From fragility to resilience: Advancing early identification and management of osteoporosis in post-menopausal women

Dear Editor,

The decrease in estrogen levels associated with menopause significantly increases the risk of fractures in post-menopausal women. According to the International Osteoporosis Foundation, over 200 million women are currently affected by osteoporosis, with post-menopausal women being particularly susceptible to this condition. Shockingly, one in three women above the age of 50 years will experience a fracture related to osteoporosis during their lifetime. Furthermore, research has concluded that approximately 30% of women in America and Europe have osteoporosis.^1,2

Osteoporosis has a direct impact on the incidence of hip fractures, with post-menopausal women experiencing three to four times more hip fractures compared to pre-menopausal women. Vertebral fractures are also prevalent, affecting around 40% of post-menopausal women, while wrist and forearm fractures are common due to the impact of osteoporosis. ² The Bone Health & Osteoporosis Foundation (BHOF) reports that a 50-year-old woman has a 50% higher chance of suffering from an osteoporotic fracture compared to a younger woman. In addition, these fractures significantly increase the risk of death within 1 year due to complications arising from the fracture, affecting over 20% of older women. ¹ Various assessment tools—such as the Osteoporosis Self-Assessment Tool (OST), Simple Calculated Osteoporosis Risk Estimation Tool (SCORE), and the United States Preventive Services Task Force (USPSTF) guidelines—are widely used for evaluating osteoporosis.^1,2 However, studies have suggested that these assessment tools, particularly the USPSTF, often fail to identify most women with incident fractures between the ages of 50 and 64 years. ³ Therefore, there is a need for improved criteria for assessing the risk of osteoporosis.

In a study by Crandall et al., the importance of identifying post-menopausal women with traumatic or nontraumatic fractures was emphasized to determine how future fracture risk varies based on the initial fracture type. ³ This study underscores the significance of early identification and treatment of osteoporosis among post-menopausal women to prevent future fractures. Understanding the role of ethnicity and race can further enhance treatment outcomes and interventions, as these factors play a crucial role in determining Bone Mineral Density (BMD), an important parameter for assessing osteoporosis risk. ⁴ It is also important to consider the site of previous fractures as a predictor of future fracture risk. ⁵ Furthermore, physical activity data collected through the Women’s Health Initiative (WHI) Physical Activity Questionnaire, which encompasses various daily life activities in multiethnic samples, can contribute to reviewing and challenging current diagnostic approaches to osteoporosis.^6,7 It is recommended to ensure regular checkups of post-menopausal women with healthcare providers to effectively monitor treatment effectiveness and adjust interventions as needed. Lifestyle modifications and a proper diet can help reduce the risk of fractures. Balance exercises are beneficial in lowering the risk of falls and improving stability, while engaging in resistance training can strengthen muscles and bones. Medications such as selective estrogen receptor modulators (e.g. raloxifene), bisphosphonates (e.g. alendronate, risedronate), osteoanabolic agents (teriparatide and abaloparatide), and monoclonal antibodies (e.g. denosumab, romosozumab) can be prescribed to slow down bone loss. Furthermore, hormone replacement therapy (HRT) plays a crucial role in managing osteoporosis in post-menopausal women. Estrogen-only pill or progestin-only pill or combination estrogen/progestin pill helps in preventing bone loss and reduces the risk of fractures. However, the decision to use HRT should be individualized, considering the woman’s overall health and potential risks associated with long-term hormone use. BMD testing using dual-energy X-ray absorptiometry (DXA) scans can assist in identifying women with low bone mass, facilitating treatment decisions and monitoring progress.^6,7

In conclusion, the hormonal changes experienced during menopause significantly increase the risk of fractures in post-menopausal women. Osteoporosis poses a significant threat to the health and well-being of this population, with high prevalence rates worldwide. Early identification and treatment of osteoporosis are crucial in preventing fractures and their associated complications. Improved assessment tools and a comprehensive understanding of the impact of ethnicity and previous fracture sites can further enhance risk assessment and treatment strategies. Regular checkups, lifestyle modifications, exercise, and appropriate medications are key components in managing osteoporosis and reducing fracture risk.