Diagnosis and Treatment of Postmenopausal Osteoporosis

Patient Guideline Summary

Publication Date: March 2, 2020

Objective

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

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

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

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

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.