Specific Therapy for Osteoporosis in Postmenopausal Women

In cases of osteoporotic fractures, additional pharmacological treatment is always necessary alongside basic therapy with vitamin D and calcium. Fractures also require effective pain management and physical therapy to improve function.

Before starting specific treatment, secondary causes of osteoporosis should be ruled out.
Medication is selected based on the T-score from bone density measurements.
Postmenopausal women at high risk of fractures, especially those who have recently experienced a fracture, should receive pharmacological treatment.

Bisphosphonates

Postmenopausal women at high risk of fractures should initially be treated with bisphosphonates (Alendronate, Risedronate, Zoledronic acid, and Ibandronate) to reduce fracture risk.

Women treated with bisphosphonates should have their fracture risk reassessed after 3–5 years.

• If the risk remains high: continue treatment.
• If the risk is low: treatment may be paused for five years.
• After treatment with Zoledronic acid, reassessment should occur after 3 years.

Denosumab

For postmenopausal women at high risk of osteoporotic fractures, Denosumab can be used as an alternative to bisphosphonates.

• Dosage: 60 mg subcutaneous injection every six months.
• Treatment should not be interrupted.
• Reassess fracture risk after 5–10 years.
• If the risk remains high: continue Denosumab or switch to another osteoporosis therapy.

When stopping Denosumab, patients should be switched to bisphosphonates, hormone therapy, or selective estrogen receptor modulators to prevent rapid bone loss and increased fracture risk.

Romosozumab

Recommended for postmenopausal women with very high fracture risk and severe osteoporosis (T-score < -2.5 and fractures) or multiple vertebral fractures.

• Treatment: 210 mg monthly as a subcutaneous injection for 12 months.
• Not recommended for women with high cardiovascular or stroke risk.
• After completing Romosozumab therapy, follow-up treatment is needed to maintain bone density gains and reduce fracture risk.

Menopausal Hormone Therapy and Tibolone

Postmenopausal women at high fracture risk but low risk of blood clots or breast cancer may be treated with selective estrogen receptor modulators (e.g., Raloxifene and Bazedoxifene), to reduce vertebral fracture risk.

Women who cannot tolerate bisphosphonates or Denosumab may be treated with hormone therapy.

• In women who had a hysterectomy, estrogen-only therapy is recommended.
• Candidates should be younger than 60 years, more than 10 years post-menopause, and at low risk for thrombosis, stroke, heart attack, or breast cancer.
• Patients must be willing to undergo hormone therapy.

Tibolone

Can be used in postmenopausal women with osteoporosis and high fracture risk who cannot tolerate bisphosphonates or Denosumab.

• Women should be under 60 years old, and more than 10 years post-menopause.
• Not recommended in women with high thrombotic or cardiovascular risk or a history of stroke, heart attack, or breast cancer.
• Tibolone is not available in the USA or Canada.

Calcitonin

Should only be prescribed if other medications (Raloxifene, Bisphosphonates, Estrogen, Denosumab, Tibolone, Abaloparatide, or Teriparatide) are not suitable.

Calcium and Vitamin D

Postmenopausal women at high risk for osteoporotic fractures and with low bone density should always receive vitamin D and calcium in addition to any medication.

If none of the standard treatments are appropriate, daily calcium and vitamin D should still be given to reduce the risk of hip and other fractures.

Bone density (DXA of the spine) should be checked every 1 to 3 years to evaluate treatment effectiveness.
Bone turnover markers (like C-terminal crosslinking telopeptide for antiresorptive therapy or procollagen type I N-terminal propeptide for anabolic therapy) can help detect poor response to therapy or non-adherence to medication.

Recommendations for Specific Drug Therapy

With Vertebral Fracture:
→ “Yes” – Immediate treatment is important due to a high risk of further vertebral fractures.