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Postmenopausal osteoporosis

Key sources
The following summarized guidelines for the evaluation and management of postmenopausal osteoporosis are prepared by our editorial team based on guidelines from the Osteoporosis Canada (OC 2023), the American College of Physicians (ACP 2023), the Society of Obstetricians and Gynaecologists of Canada (SOGC 2023; 2022), the American College of Obstetricians and Gynecologists (ACOG 2022; 2021), the American College of Endocrinology (ACE/AACE 2020), the Endocrine Society (ES 2020), and the U.S. Preventive Services Task Force (USPSTF 2018).
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Guidelines

1.Screening and diagnosis

Indications for screening, >= 65 years, SOGC: obtain screening for increased fracture risk by clinical evaluation and bone mineral density assessment in all ≥ 65 years old females. Consider obtaining community-based screening in older females to reduce the incidence of hip fractures.
B
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  • Indications for screening (< 65 years)

  • Diagnostic criteria

2.Classification and risk stratification

Risk stratification: evaluate the risk of osteoporosis in all ≥ 50 years old postmenopausal females.
B
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3.Diagnostic investigations

Initial assessment
As per OC 2023 guidelines:
Consider using the FRAX tool as the preferred method for fracture risk estimation.
C
Identify risk factors and assess for signs of undiagnosed vertebral fractures in patients with osteoporosis.
E

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  • Bone mineral density testing

  • Vitamin D levels

  • Bone turnover markers

  • Evaluation of secondary causes

  • Evaluation for fractures

4.Medical management

Indications for treatment: as per OC 2023 guidelines, initiate pharmacotherapy in postmenopausal patients with any of the following:
previous hip, vertebra, or ≥ 2 osteoporosis-related fractures
A
a 10-year major osteoporotic fracture risk of ≥ 20%
B
≥ 70 years with a T-score ≤ -2.5 of the femoral neck, total hip, or lumbar spine.
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  • Antiresorptive and anabolic therapy (bisphosphonates)

  • Antiresorptive and anabolic therapy (denosumab)

  • Antiresorptive and anabolic therapy (PTH analogs)

  • Antiresorptive and anabolic therapy (romosozumab)

  • Antiresorptive and anabolic therapy (raloxifene)

  • Antiresorptive and anabolic therapy (calcitonin)

  • Antiresorptive and anabolic therapy (combination therapy)

  • Menopausal hormone therapy

5.Nonpharmacologic interventions

Lifestyle modifications: as per SOGC 2022 guidelines, advise in all patients with osteoporosis:
practicing daily weight-bearing exercises
A
smoking cessation
B
limiting alcohol intake.
B

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  • Physical activity

  • Vitamin D supplementation

  • Calcium supplementation

  • Other supplements

6.Surgical interventions

Vertebral augmentation: do not perform vertebroplasty or kyphoplasty as first-line treatment in patients with vertebral fractures, because of unclear benefit on overall pain and a potential increased risk of vertebral fractures in adjacent vertebrae.
D

7.Preventative measures

Prevention of falls
As per ACOG 2021 guidelines:
Assess risk of falls in postmenopausal patients with low bone mineral density or osteoporosis.
E
Offer fall prevention strategies, including weight-bearing and muscle-strengthening exercises, as well as individualized multifactorial interventions (such as vision assessment and treatment, balance training, and environmental assessment and modification) in patients at risk of falls.
E

8.Follow-up and surveillance

Indications for referral: as per OC 2023 guidelines, consult with a healthcare professional with expertise in osteoporosis (such as a family physician, general internist, endocrinologist, rheumatologist, or geriatrician) when uncertainty exists about fracture risk or treatment, such as possible secondary causes of osteoporosis, comorbidities complicating management, and important adverse effects from pharmacotherapy.
E

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  • Assessment of treatment response

  • Follow-up