The grades of evidence (I-III) and levels of recommendations (A-C) are defined at the end of "Major Recommendations" field.
The following recommendations are based on good and consistent scientific evidence (Level A):
- Treatment should be initiated to reduce fracture risk in postmenopausal women who have experienced a fragility or low-impact fracture.
- Treatment should be instituted in those postmenopausal women with bone mineral density T scores less than -2 by central dual-energy x-ray absorptiometry (DXA) in the absence of risk factors and in women with T scores less than -1.5 in the presence of 1 or more risk factors.
- First-line pharmacologic options determined by the U.S. Food and Drug Administration (FDA) to be safe and effective for osteoporosis prevention (bisphosphonates [alendronate and risedronate], raloxifene, and estrogen) should be used.
- First-line pharmacologic options determined by the FDA to be safe and effective for osteoporosis treatment (bisphosphonates [alendronate and risedronate], raloxifene, calcitonin, and parathyroid hormone [PTH]) should be used.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Women should be counseled about the following preventive measures:
- Adequate calcium consumption, using dietary supplements if dietary sources are not adequate
- Adequate vitamin D consumption (400 to 800 IU daily) and the natural sources of this nutrient
- Regular weight-bearing and muscle-strengthening exercises to reduce falls and prevent fractures
- Smoking cessation
- Moderation of alcohol intake
- Fall prevention strategies
- Bone mineral density testing should be recommended to all postmenopausal women aged 65 years or older.
- Bone mineral density testing may be recommended for postmenopausal women younger than 65 years who have 1 or more risk factors for osteoporosis (see box "Risk Factors for Osteoporotic Fracture in Postmenopausal Women," below).
- Bone mineral density testing should be performed on all postmenopausal women with fractures to confirm the diagnosis of osteoporosis and determine disease severity.
- In the absence of new risk factors, screening should not be performed more frequently than every 2 years.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Women should be counseled on the risks of osteoporosis and related fragility fractures. Such counseling should be part of the annual gynecologic examination.
Table. Risk Factors for Osteoporotic Fracture in Postmenopausal Women
- History of prior fracture
- Family history of osteoporosis
- Caucasian race
- Dementia
- Poor nutrition
- Smoking
- Low weight and body mass index
- Estrogen deficiency*
- Early menopause (age younger than 45 years) or bilateral oophorectomy
- Prolonged premenopausal amenorrhea (>1 year)
- Long-term low calcium intake
- Alcoholism
- Impaired eyesight despite adequate correction
- History of falls
- Inadequate physical activity
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*A patient's current use of hormone therapy does not preclude estrogen deficiency.
Data from Osteoporosis prevention, diagnosis, and therapy. NIH Consens Statement 2000;17(1):1-45.
Definitions:
Grades of Evidence
I: Evidence obtained from at least one properly designed randomized controlled trial
II-1: Evidence obtained from well-designed controlled trials without randomization
II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group
II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments also could be regarded as this type of evidence.
III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees
Levels of Recommendation
Level A — Recommendations are based on good and consistent scientific evidence.
Level B — Recommendations are based on limited or inconsistent scientific evidence.
Level C — Recommendations are based primarily on consensus and expert opinion.
