Summary of Recommendations

Document Overview

Design and created by Guideline Central in participation with the Royal Australian College of General Practitioners.

Osteoporosis Management and Fracture Prevention in Postmenopausal Women and Men Over 50 Years of Age

Royal Australian College of General Practitioners

Publication Date: Mar 25, 2025

Page Last Updated: May 5, 2026

Risk factors, fracture risk assessment and case finding

All individuals over the age of 50 years who sustain a fracture following minimal trauma (such as a fall from standing height, or less) should be considered to have a presumptive diagnosis of osteoporosis. A
Conduct a clinical risk factor assessment in postmenopausal women and men over the age of 50 years with one or more major risk factors for minimal trauma fracture to guide bone mineral density (BMD) measurement and prompt timely referral and/or drug treatment. A
A presumptive diagnosis of osteoporosis can be made in a patient with a vertebral fracture or hip fracture in whom there is no history of significant trauma. Caution regarding diagnosis and treatment should be exercised if only a single mild vertebral deformity (height loss) is detected, especially in a patient under the age of 60 years. B
Measure BMD by dual‐energy x‐ray absorptiometry (DXA) scanning on at least two skeletal sites, including the lumbar spine and hip, unless these sites are unsuitable (eg, hip prosthesis). A
Assessment of absolute fracture risk, using the Fracture Risk Assessment Tool (FRAX; https://fraxplus.org/) may be useful in assessing the need for treatment in individuals who do not clearly fit the established criteria. B
Patients with a very high and/or imminent fracture risk should be promptly referred to a specialist for consideration of osteoanabolic therapy as first line treatment. C
Those aged > 50 years with a current or prior minimal trauma fracture should be assessed and appropriately treated. A
For those aged > 50 years with lifestyle and non‐modifiable risk factors (eg, parent with hip fracture), use FRAX to calculate absolute fracture risk. D
When FRAX risk for major osteoporotic fracture (MOF) is ≥ 10%, refer for DXA. If the risk of MOF is < 10%, DXA is not recommended. D
Re‐stratify risk with FRAX after DXA using BMD reading and treat when:
- BMD T‐score is ≤ ‐2.5;
- BMD T‐score is between ‐1.5 and ‐2.5 and the FRAX risk for MOF is ≥ 20% and/or the hip fracture risk is ≥ 3%. D
For those aged > 50 years with diseases, chronic conditions and/or medications associated with increased fracture risk, refer for BMD assessment by DXA. C
Re‐stratify risk with FRAX after DXA using BMD reading and treat when:
- BMD T‐score is ≤ ‐2.5;
- BMD T‐score is between ‐1.5 and ‐2.5 and the FRAX risk for MOF is ≥ 20% and/or the hip fracture risk is ≥ 3%. C
There is insufficient evidence to recommend population‐based systematic screening with BMD measurement for reduction of osteoporotic fractures in Australia, and case finding is recommended. B

General bone health maintenance and fracture prevention

For generally healthy older people:
- Although the absolute benefit of calcium and vitamin D supplements in short term (less than six years) studies for fracture reduction is low, there is good evidence that adequate calcium intake and vitamin D status are important for long term maintenance of bone and muscle function. C
For frail and institutionalised older people:
- Calcium and vitamin D supplementation, together with adequate protein intake, are recommended for fracture prevention. Optimisation of calcium and vitamin D should be the standard of care for this group of people. B
For people taking osteoporosis treatments:
- Calcium supplements should be recommended if their dietary calcium intake is less than 1300 mg per day.
- Vitamin D supplements should be recommended to correct low serum vitamin D levels (25‐hydroxyvitamin D < 50 nmol/L). C
For most people with olive or pale brown skin, with no other risk factors and who are at intermediate risk of skin cancer, a few minutes of sunlight exposure towards the middle of the day, with time depending on latitude, season and skin area exposed, followed by further sun protection measures should maintain vitamin D levels. People with dark skin at low risk of skin cancer have less need for sun protection, but require more time outdoors to avoid vitamin D deficiency. People at high risk of skin cancer need sun protection most of the year, which may limit vitamin D synthesis. The use of sunscreen, in practice, does not greatly affect vitamin D status. B
Opportunistic case finding should be undertaken as per the recommended algorithm1 to identify older people at risk of falls and fall‐related injury. A
Offer further assessment and/or interventions to prevent falls based on the level of risk identified. A
Exercises recommended to reduce fracture risk
- Muscle resistance (strength) training should be regular (at least twice a week), moderate to vigorous, and progressive.
- Weight‐bearing impact exercises should be performed most days (at least 50 moderate impacts) and include moderate to high loads in a variety of movements in different directions.
- Balance training activities should be challenging.
- Limit prolonged sitting (sedentary behaviour). B
Exercise programs for very frail older institutionalised people and those with a high vertebral fracture risk should be supervised, modified and tailored to minimise the potential to increase the risk of falls, injury and vertebral fractures. C
Prescribe extended and supervised exercise therapy, including targeted resistance and challenging balance training, after hip fracture to improve mobility, strength and physical performance and to reduce falls risk. B
Evidence for the benefits of exercise after vertebral and non‐hip fractures is limited, but suggests supervised resistance training will build bone once a fracture has healed to the same extent as in non‐fractured patients. For people with a vertebral fracture, exercises to strengthen back muscles, enhance flexibility and improve posture, as well as to reduce falls risk, should be considered. D

