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Who Should be treated?

Postmenopausal women who are at high risk for fracture should be treated with particularly women who have experienced a recent fracture.

Bisphosphonates: Bisphosphonates are recommended as the initial therapy in postmenopausal women at high risk for fractures. After 3 to 5 years of use, fracture risk should be reassessed.

Denosumab: Denosumab is recommended as an alternative initial treatment in postmenopausal women with osteoporosis and high fracture risk. Fracture risk should be reassessed after 5 to 10 years and therapy should be continued in women who remain at high risk.

Teriparatide and abaloparatide: Teriparatide or abaloparatide treatment is recommended for ≤2 years in postmenopausal women with osteoporosis at very high risk for fractures. To maintain improvements in bone mineral density (BMD), antiresorptive therapy should be prescribed after completing a course of teriparatide or abaloparatide.

Selective estrogen receptor modulators: Raloxifene or bazedoxifene are recommended to reduce the risk for vertebral fractures in postmenopausal women with osteoporosis and high fracture risk. Treatment should be initiated in women with a low risk for deep vein thrombosis for whom bisphosphonates or denosumab are not appropriate. Treatment with raloxifene has an added benefit of reducing incidence of breast cancer and may be particularly suitable for women at high risk for invasive estrogen receptor-positive breast cancer.

Hormonal therapy: To prevent fractures, menopausal hormone therapy is suggested for patients age <60 years or <10 years past menopause with bothersome vasomotor symptoms who have a low risk for deep vein thrombosis. Estrogen-only hormone therapy should be used in women with hysterectomy. Patients prescribed menopausal hormone therapy should not have breast cancer or a history or myocardial infarction or stroke.

Calcitonin: Nasal spray calcitonin can be prescribed to women who cannot tolerate raloxifene, bisphosphonates, estrogen, denosumab, tibolone, abaloparatide, or teriparatide.

Calcium and vitamin D: Calcium and vitamin D should be used as adjunct therapies to osteoporosis treatment in postmenopausal women with low BMD and high fracture risk. In women unable to tolerate other osteoporosis treatment, daily calcium and vitamin D supplementation is recommended to prevent hip fractures.


To assess response to treatment, dual-energy X-ray absorptiometry (DEXA) at the spine and hip should be performed every 1 to 3 years in postmenopausal women who have low BMD and high fracture risk

Considerations for long-term treatment

Drug holidays

There has been substantial research on long-term use of bisphosphonate therapy. Data indicate a residual effect after treatment stops, which supports bisphosphonate holidays. Bisphosphonate drug holidays are defined as temporary discontinuation of bisphosphonate for up to 5 years, but this period can be extended. After initiating a bisphosphonate holiday, fracture risk should be reassessed at 2- to 4-year intervals. Therapy should be reinitiated before the 5-year suggested maximum if there are changes in clinical risk status, such as a significant decline in BMD or an intervening fracture.

For medications other than bisphosphonates, benefits are quickly lost after discontinuation. Ending treatment with denosumab, for example, has been associated with loss of BMD and increased risk for vertebral fractures. As such, these therapies must be continued indefinitely or followed with bisphosphonates or an alternative to retain protective therapeutic benefits.

Atypical femoral fractures

A possible association between stress fractures of the femoral shaft and bisphosphonate therapy has been reported. This risk may be reduced by implementing a bisphosphonate drug holiday in patients at low to moderate risk for fracture.

Osteonecrosis of the jaw

Routine dental care is important for preventing osteonecrosis of the jaw in patients receiving antiresorptive therapy. The estimated absolute risk for osteonecrosis of the jaw in patients with osteoporosis was reported in 2015 to be between 0.0001% and 0.01%.

General preferences

Women receiving treatment for osteoporosis considered both the convenience of taking the medication and its impact on their daily routine. Efficacy and adverse events seemed to be considered equally. Cost and duration of treatment were found to be less important factors to choosing treatment. “When making decisions regarding who to treat, patient preferences and patient-specific clinical factors should be taken into account,” wrote the guideline authors.


Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2019;104(5):1-28.