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Premenopausal Osteoporosis
- Premenopausal fractures are rare and may be an important indicator of underlying poor bone quality and future fracture risk.
- Most premenopausal women with low trauma fracture(s) or low BMD have a secondary cause of osteoporosis or bone loss.
- Women who present with unexplained fractures or low BMD should have a thorough clinical and laboratory evaluation to search for known causes of fractures and/or bone loss.
- Measurement of BMD by DXA should not be used as the sole guide for diagnosis or treatment of osteoporosis in premenopausal women.
- Timing of peak BMD accrual and expected changes associated with pregnancy and lactation should be considered when interpreting BMD results obtained in premenopausal women.
- Evaluation of low trauma fractures or low BMD should include a thorough evaluation for potential secondary causes.
- Where possible, treatment of the underlying cause should be the focus of management.
- Premenopausal women with an ongoing cause of bone loss and those who have had, or continue to have, low trauma fractures may require pharmacologic intervention.
- Current guidelines from the Institute of Medicine47 recommend 1000 mg of calcium and 600 IU of vitamin D for premenopausal women
- Combination estrogen/progestin contraceptives can be considered (if not contraindicated) in premenopausal women with amenorrhea who are or will be treated with glucocorticoids.
- Clinical trials provide evidence of benefits of bisphosphonates and teriparatide for BMD in several types of premenopausal osteoporosis, but studies are small and do not provide evidence regarding fracture risk reduction.
- A fracture is considered low trauma if it is sustained in the setting of trauma equivalent to a fall from a standing height or less.
- Stress fractures occur in the context of continued skeletal stress and in the absence of a specific traumatic event.
Background Information
- Osteoporosis is less common in premenopausal women than in postmenopausal women.
- Both fractures and low bone mineral density (BMD), however, do occur in the premenopausal years, and young women with these conditions require specialized clinical considerations.
- Premenopausal fractures may be an important indicator of underlying poor bone quality and future fracture risk.
- Low trauma fractures in premenopausal women are usually related to known risk factors for bone fragility, called secondary causes of osteoporosis.
- Women with low BMD without a history of adult low trauma fracture and without a known cause can be said to have idiopathic low bone density.1 Based on current recommendations, such women should not be diagnosed with osteoporosis.
- BMD in premenopausal women depends primarily on achievement of peak bone mass.
- Attainment of peak bone mass varies according to:
- Gender23
- Ethnicity4
- Body size
- Menarchal age56
- Region of bone
- In healthy girls, the peak period of bone mass accrual occurs between ages 11 and 14,7 and the rate of bone mass accrual slows dramatically by approximately 2 years after menarche.2
- Although at least 90% of peak bone mass is acquired by the late teen years,789 studies have documented small additional gains between the ages of 20 and 29.10
- Moreover, population-based, cross-sectional studies suggest that the timing of peak bone mass accrual may be site specific,2 with women reaching peak bone mass at the proximal femur in their 20s and at the spine and forearm around age 30.11
- When interpreting BMD measurements in premenopausal women, the possibility that peak bone mass has not yet been achieved must always be considered.
- Low BMD in a premenopausal woman may result from the attainment of a peak bone mass that is below average due to genetic predisposition, illnesses, or medications that have a negative impact on bone density accrual.
- The factors responsible for the attainment of low peak bone mass may or may not remain active or measurable at the time of the evaluation.
- Low BMD in a premenopausal woman that is related to either genetic factors that determine peak bone mass or to a previously active secondary cause may not be associated with ongoing bone loss but could be associated with abnormal bone quality.
Epidemiology
How common is Premenopausal Osteoporosis?
- Fractures are substantially less common in premenopausal women than in postmenopausal women1112131415
- Data from the Study of Osteoporotic Fractures demonstrate that women with a history of premenopausal fracture are 35% more likely to fracture during the postmenopausal years compared with women without a history of premenopausal fracture12
- In a cross-sectional study of 1284 postmenopausal women in New Zealand, a history of fracture between ages 20 and 50 was associated with a 74% increased risk of fracture after age 50 years.15
Etiology and Risk Factors
What causes Premenopausal Osteoporosis?
- Studies of biochemical and bone remodeling characteristics suggest that the pathogenesis of idiopathic osteoporosis (IOP) is heterogeneous, with some women exhibiting evidence of low bone turnover whereas others have evidence of high bone turnover.
- Pathogenesis is likely to be diverse; causes, including excess urinary calcium excretion and insulin-like growth factor 1 (IGF-1) axis abnormalities, have been implicated.116
- Most premenopausal women with low trauma fractures or low BMD have an underlying disorder or medication exposure that has interfered with bone mass accrual during adolescence and/or has caused excessive bone loss after reaching peak bone mass.