Pharmacological approaches to prevention and treatment

Bisphosphonate therapy (alendronate, risedronate or zoledronate) should be considered for the primary prevention of vertebral fractures in women with osteopenia who are at least ten years postmenopause. B
Bisphosphonate therapy is recommended for reducing the risk of vertebral and non‐vertebral fractures in postmenopausal women and men over the age of 50 years at high risk of fracture (those with osteoporosis by BMD criteria, or prior minimal trauma fracture). A (women), C (men)
Reconsider the need to continue bisphosphonate therapy after five to ten years in postmenopausal women and men over the age of 50 years with osteoporosis who have responded well to treatment (T‐score ≥ ‐2.5 and no recent fractures). If BMD remains low (T‐score ≤ ‐2.5) and/or there are incident fragility fractures, continue treatment. Treatment should be restarted if there is bone loss, especially at the hip, or if a further minimal trauma fracture is sustained. D
Denosumab is recommended for the treatment of osteoporosis in postmenopausal women at high risk of minimal trauma fracture. A
Denosumab may be considered as an alternative to bisphosphonates for the treatment of men at increased risk of minimal trauma fracture. B
Denosumab therapy should not be interrupted. If denosumab needs to be ceased, patients should be transitioned to bisphosphonate therapy for a minimum of 12 months. C
Romosozumab is recommended as first line therapy for osteoporosis treatment in postmenopausal women at very high risk of minimal trauma fracture. A
Romosozumab is recommended as first line therapy for osteoporosis treatment in men at very high risk of minimal trauma fracture. C
Consider oestrogen replacement therapy to reduce the risk of fragility fractures in postmenopausal women within ten years of menopause. The increased risk of adverse events associated with treatment should be carefully weighed against benefits. A
Selective oestrogen receptor modulators (SERMs) should be considered as a treatment option for postmenopausal women with osteoporosis where vertebral fractures are the major osteoporosis risk (based on low spine BMD and/or an existing vertebral fracture) and where other agents are poorly tolerated. SERMs may be particularly useful in younger postmenopausal women at risk of vertebral fracture with a prior or family history of breast cancer. A
Recombinant human parathyroid hormone (teriparatide) treatment is recommended to reduce fracture risk in postmenopausal women with osteoporosis who have sustained a subsequent fracture while on antiresorptive therapy, or in those at very high fracture risk. A
Recombinant human parathyroid hormone (teriparatide) treatment is recommended to reduce fracture risk in men aged over 50 years with osteoporosis who have sustained a subsequent fracture while on antiresorptive therapy, or in those at very high fracture risk. C

