Management of Osteoporosis in Postmenopausal Women: 2021 Position Statement

Publication Date: September 1, 2021
Last Updated: February 21, 2023

Key Points

Overview, Screening and Assessment

  • Osteoporosis is a common disorder with potentially serious consequences.
  • Assessment of skeletal health should be a part of routine care for all postmenopausal women.
  • The annual examination should include measurements of height and weight; assessment for chronic back pain and kyphosis; and clinical risk factors for osteoporosis, fractures, and falls.
  • The most important risk factors for future fracture are a history of previous fracture, older age, and low BMD.
    • Fracture risk is especially high in the first 2 years after an incident fracture.
  • Bone mineral density testing is indicated for all postmenopausal women with risk factors for low BMD or fracture.
    • DXA is the preferred technique for BMD testing.
    • For untreated postmenopausal women at low fracture risk, repeat DXA testing is not useful until at least 5 years have passed, unless rapid bone loss is anticipated.
  • Vertebral imaging is appropriate for postmenopausal women aged 70 years and older or with historical height loss.
  • Secondary causes of osteoporosis should be evaluated before osteoporosis treatment has begun.
  • The routine use of biochemical markers of bone turnover in clinical practice is not recommended.

Nonpharmacologic Treatments and Lifestyle Modifications

  • Recommending and promoting healthy habits, including attention to nutrition, adequate calcium and vitamin D intake, physical activity, and avoidance of harmful habits is appropriate for all postmenopausal women.
  • None of these approaches can significantly improve BMD or correct the architectural abnormalities of osteoporosis.
  • The modest skeletal benefits of nonpharmacologic measures should not be construed as sufficient or effective therapies for postmenopausal women with osteoporosis at high risk of fracture.
  • The likelihood of falls can be decreased, however, and fracture risk may be reduced in older women. Prevention of falls is especially important in older women or those with decreased mobility.

Pharmacologic Therapy to Prevent Bone Loss

  • Intervening to prevent rapid bone loss and deterioration of skeletal structure is a unique opportunity to maintain bone health.
  • Such intervention would be most appropriate in women with low BMD who are experiencing relatively rapid bone loss because of acute estrogen deficiency in the perimenopausal and early postmenopausal periods or on discontinuing ET.
  • For younger, healthy postmenopausal women, particularly those with VMS, who are candidates for prevention of bone loss, estrogen alone (if no uterus) or combined with progestogen or BZA are the most appropriate therapies.
    • A bisphosphonate could be chosen if estrogen is contraindicated or on stopping ET.
    • Raloxifene is a good option for prevention of bone loss in postmenopausal women with an elevated risk of breast cancer and infrequent VMS.
  • Bisphosphonates to prevent bone loss can be considered in postmenopausal women with low BMD (T-score <1) and other risk factors for fracture (eg, family history) who do not meet criteria for osteoporosis treatment.

Treatment Plan

  • The choice of the initial treatment for osteoporosis is based on the patient’s current BMD and fracture risk.
  • Raloxifene is an option for the treatment of postmenopausal osteoporosis in women with a low risk of hip fracture, an elevated risk of breast cancer, and low risk of stroke and VTE.
  • Bisphosphonates are appropriate to reduce fracture risk in women with postmenopausal osteoporosis.
    • Use with caution in patients with significantly impaired renal function.
    • Consider a bisphosphonate holiday only in women at low fracture risk who no longer meet criteria for therapy.
      • Restart therapy if bone loss or fractures occur or when patient again meets criteria for treatment.
    • For patients remaining at high fracture risk after 3 to 5 years of bisphosphonate therapy, continue treatment or switch to another drug.
  • Denosumab is appropriate for women with postmenopausal osteoporosis, including those at high risk of fracture.
    • There is no limit to the duration of denosumab therapy.
    • Administration of denosumab should not be delayed or stopped beyond 7 months without subsequent therapy to prevent bone loss and vertebral fractures.
  • Osteoanabolic therapies are most appropriately used in women at very high risk of fracture, including those with prior and especially recent fractures, very low BMD (T-score below 3.0), and those who sustain fractures or lose BMD while taking anti-remodeling therapy.
    • Osteoanabolic therapies increase bone mass more rapidly and reduce racture risk more effectively than do bisphosphonates.
    • Anabolic therapy should be followed by an anti-remodeling agent to maintain bone density gains.
    • Bone mineral density gains, particularly in the hip, are greater when an anabolic drug is administered before an anti-remodeling drug, compared with the opposite sequence.
  • Bone mineral density measured while on therapy correlates with current fracture risk.
  • If the response to the initial treatment does not achieve preventing bone loss or reducing the risk of fracture, a change in treatment should be considered.
  • If drug-related AEs occur, appropriate management strategies should be instituted. If AEs persist, switching to another agent may be required.
  • Identify barriers to nonadherence to therapy and encourage adherence to the treatment plan. Providing clear information to women regarding their risk for fracture and the purpose of osteoporosis therapy may be an optimal way to improve adherence.
  • Depending on the treatment, an appropriate interval for repeat BMD testing is 1 to 2 years after beginning treatment or when a change in therapy is considered.
    • Initial DXA and follow-up scans should ideally be performed on the same instrument, using the same procedure. Interpretation of BMD changes requires careful attention to DXA quality control.
  • If progressive loss of BMD or fractures occurs while on therapy, evaluate for reasons for suboptimal response to therapy, including poor adherence and underlying medical conditions or medications.
  • Even when treatment increases T-score values above 2.5, the patient still has the diagnosis and risks of osteoporosis.
  • Referral to bone specialists is recommended for women with very low T-scores, inadequate treatment response, including progressive decline in BMD or fractures while on therapy, or additional factors (eg, renal failure, hyperparathyroidism) requiring special management.