- In a population study from Olmsted County, Minnesota, 90% of men and women ages 20 to 44 with osteoporotic fractures and low BMD were found to have a secondary cause.17
- In contrast, several case series of young women with osteoporosis from tertiary centers report that only 50% to 60% have secondary causes,181920 likely reflecting referral bias.
- Potential secondary causes are listed in the below table and fall into several broad categories:
- Estrogen deficiency
- Inflammatory diseases
- Collagen disorders
- Gastrointestinal diseases
- Glucocorticoids and other medication exposures
- Many diseases of childhood and young adulthood (eg, gastrointestinal diseases and inflammatory diseases) lead to osteoporosis through multifactorial mechanisms involving the combined effects of:
- Malnutrition
- Systemic inflammation
- Estrogen deficiency/delayed puberty
- Medication effects
- In some cases of low trauma fracture in premenopausal women, no known secondary cause can be found after extensive evaluation. These women are said to have IOP.
- Based on current guidelines, the term IOP applies only to those with a history of low trauma fractures and not to those with low BMD and no history of fractures.
- Table 1. Secondary causes of osteoporosis in premenopausal women
- Any childhood disease that has affected puberty and/or skeletal development
- Premenopausal amenorrhea (eg, pituitary diseases, medications, or exercise-induced amenorrhea)
- Anorexia nervosa
- Cushing syndrome
- Hyperthyroidism
- Primary hyperparathyroidism
- Vitamin D, calcium, and/or other nutrient deficiency
- Gastrointestinal malabsorption (celiac disease, inflammatory bowel disease, cystic fibrosis, or postoperative states)
- Rheumatoid arthritis, SLE, and other inflammatory conditions
- Connective tissue diseases, for example
- Osteogenesis imperfecta
- Marfan syndrome
- Ehlers-Danlos syndrome
- Diabetes mellitus (types 1 and 2)
- Renal disease
- Liver disease
- Hypercalciuria
- Alcoholism
- Other rare diseases, including mastocytosis, Gaucher disease, hemochromatosis, and hypophosphatasia
- Glucocorticoids
- Immunosuppressants (eg, cyclosporine)
- Antiepileptic drugs (in particular cytochrome P450 inducers, such as phenytoin and carbamazepine)
- Cancer chemotherapy
- GnRH agonists (when used to suppress ovulation)
- Depot medroxyprogesterone acetate (Depo-Provera)
- Heparin
- Other medications with probable relationships to osteoporosis: protein pump inhibitors, selective serotonin reuptake inhibitors, and low-molecular-weight heparin
Diagnosis
Approach to Diagnosis
- The main goal of the evaluation of a premenopausal woman with low trauma fractures or low BMD is to identify any secondary cause and to institute specific treatment of that cause if it is indicated.
- The diagnosis of osteoporosis in a premenopausal woman is most secure when there is a history of low trauma fracture.
- Clinical judgment is required to determine whether normal stress on fragile bone or excessive stress on normal bone has led to the pathology.
- As in all cases of unusual fracture, the diagnosis of osteoporosis should be considered only after osteomalacia (under mineralization due to causes such as severe vitamin D deficiency or hypophosphatemia) and other causes of pathologic fracture (eg, malignancy, avascular necrosis, fibrous dysplasia, and other bone lesion) have been ruled out.
- Low trauma fracture(s) in a premenopausal woman should lead to an evaluation that includes BMD testing and a thorough evaluation for potential secondary causes.
- Women with low BMD without a history of adult low trauma fracture and without a known cause can be said to have idiopathic low bone density.1 Based on current recommendations, such women should not be diagnosed with osteoporosis.
- Laboratory evaluation may target hormonal, calcium metabolism, or gastrointestinal disorders.
Workup
History
- Many secondary causes can be identified by a detailed history.
- Medical history should include information on:
- Adult and childhood fractures
- Adult and childhood illnesses and medication exposures
- Menstrual history
- Timing of recent pregnancy or lactation
- Dieting and exercise behavior
- Gastrointestinal symptoms
- Nephrolithiasis
- Family history of osteoporosis and/or nephrolithiasis
Physical Examination
- Many secondary causes can be identified by a detailed physical examination.
- Physical examination should seek signs of:
- Nutritional deficiency or eating disorder
- Cushing syndrome
- Thyroid hormone excess
- Connective tissue disorders (eg, osteogenesis imperfecta, Ehlers-Danlos syndrome, and Marfan syndrome)
- Inflammatory conditions (eg, rheumatoid arthritis and systemic lupus erythematosus [SLE])
Laboratory Tests
- Recommendations for an initial laboratory evaluation and a more extensive evaluation are given in the below table.
