Last updated February 20, 2023

Management of Postmenopausal Osteoporosis

Key Points

  • Osteoporosis is a common disease that can result in bone fractures.
  • Through screening, risk assessment, and pharmacologic treatment, fractures can be prevented.
  • DEXA scans should be used for screening starting at age 65 for most women.
  • Biphosphonates are the first line therapy for patients found to be high risk patients and should be used for most postmenopausal patients
  • DEXA scan T score of ≤–2.5 gives diagnosis of osteoporosis
  • Evaluate all patients for secondary causes of bone loss before starting pharmacotherapy
  • Breast cancer patients/survivors are at high risk of osteoporosis development if they were treated with chemotherapy or aromatase inhibitors
  • Pharmacologic treatment is recommended for all patients at high risk of fracture
  • Bisphosphonates should be initial therapy for most postmenopausal patients
  • DXA testing every 1 to 3 years if patient is on pharmacotherapy until findings are stable



  • Dual Energy X-Ray (DEXA) is preferred method
    • Hip and lumbar bone mineral density measurements most accurate
    • Osteoporosis diagnosed with T Score ≤–2.5
    • T-score between −1.0 and −2.5 and increased risk of fracture using a formal clinical risk-assessment tool such as the US Fracture Risk Assessment (FRAX) tool
  • Clinically diagnosed if patient has a fragility fracture
    • Fracture occurs after a fall at less than standing height
    • Usual site: Hip | Humerus | Rib | Pelvis | Wrist | Spine
    • Includes asymptomatic vertebral fracture


Lifestyle Modifications

  • Weight bearing exercises
  • Adequate intake of vitamin D and calcium
    • Calcium RDA:
      • Age 19 to 50 years: 1000 mg per day
      • >50 years: 1200 mg per day
    • Vitamin D RDA
      • ≤70 years: 600 IU
      • >70 years: 800 IU per day
  • Fall prevention strategies

Pharmacotherapy: Work-up and Candidates for Treatment

  • Patient with high risk of fracture should be treated pharmacologically
  • Before starting pharmacotherapy, patients should be evaluated for secondary causes of bone loss
    • HIV/AIDs
    • Anorexia
    • Diabetes
    • Hyperparathyroidism
    • Renal impairment
    • Rheumatoid arthritis
    • Turner’s syndrome
    • Vitamin D Deficiency
    • Medication induced
  • Secondary Osteoporosis Evaluation
    • Complete blood count
    • Metabolic profile
    • 24-hour collection for Ca, Na, Cr excretion
    • Liver function tests
    • TSH with or without free T4
    • 25-hydroxyvitamin D

Pharmacotherapy Options

  • Bisphosphonates
    • First line therapy
    • Discontinue in patients who are at low-to-moderate risk if stable after
      • 5 years of treatment with oral bisphosphonates or
      • 3 years of treatment with IV zoledronic acid
  • Denosumab
    • Use if a patient prefers less frequent medication administration
    • 6-month subcutaneous administration
    • Patients who discontinue denosumab therapy should be transitioned to treatment with another antiresorptive agent
  • Raloxifene
    • Can be used for postmenopausal women who
      • Are at increased risk of vertebral fracture and breast cancer
      • Have low risk of venous thromboembolism
      • Have no significant vasomotor symptoms
  • Teriparatide and abaloparatide
    • Parathyroid hormone analogs
    • Can be used in postmenopausal women for up to 2 years
      • Who are at very high risk of fracture
      • Continue to sustain fractures
      • Have significant bone loss while taking antiresorptive therapy
  • Romosozumab
    • Sclerostin-binding inhibitor
    • Can be used in postmenopausal women for up to 1 year
    • Should meet the following criteria
      • Not at increased risk of cardiovascular disease/stroke and have high risk of fracture or
      • Other treatments have not been effective
Note: If unable to tolerate pharmacologic therapy, patient should consume the recommended daily allowance of calcium and vitamin D, ideally through diet although supplementation acceptable

Treatment Monitoring

  • DXA testing every 1 to 3 years if patient is on pharmacotherapy until findings are stable

Recommendation Grading




Management of Postmenopausal Osteoporosis

Authoring Organization

Publication Month/Year

April 1, 2022

Document Type


Country of Publication


Inclusion Criteria

Female, Older adult

Health Care Settings


Intended Users

Nurse, nurse practitioner, physician, physician assistant



Diseases/Conditions (MeSH)

D015663 - Osteoporosis, Postmenopausal


postmenopausal osteoporosis

Source Citation

ACOG Committee on Clinical Practice Guidelines–Gynecology. Management of Postmenopausal Osteoporosis: ACOG Clinical Practice Guideline No. 2. Obstet Gynecol. 2022 Apr 1;139(4):698-717. doi: 10.1097/AOG.0000000000004730. Erratum in: Obstet Gynecol. 2022 Jul 1;140(1):138. PMID: 35594133.