Management of Osteoporosis in Postmenopausal Women

The 2021 Position Statement of The North American Menopause Society

Menopause. 2021;28(9):973-997. 

In This Article

Abstract and Introduction


Objective: To review evidence regarding osteoporosis screening, prevention, diagnosis, and management in the past decade and update the position statement published by The North American Menopause Society (NAMS) in 2010 regarding the management of osteoporosis in postmenopausal women as new therapies and paradigms have become available.

Design: NAMS enlisted a panel of clinician experts in the field of metabolic bone diseases and/or women's health to review and update the 2010 NAMS position statement and recommendations on the basis of new evidence and clinical judgement. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

Results: Osteoporosis, especially prevalent in older postmenopausal women, increases the risk of fractures that can be associated with significant morbidity and mortality. Postmenopausal bone loss, related to estrogen deficiency, is the primary contributor to osteoporosis. Other important risk factors for postmenopausal osteoporosis include advanced age, genetics, smoking, thinness, and many diseases and drugs that impair bone health. An evaluation of these risk factors to identify candidates for osteoporosis screening and recommending nonpharmacologic measures such as good nutrition (especially adequate intake of protein, calcium, and vitamin D), regular physical activity, and avoiding smoking and excessive alcohol consumption are appropriate for all postmenopausal women. For women at high risk for osteoporosis, especially perimenopausal women with low bone density and other risk factors, estrogen or other therapies are available to prevent bone loss. For women with osteoporosis and/or other risk factors for fracture, including advanced age and previous fractures, the primary goal of therapy is to prevent new fractures. This is accomplished by combining nonpharmacologic measures, drugs to increase bone density and to improve bone strength, and strategies to reduce fall risk. If pharmacologic therapy is indicated, government-approved options include estrogen agonists/antagonists, bisphosphonates, RANK ligand inhibitors, parathyroid hormone-receptor agonists, and inhibitors of sclerostin.

Conclusions: Osteoporosis is a common disorder in postmenopausal women. Management of skeletal health in postmenopausal women involves assessing risk factors for fracture, reducing modifiable risk factors through dietary and lifestyle changes, and the use of pharmacologic therapy for patients at significant risk of osteoporosis or fracture. For women with osteoporosis, lifelong management is necessary. Treatment decisions occur continuously over the lifespan of a postmenopausal woman. Decisions must be individualized and should include the patient in the process of shared decision-making.


Osteoporosis can be a serious health threat for postmenopausal women by predisposing them to fractures that may be associated with substantial morbidity and mortality, especially in older women. Clinical management cannot be defined or confined only by "evidence." There is no single or optimal management strategy for a chronic disorder such as osteoporosis. When evidence is lacking, clinicians use clinical judgement, consisting of individualized management decisions for each patient and for different stages in the course of the disease and based on a combination of known evidence, knowledge of the physiology of the problem being addressed, and their experience.[1]

The North American Menopause Society (NAMS) creates position statements on specific disorders to provide reliable and accurate information regarding management of menopause-associated health conditions. Here, NAMS provides guidance on the diagnosis, assessment, prevention, and treatment of osteoporosis in postmenopausal women in North America.

The recommendations herein are based, where possible, on evidence provided by clinical trials and, where evidence does not exist, current best clinical practice in the opinions and clinical judgment of an editorial panel consisting of clinicians and researchers with expertise in metabolic bone diseases or women's health. These statements do not represent guidelines or codified practice standards as defined by regulating bodies and insurance agencies. Rather, the editorial panel has attempted to provide sufficient information for clinicians to approach postmenopausal women with or at risk for osteoporosis with a confident understanding of management options. The recommendations are focused on the perceptions of the needs of healthcare professionals caring for the skeletal health of postmenopausal women in the primary care setting. The guidance provided herein is generally consistent with recommendations for the assessment and treatment of postmenopausal osteoporosis available from several other North American societies and organizations.[2–8]

This position statement is an update of the 2010 position statement, "Management of Osteoporosis in Postmenopausal Women."[9] Since then, several new medications with sophisticated mechanisms of action have received government approval on the basis of randomized, controlled trial (RCT) data. In addition, new knowledge about the pathophysiology and epidemiology of postmenopausal osteoporosis has become available, as have new perspectives about the role of hormone therapy (HT) in the management of skeletal health, longer experience with the efficacy and safety of older osteoporosis drugs, the potential role of drug holidays for bisphosphonates, and new paradigms regarding sequential use of and anabolic and antiremodeling osteoporosis therapies. These advances have created the need to update the position statement.