Article by Dr Ramiya Al-Alousi. Dr Al-Alousi’s article was first published in Her Life Her Health. The Primary Care Women’s Health Forum is bringing the Her Life Her Health publication to life at Her Life Her Health: The Virtual Event on Friday 17 September. Click here for more details.

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With figures showing as many as 1 in 2 women over the age of 50 years are sustaining a potentially preventable fragility fracture1, it becomes paramount that more focus is given to optimising bone health. The resulting aftermath of such fractures is that of disability, pain, loss of confidence and increased mortality, with a staggering estimated annual cost to the NHS of £4.4 billion2. The risk of osteoporotic fractures increases steeply in women after the age of 65 years with around a third of patients who sustain hip fractures dying within the following 12 months3.

NICE recommends that all women over the age of 65 undergo a fracture risk assessment4. There are numerous factors that increase this risk further including untreated early menopause, parental hip fracture, alcohol of 3 or more units daily and chronic health conditions. Various medications accentuate the problem such as long-term SSRIs/PPIs, antiepileptic drugs, and steroids.

Treatment options

First line:

  • Bisphosphonates have anti-resorptive effects with varying strengths, the most potent oral therapy being alendronate, and parentally being zoledronate5. Poor compliance with oral medications is a key reason for treatment failure. Strategies to improve this include detailed counselling on how to take, expected side effects and duration of treatment. The Royal Osteoporosis Society (ROS) suggests follow-up within 4 months and then annually1 where adherence is checked and reinforced similar to the management of other silent conditions like hypertension.

Second line:

  • Denosumab, a monoclonal antibody that inhibits osteoclasts, is administered as a 60mg 6-monthly subcutaneous injection. The MHRA emphasised the risk of multiple rebound and potentially life-changing vertebral fractures after stopping or delaying denosumab treatment6. Timely injections, which can now be self-injected, are crucial as is switching to bisphosphonates when discontinuing treatment.
  • Teriparatide, a recombinant form of parathyroid hormone with bone forming effects, is given as a daily 20µg subcutaneous injection over two years. In those with severe spinal osteoporosis, SIGN highlights superior outcomes if this is used first line before transition onto bisphosphonates. Consider this in women with T score <-1.5 and two or more moderate vertebral fractures on x-ray, or a spinal BMD of <-4.05.

Other options:

  • The British Menopause Society advocates that HRT could be a first-line treatment for osteoporosis in healthy women under 60 years if benefit outweighs risks, but does not recommend this solely for osteoporosis management in women over this age7.
  • HRT/Tibolone can be used if there are coexisting menopausal symptoms and after appropriate risk/benefit counselling. Bone conserving effect at all sites can be achieved from even low doses of 0.5mg estradiol daily8 which may be more suitable if being considered in the older postmenopausal woman. Benefits wear off soon after treatment cessation although long-term effects have been shown if HRT is given at the time of menopause7.

Strontium ranelate and raloxifene have a limited role reserved for women who cannot use other osteoporosis medications, and are associated with increased VTE and cardiovascular risk5.

The impact of COVID-19

According to the Royal Osteoporosis Society (ROS), there has been a significant drop in the administration of injectable drugs during 20209, with denosumab delays in particular carrying stark effects on further fracture potential. With restrictions resulting in reduced physical activity and sunlight exposure, the rapid deconditioning that ensues has amplified the risk of falls and therefore fractures. This is further heightened by decreased uptake of online fracture risk assessments and follow-up of all fragility fractures causing an overall under-diagnosis of osteoporosis. The effects of COVID-19 are therefore prominent and will be evident for many years to come. ROS offers a wealth of resources and a helpline for professionals or patients run by specialist nurses which can provide much needed support during these ongoing challenges.

Top Tips

  1. Review the need for medications like SSRIs/PPIs - consider stopping if appropriate
  2. Always think of vertebral fractures in back pain presentations – these are underdiagnosed and almost always signify osteoporosis
  3. To protect against the rapid bone loss with steroid initiation, consider starting bone protection in patients with high fracture risk at the onset of steroid therapy if ≥7.5mg/day or equivalent for ≥3months
  4. Check if there is a Fracture Liaison Service in your area – this provides multidisciplinary and cost-effective care for secondary fracture prevention.5


  1. ROS 2017. Quality standards for osteoporosis and prevention of fragility fractures. 
  2. NOGG 2017. Clinical guideline for the prevention and treatment of osteoporosis. 
  3. NICE 2017. Hip fracture: management. 
  4. NICE CKS 2020. Osteoporosis – prevention of fragility fractures.
  5. SIGN 145. 2020. Management of osteoporosis and the prevention of fragility fractures. 
  6. MHRA 2020. 
  7. Hillard et al. 2017. Management of the menopause. 6th British Menopause Society.
  8. Marco Gambacciani M, et al. 2008. Ultra low-dose hormone replacement therapy and bone protection in postmenopausal women. Maturitas. 2008 Jan 20;59(1):2-6.  
  9. ROS 2020. Delivering core NHS and care services during the pandemic and beyond. 

This article originally appeared in the Spring 2021 edition of Her Life Her Health and is reproduced with permission from the Primary Care Women's Health Forum.


Go to the profile of Janet Kyriakides
11 months ago

This was helpful 

Review  the need for long term SSRI and PPI