more fragility fractures are generally considered evidence of treatment failure.

Abbreviations

BTMs: Bone Turnover Markers
DXA: Dual Energy X-ray Absorptiometry
FRAX: Fracture Risk Assessment Tool
IU: International Unit

Source Citation

Camacho PM, Petak SM, Binkley N, Diab DL, Eldeiry LS, Farooki A, Harris ST, Hurley DL, Kelly J, Lewiecki EM, Pessah-Pollack R, McClung M, Wimalawansa SJ, Watts NB. AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS/AMERICAN COLLEGE OF ENDOCRINOLOGY CLINICAL PRACTICE GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF POSTMENOPAUSAL OSTEOPOROSIS- 2020 UPDATE EXECUTIVE SUMMARY. Endocr Pract. 2020 May;26(5):564-570. doi: 10.4158/GL-2020-0524. PMID: 32427525.

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.