Management of postmenopausal osteoporosis

Postmenopausal women experience ongoing loss of bone mass, with resulting increases in the risk of fracture. This review describes the nature of postmenopausal bone loss, the definition of osteoporosis, and the current status of fracture risk estimation, which is pivotal in osteoporosis management. Important lifestyle measures include taking a balanced diet to maintain a healthy weight throughout life, safe physical activity, not smoking, and moderating alcohol intake. Severe vitamin D deficiency accelerates bone loss so should be avoided. Falls prevention becomes increasingly important with age, since falls cause most fractures. Pharmaceuticals to increase bone mass and prevent fractures either act by inhibiting bone resorption or by stimulating bone formation. Bisphosphonates are the most widely used anti-resorptives, often taken as weekly oral doses. The intravenous bisphosphonate, zoledronate, has a long duration of action with effects on bone turnover, density and fractures over a decade after a single dose. It is increasingly used in both prevention and treatment of osteoporosis. Denosumab is effective in preventing fractures but has a rapid offset of effect after its cessation. Some anabolic agents act via the PTH1 receptor, producing substantial increases in spine bone density but are not yet proven to prevent hip fractures. Romosozumab is a monoclonal antibody directed at sclerostin. It has both anabolic and anti-resorptive effects, and shows broad anti-fracture efficacy. Anabolics are used for 1-2 years in those with high fracture risk, before transition to long-term anti-resorptive therapy. Treatment sequence options are discussed but more research is needed to establish which provide optimal fracture reduction.