  • Osteoporosis is a chronic, progressive health issue affecting a large proportion of postmenopausal women.
  • Menopause practitioners should be familiar and comfortable with approaches to the assessment and management of bone health in their patients.
  • Once diagnosed, patients with osteoporosis require lifelong management.
  • Management of bone health in postmenopausal women involves assessment of risk factors for low BMD and fracture, encouraging healthy lifestyle habits to reduce risk factors, and if indicated, pharmacologic therapy.
  • Effective tools for diagnosing osteoporosis and assessing fracture risk are available, and well-studied strategies exist for managing bone health in women at both low and high risk of fracture.
  • By individualizing treatment approaches and monitoring and adjusting those approaches if the clinical picture changes, the consequences of osteoporosis on a menopausal woman’s activity and well-being can be minimized.


  • Encourage all postmenopausal women to employ lifestyle practices that reduce the risk of bone loss and osteoporotic fractures: maintaining a healthy weight, eating a balanced diet, obtaining adequate calcium and vitamin D, participating in regular physical activity, avoiding excessive alcohol consumption, not smoking, and using measures to prevent falls.
  • The annual examination should include measurements of height and weight, assessment for chronic back pain, kyphosis, and clinical risk factors for osteoporosis, fractures, and falls.
  • Evaluate BMD in all women
    • Aged 65 years and older.
    • With history of fracture (other than skull, facial bone, ankle, finger, and toe) after menopause.
    • With medical causes of bone loss such as AE therapy and systemic glucocorticoid therapy of more than 3 months.
  • Consider BMD testing for postmenopausal women aged younger than 65 years who have one or more of these risk factors:
    • Discontinued estrogen with additional risk factors for fracture.
    • Thinness (body weight < 127 lb [57.7 kg] orBMI < 21 kg/m2)
    • History of hip fracture in a parent.
    • Current smoking.
    • Excessive alcohol intake.
    • Long-term use of medications associated with bone loss such as prednisone or an AI.
  • Use DXA as the preferred technique for BMD testing and the lowest T-scores at the LS, TH, or FN for diagnostic categorization.
  • Vertebral imaging is appropriate for women aged 70 years and older or with historical height loss of more than 1.5 in.
  • The IOM recommends daily intake of calcium 1,000 mg to 1,200 mg and vitamin D3 400 IU to 800 IU for women aged 50 years and older.
  • Routine use of calcium and vitamin D supplements is not recommended. Supplements should only be used when daily targets of calcium and vitamin D are not achieved from dietary sources.
  • Drug therapy is recommended to prevent bone loss in postmenopausal women with
    • Premature menopause, at least until the average age of natural menopause.
    • Low BMD (T-score < 1.0) and experiencing relatively rapid bone loss because of acute estrogen deficiency in the menopause transition or on discontinuing ET.
    • Low BMD (T-score < 1.0) and other risk factors for fracture (eg, family history) but who do not meet the criteria for osteoporosis treatment.
  • Drug therapy is recommended to treat osteoporosis in these populations:
    • All postmenopausal women who have had a vertebral or hip fracture.
    • All postmenopausal women who have BMD values consistent with osteoporosis (ie, T-scores < 2.5) at the LS, FN, or TH region.
    • All postmenopausal women who have T-scores from 1.0 to 2.5 and any one of
      • History of fracture of proximal humerus, pelvis, or distal forearm.
      • History of multiple fractures at other sites (excluding face, feet, and hands).
      • Increased fracture risk according to country-specific thresholds using FRAX. In the United States, those thresholds are a 10-year risk of major osteoporotic fracture (spine, hip, shoulder, and wrist) of at least 20% or of hip fracture of at least 3%.
  • Perform comprehensive evaluation, including thorough medical history, physical examination, laboratory evaluation and, in women with historical height loss and kyphosis, vertebral imaging before beginning osteoporosis therapy.
  • Ensure adequate total daily intake of calcium (1,000-1,200 mg) and vitamin D (400-800 IU) as adjunct therapy for all postmenopausal women receiving pharmacologic interventions for osteoporosis.
  • Consider osteoanabolic therapies for patients at very high risk of fracture, including older women with recent fractures, T-scores 3.0 and lower, or multiple other risk factors.
  • During therapy, reevaluate the treatment goals and the choice of medication on an ongoing basis through periodic medical examination and follow-up BMD testing.
  • Once diagnosed, patients with osteoporosis require lifelong management to prevent fractures.


