MHT and IV bisphosphonates are key to improving bone density and reducing fracture risk in early menopause
Women experiencing early menopause need screening for osteoporosis and fractures and should be treated with MHT and intravenous bisphosphonates, according to one expert.
In addition, knowing when to screen and treat younger women with other risk factors for osteoporosis is challenging, as most risk predictors are only applicable to older women.
Speaking to delegates at the Australasian Menopause Society in New Zealand last month, Dr Susannah O’Sullivan, an endocrinologist with a particular interest in osteoporosis, shared how she approaches working with this group of patients.
“Once you begin monitoring and treatment, that’s for the rest of the patient’s life. You need to balance the desire to prevent irreversible bone loss [with] not starting treatment so early that they get no benefit from it [and instead] incur the morbidity and side effects of treatment,” Dr O’Sullivan said.
Dr O’Sullivan encouraged a targeted approach, homing in on those with osteoporosis and/or an immediate fracture risk, and those with an increased lifetime risk of osteoporosis and fracture.
Those were two groups who would reap the benefits of treatment while minimising the negative consequences, she said.
Common risk factors for osteoporosis and fracture include a personal or parental history of fractures, smoking, low body weight, excessive alcohol consumption, low peak bone mass, low bone mass density and early menopause.
Dr O’Sullivan recommended commencing treatment, or at least discussing potential treatment options, in women with osteoporosis and an increased fracture risk as soon as possible. Patients with osteoporosis but no immediate risk factors should have their bone turnover and density levels (re)assessed to determine whether they have an increased rate of bone loss and therefore warrant treatment.
Patients without osteoporosis but with an increased fracture risk should also have their bone turnover and density levels checked, and those with an increased rate of bone loss should begin treatment. Patients without osteoporosis or any of the relevant risk factors can continue with routine bone density monitoring.
Dr O’Sullivan recommended MHT and intravenous bisphosphonates as first-line treatment options.
“MHT is my preference in this young treatment group because it treats symptoms other than bone density. But be mindful that the dose you need to treat symptoms might not be enough to maintain bone density,” said Dr O’Sullivan.
A secondary treatment option may be required as the benefits seen in the first post-menopause decade may not persist in later life, she added.
“Intravenous bisphosphonates are appealing because you might be able to give them three-to-five yearly, but you need to be mindful of the acute phase reaction,” she told delegates.
Denosumab and oral bisphosphonates should be viewed as second-line options due to the lack of evidence supporting their long-term efficacy and safety in younger women, according to Dr O’Sullivan.
Non-pharmacological measures for preventing bone loss, such as adequate dietary calcium and sun exposure, regular weight bearing exercise and maintaining a healthy BMI, were also recommended.
