Guideline sources The following summarized guidelines for the evaluation and management of postmenopausal osteoporosis are prepared by our editorial team based on guidelines from the American College of Physicians (ACP 2023), the American College of Obstetricians and Gynecologists (ACOG 2022; 2021), the American College of Endocrinology (ACE/AACE 2020), the Endocrine Society (ES 2020), the U.S. Preventive Services Task Force (USPSTF 2018), and the Osteoporosis Canada Foundation (OC 2010). 1 2 3 4 5 6 7 8 Guidelines 1. Screening and diagnosis Indications for screening: As per ACOG 2021 guidelines, screen for osteoporosis in 65 years old postmenopausal patients with bone mineral density testing to prevent osteoporotic fractures. A Show 2 more https://web.pathway.md/diseases/recjdaADto3rVuTTn 1/8 6/29/23, 11:21 PM Postmenopausal osteoporosis Pathway As per USPSTF 2018 guidelines, screen for osteoporosis in 65 years old females, and in younger females if the fracture risk is greater than or equal to that of a white female without additional risk factors at 65 years of age. B As per OC 2010 guidelines, assess for osteoporosis and fracture risk in all patients > 50 years of age experienced a fragility fracture. A Diagnostic criteria: Diagnose osteoporosis based on: presence of fragility fractures in the absence of other metabolic bone disorders, even with a normal bone mineral density B T-score -2.5 in the anteroposterior lumbar spine, femoral neck, total hip, or 1/3 radius, even in the absence of a prevalent fracture. B Show 2 more 2. Classification and risk stratification Risk stratification: evaluate the risk of osteoporosis in all 50 years old potmenopausal females. B Show 2 more 3. Diagnostic investigations Initial assessment: obtain a detailed history, perform physical examination and assess the clinical fracture risk using the WHO Fracture Risk Assessment Tool or other fracture risk assessment tool in the initial evaluation of patients with osteoporosis. B Bone mineral density testing: Consider obtaining bone mineral density testing based on clinical fracture risk profile. C Use axial DEXA measurement (lumbar spine and hip; 1/3 radius if indicated) for the bone mineral density measurement. B Vitamin D levels: obtain serum 25-hydroxyvitamin D levels in patients at risk for vitamin D insufficiency, particularly if having osteoporosis. B Bone turnover markers: consider obtaining bone turnover markers in the initial evaluation and follow-up of patients with osteoporosis. Recognize that elevated levels can predict more rapid rates of bone loss and higher fracture risk. B Evaluation for fractures: evaluate patients with osteoporosis for prevalent vertebral fractures. B Evaluation for secondary causes: As per ACOG 2022 guidelines, evaluate patients for secondary causes of bone loss before initiating pharmacotherapy for osteoporosis. E As per AACE 2020 guidelines, evaluate patients for causes of secondary osteoporosis. B 4. Medical management https://web.pathway.md/diseases/recjdaADto3rVuTTn 2/8 6/29/23, 11:21 PM Postmenopausal osteoporosis Pathway Indications for treatment: As per ACOG 2022 guidelines, initiate pharmacotherapy for osteoporosis in patients at high risk of fracture. A As per AACE 2020 guidelines, initiate pharmacologic therapy in patients with osteopenia or low bone mass and a history of fragility fracture of the hip or spine. A Show 2 more As per ES 2020 guidelines, initiate pharmacotherapy in postmenopausal patients with osteoporosis at high risk of fractures, especially in patients with a recent fracture. A Antiresorptive and anabolic therapy: As per ACP 2023 guidelines, initiate bisphosphonates for initial pharmacologic treatment to reduce the risk of fractures in postmenopausal patients with primary osteoporosis. A Show 3 more As per ACOG 2022 guidelines, initiate bisphosphonates as initial therapy in most postmenopausal patients at increased risk of fracture. A Show 5 more As per AACE 2020 guidelines, initiate alendronate, risedronate, or zoledronate as initial therapy to reduce hip, non-vertebral, and spine fractures in most patients with osteoporosis at high risk of fracture. A Show 5 more Landmark trials: Alendronate phase III osteoporosis treatment study In postmenopausal women with