TABLE 1. Diagnostic categories based on femoral neck T-scores

  • Normal - T-score ≥ -1.0
  • Low bone mass - T-score between 1.0 and 2.5
  • Osteoporosis - T-score ≤ 2.5

TABLE 2. Diagnosing osteoporosis in postmenopausal women

  1. BMD T-score by DXA of 2.5 or lower in the LS or proximal femur (TH or FN)
  2. History of vertebral (spine) or hip fracture, irrespective of BMD or other risk factors
  3. Low bone mass (T-score between 1.0 and 2.5) and any of the following
    1. History of fracture of proximal humerus, pelvis, or distal forearm
    2. History of multiple fractures at other sites (excluding face, feet, and hands)
    3. Increased fracture risk using FRAX country-specific thresholds

Risk factors for low bone density

  • Advanced age.
    • Bone loss decreases progressively with advancing age, and the prevalence of osteoporosis increases as women grow older.
  • Thinness.
    • Bone density in healthy women is strongly correlated with body weight.40 Being thin—often cited as body weight less than 127 lb (57.7 kg), the lower quartile of weight for US women aged older than 65 years, or body mass index (BMI) less than 21 kg/m2 —is a risk factor for low BMD.
  • Genetics.
    • Family studies demonstrate that 50% to 85% of the variance in BMD is genetically determined.41 Many genes have been weakly associated with low bone mass in humans.
  • Smoking.
    • Women who currently smoke have lower BMD than do nonsmokers.42 Smokers are generally thinner and have earlier menopause and lower serum estradiol levels than nonsmokers.
  • Diseases and drugs.
    • Many diseases and drugs adversely affect the skeleton (Table 3).4,7 These include eating disorders, chronic inflammatory illnesses (ie, rheumatoid arthritis), diseases causing malabsorption (ie, celiac disease), and various endocrinopathies (hyperparathyroidism, Cushing syndrome). Drugs can cause bone loss by increasing bone resorption (aromatase inhibitors [AIs]), impairing vitamin D metabolism (phenytoin), or reducing bone formation glucocorticoids), as can surgeries such as gastric bypass.

TABLE 4. Risk factors used in FRAX

  • Age (40-90 y)
  • Sex
  • Weighta
  • Heighta
  • Previous fracture
  • Parental history of hip fracture Current tobacco smoking
  • Use of glucocorticoids Rheumatoid arthritis
  • Alcohol intake of more than two units daily Secondary osteoporosisb
  • FN BMD if available

Indications for bone density testing

Bone density should be measured in postmenopausal women with risk factors for low bone density where knowing the result will influence clinical management:
  • Those with a history of fracture since menopause
  • Those with known medical causes of bone loss or fracture
  • Those aged 65 years and older
  • Those aged 50 years and older with one or more of these additional risk factors:
    • Body weight less than 127 lb (57.7 kg) or BMI less than 21 kg/m2
    • History of hip fracture in a parent
    • Current smoker
    • Discontinuing estrogen with additional risk factors for fracture

TABLE 5. Suggested laboratory tests for osteoporosis evaluation

Routine Tests
  • Complete blood count
  • Serum calcium
  • Serum albumin
  • Serum phosphate
  • Serum creatinine
  • Serum alkaline phosphatase

Special Tests
  • Serum 25-hydroxyvitamin D
  • Serum PTH
  • 24-hour urinary calcium
  • 24-hour urinary cortisol
  • Serum protein electrophoresis
  • Tissue transglutaminase
  • Serum tryptase
  • Serum TSH

Recommendation Grading




Management of Osteoporosis in Postmenopausal Women: 2021 Position Statement

Authoring Organization

Publication Month/Year

September 1, 2021

Last Updated Month/Year

August 14, 2023

Supplemental Implementation Tools

Document Type


Country of Publication


Inclusion Criteria

Female, Adult, Older adult

Health Care Settings


Intended Users

Nurse, nurse practitioner, physician, physician assistant


Assessment and screening, Treatment, Management

Diseases/Conditions (MeSH)

D015663 - Osteoporosis, Postmenopausal, D010024 - Osteoporosis


osteoporosis, menopause, Bone Health, postmenopausal osteoporosis

Source Citation

Management of osteoporosis in postmenopausal women: the 2021 position statement of The North American Menopause Society. Menopause. 2021 Sep 1;28(9):973-997. doi: 10.1097/GME.0000000000001831. PMID: 34448749.