Special issues

For the management of osteoporosis in frail and older people (> 75 years of age), consider a multifactorial approach (environment, pharmacological treatments, exercise, nutrition) to reduce falls and fracture risk. C
All women commencing aromatase inhibitor therapy should have baseline assessment of fracture risk before commencing therapy, including clinical risk factors, biochemistry and BMD (DXA) measurement, with ongoing monitoring based on risk factors. A
Women commencing aromatase inhibitor therapy who fall within one of the following two categories should commence antiresorptive therapy unless contraindicated:
- age ≥ 70 years with BMD T‐score ≤ ‐2.0;
- age > 50 years with a minimal trauma fracture (including radiological vertebral fracture) or a high estimated ten‐year fracture risk. A
There is limited evidence specific to women receiving aromatase inhibitors to guide firm recommendations outside these criteria, especially in pre‐menopausal women. A
The duration of anti‐resorptive treatment in women undergoing, or who have completed, aromatase inhibitor therapy should be individualised and based on absolute fracture risk. D
General measures to prevent bone loss should be implemented in all women commencing aromatase inhibitor therapy. C
All men commencing androgen deprivation therapy (ADT) should have a baseline assessment of fracture risk, including BMD assessment by DXA. A
All men receiving ADT with a history of minimal trauma fracture should be commenced on anti‐resorptive therapy, unless contraindicated. A
Bone health should be reviewed every one to two years in men on continuous ADT. C
General measures to prevent bone loss should be implemented in all men commencing ADT. C
MRONJ is a rare complication of osteoporosis therapy and most patients will not be at increased risk of MRONJ. Consider patient risk of MRONJ before starting osteoporosis therapy and ensure that high risk patients receive dental review before therapy initiation. Given the long in vivo half‐life of bisphosphonates, there is little benefit to their cessation before dental extraction. Invasive dental procedures in patients on denosumab should be performed just before the next six‐monthly injection because the in vivo effect on bone suppression will be waning. C

Grades of Recommendations and Evidence Hierarchy

Document Overview

Document Title: Osteoporosis Management and Fracture Prevention in Postmenopausal Women and Men Over 50 Years of Age

Authoring Society: Royal Australian College of General Practitioners

Document Publication Date: Mar 25, 2025

Page Last Reviewed/Updated: May 5, 2026

Document Type: Guideline

Country of Publication: Australia

Full Text Freely Available: Yes

Full Text Guideline: healthybonesaustralia.org.au/wp-content/uploads/2024/03/hba-racgp-guidelines-2024.pdf

Source Citation: Wong P, Chen W, Ewald D, Girgis C, Rawlin M, Tsingos J, Waters J. 2024 Royal Australian College of General Practitioners and Healthy Bones Australia guideline for osteoporosis management and fracture prevention in postmenopausal women and men over 50 years of age. Med J Aust. 2025 Mar 25. doi: 10.5694/mja2.52637. Epub ahead of print. PMID: 40134107.

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases

Document Objectives: This updated guideline replaces the previous Royal Australian College of General Practitioners and Osteoporosis Australia (now, Healthy Bones Australia) guideline from 2017. The accumulation of high quality evidence supporting improvements in clinical practice over the past five years, need for expert consensus and opinion, and new developments in pharmacological management of osteoporosis, especially the role of osteoanabolic therapies, prompted this update. The aim was to provide clear, evidence‐based recommendations to assist Australian general practitioners in managing patients over 50 years of age with poor bone health. However, it is useful for any health care professional caring for people with poor bone health and for health administrators and bureaucrats responsible for resource provision and allocation.

Scope: Diagnosis, Prevention

Diseases/Conditions (MeSH)

D015663 - Osteoporosis, Postmenopausal

D010024 - Osteoporosis

D058866 - Osteoporotic Fractures

D015663 - Osteoporosis, Postmenopausal

D010024 - Osteoporosis

D058866 - Osteoporotic Fractures

Keywords: osteoporosis, postmenopausal osteoporosis

Target Patient Population: Patients over 50 years of age with poor bone health

Target Provider Population: Australian general practitioners managing patients over 50 years of age with poor bone health

Inclusion Criteria: Male, Female, Adult, Older Adult

Health Care Settings: Ambulatory

Intended Users: Nurse, Nurse Practitioner, Physician, Physician Assistant

Study Type	Description
Level I	A systematic review of Level II studies
Level II	An RCT or prospective cohort study
Level III	A pseudo-RCT, case-control study, retrospective cohort study, comparative study with concurrent controls or comparative study without concurrent controls
Level IV	Case series, study of diagnostic yield, cohort study of persons at different stages of disease or cross-sectional study

Grade	Description
A	Body of evidence can be trusted to guide practice
B	Body of evidence can be trusted to guide practice in most situations
C	Body of evidence provides some support for recommendation(s), but care should be taken in its application
D	Body of evidence is weak and recommendation must be applied with caution. (The review committee also applied a Grade D to recommendations where there is expert consensus in the absence of a strong body of evidence)

Osteoporosis Management and Fracture Prevention in Postmenopausal Women and Men Over 50 Years of Age

Summary of Recommendations

Risk factors, fracture risk assessment and case finding

General bone health maintenance and fracture prevention

Pharmacological approaches to prevention and treatment

Ongoing monitoring

Special issues

Grades of Recommendations and Evidence Hierarchy

Document Overview

Supplemental Implementation Resources

Document Scope, Criteria, and Use Cases