- The laboratory evaluation should aim to identify conditions such as:
- Vitamin D and/or calcium deficiency (and laboratory evidence that may distinguish osteomalacia from osteoporosis)
- Hyperthyroidism
- Hyperparathyroidism
- Cushing syndrome
- Early menopause
- Renal or liver disease
- Celiac disease and other forms of malabsorption
- Idiopathic hypercalciuria
- Bone turnover markers may be measured with the goal of distinguishing those likely to have stable BMD from those with an ongoing process of bone loss, who may have a higher short-term risk of fracture.
- Those with elevated bone turnover markers may also be more likely to have a diagnosable secondary cause.
- Bone turnover markers also increase after a fracture, however, and when bone turnover markers are assessed in women during very early adulthood, they may be elevated as a result of the active bone accrual occurring in that individual and may not reflect a process of bone loss.
- Laboratory evaluationInitial laboratory evaluation
- Complete blood cell count
- Electrolytes and renal function
- Serum calcium and phosphate
- Serum albumin, transaminases, and total alkaline phosphatase
- Serum thyroid-stimulating hormone
- Serum 25-hydroxyvitamin D
- PTH
- 24-Hour urine for calcium and creatinine
- Estradiol, luteinizing hormone, follicle-stimulating hormone, and prolactin
- Screening for Cushing syndrome: 24-hour urine for free cortisol (or dexamethasone suppression test)
- Celiac screen (serologies)
- Serum/urine protein electrophoresis
- Erythrocyte sedimentation rate or C-reactive protein
- Vitamin A/retinol level
- Specific testing for other rare conditions (eg, mastocytosis, Gaucher disease, hypophosphatasia, and hemochromatosis)
- If genetic diseases, such as Gaucher disease, hypophosphatasia or oesteogenesis imperfecta are considered, genetic testing may be pursued.
- Bone turnover markers
- Transiliac crest bone biopsy
Imaging Studies
- In postmenopausal women, BMD assessment by DXA is a cornerstone of fracture risk prediction models used for therapeutic decision making because of the wealth of longitudinal observational and interventional studies correlating DXA findings with fracture incidence in this population.
- In premenopausal women, cross-sectional studies have reported lower BMD by DXA in those with fractures.
- Premenopausal women with Colles fractures have been found to have significantly lower BMD at the nonfractured radius,21 lumbar spine, and femoral neck22 than controls without fractures.
- Female military recruits and athletes with stress fractures were also found to have lower BMD than controls.232425
- There are few longitudinal prospective studies, however, relating BMD by DXA to fracture risk in premenopausal women.
- Because of this, and because fracture rates are much lower in premenopausal than postmenopausal women,121415 the predictive relationship between BMD and short-term fracture incidence is unclear in premenopausal women.
- The World Health Organization Fracture Risk Assessment Tool provides fracture probability only for those aged 40 and above and is intended to be applied to postmenopausal women.
- For these reasons, measurement of BMD by DXA should not be used as the sole guide for diagnosis or treatment of osteoporosis in premenopausal women.
- Screening BMD by DXA is not recommended in premenopausal women.26
- BMD measurement is recommended in young women with a history of low trauma fracture and in those with known causes of bone loss (discussed later).
- Two organizations have provided guidelines regarding DXA interpretation in premenopausal women.
- The International Society for Clinical Densitometry (ISCD) recommends use of BMD Z scores (comparison to age-matched norms) rather than T scores (comparison to premenopausal norms) at the lumbar spine, hip, and forearm.26
- A Z score less than or equal to -2.0 should be interpreted as “below the expected range for age” and a Z score greater than -2.0 as “within the expected range for age.”26
- The diagnostic categories of “osteopenia” and “osteoporosis” based solely on BMD T score should not be applied in premenopausal women; however, T scores may be used in the perimenopausal period.
- The ISCD26 and others27282930 have recommended that young, otherwise healthy women should not be diagnosed with osteoporosis solely on the basis of low areal BMD (aBMD) by DXA unless there is a history of fragility fracture or a secondary cause of osteoporosis (discussed later).
- The International Society for Clinical Densitometry (ISCD) recommends use of BMD Z scores (comparison to age-matched norms) rather than T scores (comparison to premenopausal norms) at the lumbar spine, hip, and forearm.26
- The International Osteoporosis Foundation (IOF) recommends use of Z score less than -2 to define low bone mass in children, adolescents, those under 20 years, and some over 20 years in the context of delayed puberty.
- In contrast to ISCD, the IOF recommends use of T scores in those aged 20 to 50 years and suggests use of T score less than -2.5 to define osteoporosis, particularly in those with known secondary causes or in the context of low trauma fractures that provide evidence of bone fragility.31
Diagnostic Procedures
- Transiliac crest bone biopsy after double tetracycline labeling may be useful in certain clinical scenarios when it is necessary to examine bone remodeling, rule out osteomalacia, differentiate between different types of renal osteodystrophy, or complete an examination for rare secondary causes.
