Guideline No. 422g: Menopause and Osteoporosis

Objective Provide strategies for improving the care of perimenopausal and postmenopausal women based on the most recent published evidence. Target Population Perimenopausal and postmenopausal women. Benefits, Harms, and Costs Target population will benefit from the most recent published scientific evidence provided via the information from their health care provider. No harms or costs are involved with this information since women will have the opportunity to choose among the different therapeutic options for the management of the symptoms and morbidities associated with menopause, including the option to choose no treatment. Evidence Databases consulted were PubMed, MEDLINE, and the Cochrane Library for the years 2002–2020, and MeSH search terms were specific for each topic developed through the 7 chapters. Validation Methods The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). Intended Audience physicians, including gynaecologists, obstetricians, family physicians, internists, emergency medicine specialists; nurses, including registered nurses and nurse practitioners; pharmacists; medical trainees, including medical students, residents, fellows; and other providers of health care for the target population. SUMMARY STATEMENTS 1Secondary causes of bone loss should be excluded before confirming the presence of postmenopausal osteoporosis (moderate). 2The Fracture Risk Assessment Tool (FRAX) can be used to evaluate 10-year fracture risk (high). Alternatively, the Canadian Association of Radiologists and Osteoporosis Canada (CAROC) assessment tool may be used to evaluate the 10-year fracture risk (moderate). 3Ensure patients with postmenopausal osteoporosis receive a calcium-enriched diet (1200 mg elemental calcium daily) and adequate vitamin D supplementation, aiming for a 25-hydroxyvitamin D level of 75–125 nmol/L (30–50 ng/mL) (high). 4Health care providers should treat all patients with osteoporosis at intermediate risk with a 10%–20% risk of major osteoporotic fracture over the next 10 years with pharmacologic therapy (high). 5Health care providers should treat all patients at high risk of fracture (with a ≥20% risk of MOF or ≥3% risk of hip fracture over the next 10 years with pharmacologic therapy (high). 6Health care providers should treat all patients at very high fracture risk (recent fracture within the past 12 months or multiple fragility fractures or major osteoporotic fracture risk >30% or hip fracture risk >4.5%) preferably with an anabolic agent followed by an antiresorptive agent (moderate). 7Patients taking bisphosphonates should be considered for a bisphosphonate drug holiday after 5 years of bisphosphonate therapy, if the fracture risk is intermediate and femoral neck T-score is better than –2.5 and in the absence of prior fragility fracture (moderate). 8Atypical femoral fractures are associated with long-term bisphosphonate therapy and are uncommon. It is important to ask about thigh or groin pain in patients on antiresorptive therapy and the antiresorptive therapy should be stopped in the presence of an atypical femoral fracture (moderate). 9Osteonecrosis of the jaw is a rare complication of antiresorptive therapy, and the incidence seen in patients prescribed antiresorptive therapy ranges from 1 in 10 000 to 1 in 100 000 patient-years (high). 10Romosozumab, teriparatide, or denosumab should not be stopped without replacing these agents with an antiresorptive agent in order to prevent declines in bone mineral density and bone strength following cessation of drug therapy. (high). RECOMMENDATIONS 1All adults ≥65 years should be screened for increased fracture risk by clinical evaluation and bone mineral density assessment. Community-based screening in older women may be effective in reducing the incidence of hip fracture (conditional, moderate). 2In postmenopausal women <65 years, evaluate fracture risk clinically without bone mineral density assessment (FRAX without bone mineral density). A bone mineral density assessment should be considered for patients with diseases or drugs associated with an increased risk of fracture or in the presence of a prior fragility fracture (conditional, low). If the FRAX score for MOF without bone mineral density is >10%, a bone mineral density assessment should also be considered. 3All patients with osteoporosis should be treated. After a fragility fracture, the risk of a subsequent fracture is highest in the next 12–24 months (imminent fracture risk). Pharmacologic therapy should be initiated after a fragility fracture without delay. (strong, high). 4Bisphosphonates may be offered to patients with osteoporosis at an intermediate risk of fracture in the absence of contraindications, ideally for up to 5 years (strong, high). Fracture risk should be revaluated after 3 to 5 years of bisphosphonate therapy, and a drug holiday should be considered (strong, moderate). 5Denosumab may be offered for up to 10 years in patients at high or very high risk of fracture in the presence of a normal serum calcium (adjusted for albumin or ionized calcium), normal vitamin D, and estimated glomerular filtration rate (eGFR) >15 mL/min/1.73 m2. If denosumab is discontinued, it should be replaced with an alternative treatment option (strong, high). 6Romosozumab may be offered to those at high or very high risk of fracture for up to 1 year (strong, high). After 1 year of therapy, romosozumab should be followed by an antiresorptive agent (strong, moderate). Romosozumab is contraindicated in the presence of a recent myocardial infarction or stroke or for patients with a high risk for major adverse cardiovascular events. 7Teriparatide or abaloparatide (for up to 2 years) may be offered to patients with a high or very high risk of fracture and should be followed by an antiresorptive agent (strong, high). Teriparatide and abaloparatide are not advised in patients with a history of cancer, radiation exposure, hypercalcemia, or hyperparathyroidism. 8Raloxifene or bazedoxifene may be offered to postmenopausal women with an intermediate risk of fracture who are at increased risk of breast cancer and at low risk of thromboembolic disease (conditional, ungraded). 9Menopausal hormone therapy may be given to postmenopausal women experiencing menopausal symptoms at low, intermediate, or high fracture risk if they are under the age of 60 years, with no history of breast cancer or thromboembolic disease and at a low risk of cerebrovascular or cardiovascular disease (conditional, moderate). 10A daily weight-bearing exercise program, as well as a calcium-enriched diet with adequate vitamin D supplementation, are advised (strong, high). Limitation of alcohol intake and smoking cessation should also be emphasized (strong, moderate).