osteoporosis, alendronate was superior to placebo with respect to new vertebral fractures. Liberman UA et al. N Engl J Med. 1995 Nov 30. As per ES 2020 guidelines, initiate bisphosphonates (alendronate, risedronate, zoledronic acid, or ibandronate) as initial therapy to reduce fracture risk in postmenopausal patients with osteoporosis at high risk of fractures. A Show 10 more As per OC 2010 guidelines, initiate alendronate, risedronate, zoledronic acid, or denosumab as first-line therapy for the prevention of fractures in menopausal females requiring treatment for osteoporosis. A Show 16 more Duration of treatment: As per ACOG 2022 guidelines, consider discontinuing bisphosphonates to allow a drug holiday for low-to-moderate risk patients being stable after 5 years of treatment with oral bisphosphonates or after 3 years of therapy with IV zoledronic acid. Consider continuing treatment for longer durations of up to 10 years for oral bisphosphonates or up to 6 years for IV zoledronic acid in patients at high risk of fracture. C As per AACE 2020 guidelines, limit treatment with abaloparatide and teriparatide to 2 years and follow abaloparatide or teriparatide therapy with a bisphosphonate or denosumab. A https://web.pathway.md/diseases/recjdaADto3rVuTTn 3/8 6/29/23, 11:21 PM Postmenopausal osteoporosis Pathway Show 6 more 5. Nonpharmacologic interventions Lifestyle modifications: Advise patients: to maintain an active lifestyle, including weight-bearing, balance, and resistance exercises A to avoid or stop smoking B to limit alcohol intake to 2 units per day. B Physical activity: As per ACOG 2021 guidelines, offer routine aerobic physical activity (moderate-to-high impact) and weight-bearing exercises (muscle strengthening or exercise against resistance) to maintain bone health and prevent bone loss. B As per AACE 2020 guidelines, consider offering physical therapy to reduce discomfort, prevent falls, and improve quality of life in patients with osteoporosis. B Vitamin D supplementation: As per ACOG 2021 guidelines: Counsel patients to consume the recommended daily allowance of dietary vitamin D for bone health and general health. E Counsel patients receiving osteoporosis pharmacotherapy and patients with postmenopausal osteoporosis not tolerating pharmacotherapy to consume the recommended daily allowance of vitamin D through diet (preferably), supplementation, or both. E As per AACE 2020 guidelines, target serum 25-hydroxyvitamin D levels 30 ng/mL in patients with osteoporosis (preferable range, 30-50 ng/mL). A Show 2 more As per ES 2020 guidelines: Consider offering vitamin D supplementation as an adjunct to osteoporosis therapies in postmenopausal patients with low mineral density and at high risk of fractures with osteoporosis. C Offer daily vitamin D supplementation to prevent hip fractures in postmenopausal patients with osteoporosis at high risk of fractures unable to tolerate bisphosphonates, estrogen, selective estrogen response modulators, denosumab, tibolone, teriparatide, and abaloparatide. B As per USPSTF 2018 guidelines: Insufficient evidence to assess the balance of the benefits and harms of daily calcium supplementation at doses of > 1,000 mg for primary prevention of fractures in community- dwelling, postmenopausal females. I Do not offer daily calcium supplementation at doses of 1,000 mg for primary prevention of fractures in community-dwelling, postmenopausal females. D Calcium supplementation: As per ACOG 2021 guidelines: https://web.pathway.md/diseases/recjdaADto3rVuTTn 4/8 6/29/23, 11:21 PM Postmenopausal osteoporosis Pathway Counsel patients to consume the recommended daily allowance of dietary calcium for bone health and general health. E Counsel patients receiving osteoporosis pharmacotherapy and patients with postmenopausal osteoporosis not tolerating pharmacotherapy to consume the recommended daily allowance ofcalcium through diet (preferably), supplementation, or both. E As per AACE 2020 guidelines, advise patients to maintain adequate dietary intake of calcium, to a total intake (including diet plus supplement, if needed) of 1,200 mg/day for females aged 50 years. B As per ES 2020 guidelines: Consider offering calcium supplementation as an adjunct to osteoporosis therapies in postmenopausal