- New guidelines from the Endocrine Society for management of osteoporosis in postmenopausal women urge pharmacologic treatment of women with high fracture risk, especially women with a recent fracture.
- Pharmacologic treatment plans should also include nutritional, lifestyle, and fall prevention interventions and, except with anabolic therapy, calcium and vitamin D supplementation.
- Risk assessment of fracture in postmenopausal women should rely on country-specific tools.
- Bisphosphonates are recommended as first-line treatment, including alendronate, risedronate, zoledronic acid, and, except for nonvertebral or hip fracture risk, ibandronate.
- Reassess fracture risk after 3-5 years.
- Continue therapy if still high risk.
- Consider bisphosphonates “holiday” of 2-5 years without bisphosphonates if low-to-moderate risk.
- Restart bisphosphonates if fracture occurs, bone mineral density drops significantly, or other risk factors appear.
- Denosumab is alternative for bisphosphonates.
- Reassess fracture risk after 5-10 years; continue denosumab or change therapy if still high risk.
- Do not interrupt denosumab treatment and replace with antiresorptive if discontinuing.
- Teriparatide and abaloparatide recommended (up to 2 years) in women with very high fracture risk, including severe or multiple vertebral fractures.
- Raloxifene or bazedoxifene recommended in women with high fracture risk alongside a low risk of deep vein thrombosis, high risk of breast cancer, or inability to take bisphosphonates/denosumab.
- Menopausal hormone therapy—tibolone (except in U.S. or Canada) or estrogen—or calcitonin indicated for women with specific described characteristics and/or inability to tolerate other recommended drugs.
- Use dual-energy X-ray absorptiometry (DEXA) every 1-3 years to monitor bone mineral density in high-risk women receiving osteoporosis treatment.
- DEXA alternatives to assess therapy response or adherence include bone turnover markers.