Treatment and Management
Note: In this algorithm, we considered that a determination of fracture risk would include measurement of
lumbar spine and hip BMD, and inserting the total hip or femoral neck BMD value into the FRAX tool. Using
that FRAX algorithm, we define the following risk categories:
Low risk includes no prior hip or spine fractures, a BMD T-score at the hip and spine both above -1.0,
and 10-year hip fracture risk <3% and 10-year risk of major osteoporotic fractures <20%.
Figure 1. Algorithm for the Management of Postmenopausal Women
Intolerant to or
inappropriate for
above therapies
All Postmenopausal
1) Lifestyle and nutritional optimization
calcium and
2) Determine the 10-year fracture risk according
Low–Moderate Risk High–Very High Risk
Low Risk
Moderate
Risk
Reassess
fracture risk in
2–4 yrs
(2.1) Bisphosphonates
(2.2) Reassess fracture risk in
3-5 yrs
(2.2) (5 yrs for oral, 3 yrs for IV)
(8.1) Calcium + Vitamin D as
adjunct therapy
(3.1) Denosumab
(3.2) Reassess fracture
risk in 5-10 yrs
(8.1) Calcium + Vitamin
D as adjunct therapy
Low-Moderate Risk
(2.2) Consider a drug
holiday
(9.1) Reassess fracture
risk every 2-4 yrs
(2.2) If bone loss or
patient becomes high
risk, consider restarting
therapy
High Risk
(2.2) Continue
therapy or switch to
another therapy
Age <60 or <10 yrs
past menopause
Low VTE risk
Age >60
No Vasomotor
Symptoms High
Breast Cancer Risk
With Vasomotor
Symptoms
(5.1) SERM
(raloxifene,
bazedoxifene)
(6.1+ 6.2) HT (no uterus,
Estrogen; with uterus,
Estrogen + Progestin) or
Tibolone
OR
(4.2)
