This is an update of the evidence-based position statement published by The North American Menopause Society (NAMS) in 2006 regarding the management of osteoporosis in postmenopausal women.

Osteoporosis, which is especially prevalent among older postmenopausal women, increases the risk of fractures. Hip and spine fractures are associated with particularly high morbidity and mortality in this population. Given the health implications of osteoporotic fractures, the primary goal of osteoporosis therapy is to prevent fractures, which is accomplished by slowing or stopping bone loss, maintaining bone strength, and minimizing or eliminating factors that may contribute to fractures.

Evaluation recommendations:

Your physician should evaluate your personal history of fractures, height, weight, kyphosis(extreme curvature of the upper back), smoking, and alcohol history. There should also be review of your age history of starting menstral cycle and when is ended.

BMD (Bone Mineral Density) evaluation recommendations:

NAMS recommends that BMD be measured in the following populations:

  • All women age 65 and over, regardless of clinical risk factors
  • Postmenopausal women with medical causes of bone loss (eg, steroid use, hyperparathyroidism), regardless of age
  • Postmenopausal women age 50 and over with additional risk factors (see below)
  • Postmenopausal women with a fragility fracture (eg, fracture from a fall from standing height)

Lifestyle Approach to treatment:
Lifestyle approaches alone may not be sufficient to prevent bone loss or reduce fracture risk, but they form the necessary foundation for pharmacologic approaches to the prevention or management of osteoporosis.

A balanced diet is important for bone development and maintenance, as well as for general health. Some populations, such as women over age 65, edentulous women, women with reduced appetites from any cause, or women who diet frequently or have eating disorders, may not consume adequate vitamins and minerals to maintain optimal bone mass.

Nutrition appropriately focuses on calcium and vitamin D, vitamin K, magnesium, protein, and isoflavones.
Evidence has established the role of adequate calcium intake in bone health, primarily in the development of peak bone mass and in preventing bone loss. The evidence for calcium's ability to reduce fracture risk is not as strong. However, in a 5-year, double-blind, placebo-controlled trial of postmenopausal women with a mean age of 75 years, the 830 women who were compliant with their calcium supplements had a significant reduction in the hazard ratio for fracture.
Vitamin D deficiency, now recognized as exceedingly widespread, will contribute as well to declining calcium absorption. Estrogen deficiency also appears to result in an increase in urinary calcium excretion. This combination of circumstances necessitates an increase in the daily calcium intake in women over age 50 and in the setting of estrogen deficiency.

Calcium supplements and calcium-fortified foods are additional sources of calcium for women unable to consume sufficient dietary calcium; most women will need an additional 600 to 900 mg/day over their usual daily intake to reach recommended levels. Calcium citrate supplements are well absorbed when taken with meals or on an empty stomach; calcium carbonate is better absorbed when taken with food. In all cases, it is best to take calcium in divided doses for better absorption. There appears to be no benefit to consumption of amounts in excess of 1,500 mg/day.

Vitamin D is actually a steroid prohormone rather than a vitamin, as it can be produced in the human body through the interaction of sunlight with the skin. Nevertheless, this nutrient is commonly characterized as a vitamin. The 1997 NAS-recommended dietary allowance (RDA) for vitamin D is 400 IU/day for women ages 51 to 70 and 600 IU/day for women older than age 70.[106] Current expert opinion, however, is that this intake level is inadequate to maintain vitamin D deficiency for optimum bone health.

Dietary sources of vitamin D are limited to fortified dairy products and fatty fish. Therefore, the use of a supplement containing vitamin D is the most practical means of addressing vitamin D sufficiency.

The NAS has established the upper limit of safe intake for vitamin D as 2,000 IU/day. However, many authorities consider this amount to be overly conservative. Doses greater than 10,000 IU/day may be associated with risks of hypercalciuria and hypercalcemia.

Magnesium :Another nutrient, magnesium, is sometimes mentioned as a necessary supplement for the protection of bone health and/or for absorption of calcium. The RDA for magnesium is 320 mg/day in women age 31 and older. Magnesium is plentiful in foods.  Green leafy vegetables, unpolished grains, and nuts are rich in magnesium.

Protein : For women older than age 75, data from the Framingham Osteoporosis Study, a longitudinal cohort study, suggest that adequate protein intake may help minimize bone loss. Dietary protein overall is positively linked to the maintenance of bone and muscle health. Therefore, some experts suggest that the current recommended intake of protein may be inadequate for optimum skeletal and muscle health

Isoflavones : Isoflavones are a class of phytoestrogens found in rich supply in soybeans, soy products, and red clover. Data suggesting any benefit of dietary isoflavones in the prevention or treatment of postmenopausal osteoporosis, regardless of the source, are relatively weak.

Exercise
Weight-bearing and strength-training exercises are beneficial to bone development and maintenance.
Extreme exercise is not necessary, however, to effect a bone benefit. Even mild forms of exercise that improve agility and balance can benefit the skeleton. Active weight-bearing or strength-training exercises can increase bone mass if they increase muscle mass and strength. Weight-bearing exercise can be as simple as brisk walking. Jogging or running provides impact-loading benefits to the skeleton. A meta-analysis found that postmenopausal women who exercised increased their spinal BMD by approximately 2%.

All postmenopausal women should be encouraged to employ lifestyle practices that reduce the risk of bone loss and osteoporotic fractures: maintaining a healthy weight, eating a balanced diet, obtaining adequate calcium and vitamin D, participating in appropriate exercise, avoiding excessive alcohol consumption, not smoking, and utilizing measures to prevent falls. Periodic reviews of calcium and vitamin D intake and lifestyle behaviors are useful. After menopause, a woman's risk of falls should be assessed annually and at any time her physical or mental status changes.


01/20/2010; Menopause. 2010;17(1):25-54. © 2010 The North American Menopause Society