patients with low mineral density and at high risk of fractures with osteoporosis. C Offer daily calcium supplementation to prevent hip fractures in postmenopausal patients with osteoporosis at high risk of fractures unable to tolerate bisphosphonates, estrogen, selective estrogen response modulators, denosumab, tibolone, teriparatide, and abaloparatide. B As per USPSTF 2018 guidelines: Insufficient evidence to assess the balance of the benefits and harms of vitamin D supplementation of > 400 IU/day for primary prevention of fractures in community-dwelling, postmenopausal females. I Do not offer vitamin D supplementation of 400 IU/day for primary prevention of fractures in community-dwelling, postmenopausal females. D 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 As per AACE 2020 guidelines, counsel patients on reducing risk of falls, particularly among the elderly. A https://web.pathway.md/diseases/recjdaADto3rVuTTn 5/8 6/29/23, 11:21 PM Postmenopausal osteoporosis Pathway 8. Follow-up and surveillance Indications for referral: evaluate and treat patients experiencing fragility fractures. Consider referring these patients to an osteoporosis specialist or a fracture liaison team, if available. B Show 4 more Assessment of treatment response: As per ACOG 2022 guidelines, consider obtaining dual energy X-ray absorptiometry testing every 1-3 years during osteoporosis pharmacotherapy, depending on clinical circumstances, until findings are stable. C As per AACE 2020 guidelines, regard stable or increasing bone mineral density with no evidence of new fractures or vertebral fracture progression as a response to therapy for osteoporosis. A Show 2 more As per ES 2020 guidelines, consider monitoring the bone mineral density by DEXA at the spine and hip every 1-3 years to assess the response to treatment in postmenopausal patients with a low bone mineral density and at high risk of fractures being treated for osteoporosis. C Follow-up: As per AACE 2020 guidelines, obtain a baseline axial (lumbar spine and hip; 1/3 radius if indicated) DEXA and repeat every 1-2 years until findings are stable. Consider obtaining 1/3 radius DEXA as an alternative site if the lumbar spine/hip are not evaluable or as an additional site in patients with primary hyperparathyroidism. Consider repeating it every 1-2 years or at a less frequent interval, depending on clinical circumstances. B Show 2 more As per ES 2020 guidelines: Reassess the fracture risk after 3-5 years in postmenopausal patients with osteoporosis taking bisphosphonates. Continue bisphosphonates in patients remaining at high risk of fractures and consider offering bisphosphonate holiday in patients at low-to-moderate risk of fractures. B Consider reassessing the fracture risk after 5-10 years in postmenopausal patients with osteoporsis taking denosumab. Decide on continuing denosumab or initiating other osteoporosis therapies in patients remaining at high risk of fractures. C Clinical findings Patient demographics Symptoms Age 65 Acute back pain Elderly age Loss of height Female sex Past obstetric history Past medical history Postmenopause Bone fracture Head and neck exam Fragility fracture https://web.pathway.md/diseases/recjdaADto3rVuTTn 6/8 6/29/23, 11:21 PM Postmenopausal osteoporosis Pathway tooth count Anthropomorphic exam Imaging findings weight lumbar spine T-score Musculoskeletal exam mid-third radius T-score Stooped posture total hip T-score femoral neck T-score Studies 2018 Zoledronate for osteopenia In postmenopausal women with osteopenia, zoledronate was superior to placebo with respect to fragility fracture. Reid IR et al. N Engl J Med. 2018 Dec 20. 1995 Alendronate phase III osteoporosis treatment study In postmenopausal women with osteoporosis, alendronate was superior to placebo with respect to new vertebral fractures. Liberman UA et al. N Engl J Med. 1995 Nov 30. References 1. Pauline M Camacho, Steven M Petak, Neil Binkley et al. 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Pharmacologic Treatment of Primary Osteoporosis or Low Bone Mass to Prevent Fractures in Adults: A Living Clinical Guideline From the American College of Physicians. Ann Intern Med. 2023 Jan 3. Online ahead of print. Open https://web.pathway.md/diseases/recjdaADto3rVuTTn 8/8