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2010 NAMS Recommendations for Managing Osteoporosis in Postmenopausal Women

Updates to the 2006 recommendations incorporate new findings.

The North American Menopause Society (NAMS) has updated its evidence-based position statement on osteoporosis in postmenopausal women. Osteoporosis is defined as a bone-mineral density (BMD) T-score 2.5 or the presence of a fragility fracture. Key recommendations are:

PREVENTION

Educate women about risk-reduction strategies: healthy nutrition, adequate calcium (1200 mg daily) and vitamin D (800–1000 IU daily) intake, exercise, and fall prevention.

Assess fall risk annually and when physical or mental status changes.

DETECTION

Assess height, weight, back pain, kyphosis, and clinical risk factors for osteoporosis (e.g., steroid use, hyperparathyroidism) annually.

Consider BMD testing in postmenopausal women who are 50 and have 1 of the following risk factors: fracture after menopause, body-mass index <21 kg/m² or weight <127 lbs, parental history of hip fracture, current smoking, rheumatoid arthritis, or excessive alcohol intake.

In the absence of these risk factors, BMD assessment should be performed at age 65.

Routine use of biochemical markers of bone turnover is not recommended.

TREATMENT

Initiate drug therapy (preferably with bisphosphonates as first-line agents) in all postmenopausal women who have any of the following: osteoporotic hip or vertebral fractures; dual x-ray absorptiometry (DXA)-defined osteoporosis; or T-scores from –1.0 to –2.5 and FRAX scores that indicate 3% 10-year risk for hip fracture or 20% 10-year overall osteoporotic fracture risk.

Assess treatment adherence barriers and promote adherence; provide clear information about fracture risk and treatment purpose.

Generally, treatment should span a period of years; fracture risk after discontinuation has not been adequately studied.

FOLLOW-UP BMD MEASUREMENT

Repeating BMD measurement after 1 to 2 years of treatment is appropriate; thereafter, repeated measurements are of little value in women with stable BMD. Measuring BMD is of limited use in predicting effectiveness of antiresorptive therapies for lowering fracture risk; moreover, changes in BMD can lag behind therapeutic benefits.

Measuring BMD in untreated women is not useful until 2 to 5 years after initial testing.

Comment: Many postmenopausal women who are younger than 65 and who have DXA-determined T-scores of –1.0 to –2.5 are prescribed bisphosphonates indefinitely, despite otherwise being at low risk for fractures. These updated NAMS guidelines emphasize that BMD should be assessed in women younger than 65 only when specific risk factors are present. In addition, FRAX evaluation allows 10-year fracture risk to be estimated in women who have low bone mass but who do not meet criteria for osteoporosis. For most women in their 50s and 60s who have low bone mass (but not osteoporosis), FRAX evaluation indicates that prescription therapy is not required. The NAMS recommendations for interval DXA scanning (i.e., one-time evaluation 1 to 2 years after initiating therapy and no further assessments thereafter in women with stable BMD) are useful, as DXA scanning tends to be overused in clinical practice. Guidelines from the American College of Obstetricians and Gynecologists (which predate the development of FRAX) and the National Osteoporosis Foundation also are available online.

— Diane E. Judge, APN/CNP

Published in Journal Watch Women's Health February 18, 2010

Citation(s):

Bonnick SL et al. Position statement: Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society. Menopause 2010 Jan/Feb; 17:25.

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Reader Remarks:

Review and add to remarks on this article

• Biochemical markers
  Darlene Orlov, 19 Feb 2010 11:40 AM EST
  Please explain why routine use of biochemical markers of bone turnover is not recommended.
• osteoporosis
  Michael A. van Straten, 19 Feb 2010 11:40 AM EST
  I am astounded that diet and vitamin D plus calcium supplementation are not included as part of the trearment guidelines.... [more]
• NAMS on osteopenia
  William Beckman, 19 Feb 2010 11:40 AM EST
  Predictable response from an organization wedded to big PHARMA. Please remember this is an OPINION paper. We safely use Vitamin... [more]
• Prevention?
  Bill B Wegesser PA-C, LDS Hospital SLC UT, 19 Feb 2010 11:40 AM EST
  I would suggest a baseline Vit D 25 OH level, and most folks will need 2000 to 3000 Int Units... [more]
• Osteoporosis managment
  Joseph M. Beals, Private office, 19 Feb 2010 11:40 AM EST
  Helpful guidelines
• male osteoporosis
  Robert W. Crane, retired, 22 Feb 2010 12:32 PM EST
  Almost no data on male osteroporosis. My radiologist even read my bone scan as showing "postmemopausal" osteoporosis in spite of... [more]
• efficacy of bisphosphonates
  Laurie L Goldman, South End Community Health Center, 22 Feb 2010 12:32 PM EST
  Article does not address the efficacy of bisphosphonates in fracture reduction in postmenopausal women with osteoporosis.
  
  Neither does it address... [more]
• 2010 Guidelines
  Victoria A Flaig, 22 Feb 2010 12:32 PM EST
  These guidelines are helpful in several areas but are incomplete and short sited for a chronic disease. Fracture patients obviously... [more]
• Many tools
  Kelly Latta, 23 Feb 2010 10:56 AM EST
  While it is often a knee jerk reaction to oppose Big Pharma, the issue is not who pays for the... [more]
• progesterone
  Pam McCarthy, massachusetts, 2 Mar 2010 1:54 PM EST
  Would Dr/Mr Beckman like to expand on the above comment regarding the use of progesterone. Could you privide data/ references?... [more]
• bisphosphonates
  Tamora Sadot, 12 Mar 2010 11:38 AM EST
  there should be more options than being prescribed bisphosphonates indefinitely

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