Treatment
Approach to Treatment
- The main goal of the evaluation of a premenopausal woman with low trauma fractures or low BMD is to identify any secondary cause and to institute specific treatment of that cause if it is indicated.
- Correction or treatment of several of these conditions has been associated with measurable BMD improvement in some populations, although some have not been specifically studied in premenopausal women, including:
- Anorexia nervosa32
- Estrogen deficiency
- Hypercalciuria33
- Celiac disease343536
- Crohn disease37
- Endogenous and iatrogenic hypercortisolism
- Hyperparathyroidism38
- For all patients, it is appropriate to recommend adequate:
- Weight-bearing exercise39
- Nutrition
- Calcium and vitamin D
- Lifestyle modifications, such as
- Smoking cessation
- Avoidance of excess alcohol
- In premenopausal women with isolated low BMD, no fractures, and no known secondary cause after thorough evaluation, pharmacologic therapy is rarely justified.
- Although these women may have bone microarchitectural abnormalities underlying their low BMD,140 they are expected to have stable BMD41 and a low short-term risk of fracture.
- In premenopausal women with a history of low trauma fracture and no known cause found after extensive evaluation, the use of medications to decrease fracture risk could be considered on a case-by-case basis.
- Fracture location and frequency as well as BMD trajectory should help guide treatment decisions.
- Few data are available to delineate the specific risks or benefits of medications for osteoporosis in women with IOP.
- In premenopausal women with low BMD or low trauma fractures and a known secondary cause of osteoporosis, the first goal of management should be to address the underlying cause.
- Bone density benefits have been shown in the context of intervention for several such secondary causes in premenopausal women:
- Estrogen replacement for those with estrogen deficiency424344
- Discontinuation of medications, for example, depot medroxyprogesterone acetate (Depo-Provera)4546
- Gluten-free diet for celiac disease343536
- Nutritional rehabilitation and weight gain for anorexia nervosa32
- Parathyroidectomy for primary hyperparathyroidism38
- Continuing or severe effects of the secondary cause may lead to a necessity for pharmacologic therapy.
- Bone density benefits have been shown in the context of intervention for several such secondary causes in premenopausal women:
- Combination estrogen/progestin contraceptives can be considered (if not contraindicated) in premenopausal women with amenorrhea who are or will be treated with glucocorticoids.
Nondrug and Supportive Care
- For all patients, it is appropriate to recommend adequate:
- Weight-bearing exercise39
- Nutrition
- Calcium and vitamin D
- Lifestyle modifications, such as
- Smoking cessation
- Avoidance of excess alcohol.
- Exercise recommendations must also be tailored to the individual patient, because excessive exercise in premenopausal women may lead to weight loss and/or hypothalamic amenorrhea, exacerbating low bone density.
Drug Therapy
- Current guidelines from the Institute of Medicine47 recommend 1000 mg of calcium and 600 IU of vitamin D for premenopausal women.
- These recommendations could be tailored to the individual based on evaluation of calcium metabolism
- Combination estrogen/progestin contraceptives can be considered (if not contraindicated) in premenopausal women with amenorrhea who are or will be treated with glucocorticoids.
- Alendronate, risedronate, and teriparatide have been approved by the FDA for use in women (including premenopausal women) receiving glucocorticoids.
- Few premenopausal women, however, participated in the relevant large registration trials for bisphosphonates and teriparatide in glucocorticoid-induced osteoporosis and none of the premenopausal women in those trials fractured.48495051
- Guidelines from the American College of Rheumatology suggest that bisphosphonates or teriparatide could be considered for premenopausal women of childbearing potential with a history of fragility fracture, if there is glucocorticoid exposure of at least 7.5 mg of prednisone or equivalent per day for greater than or equal to 3 months.52
- A study comparing teriparatide and alendronate for glucocorticoid-induced osteoporosis included some premenopausal women.
- Overall, teriparatide was associated with significantly greater increases in lumbar spine and total hip BMD and resulted in significantly fewer incident vertebral fractures than alendronate.53
- The BMD responses were similar in premenopausal women as in men and postmenopausal women, but no fractures occurred in either premenopausal group.48
- The effects of oral contraceptives on fracture risk are unclear.54
- Use of oral contraceptives to replace estrogen in those who are estrogen deficient may have beneficial effects on bone mass.424344
- Oral reproductive hormone replacement has been shown to be insufficient for the treatment of osteoporosis in anorexia nervosa, a more complex condition.324355
- A majority of studies of oral contraceptives in healthy premenopausal women without preexisting estrogen deficiency show no effect of oral contraceptives on bone mass.435456
- Some studies have also documented an adverse effect of low dose (<30 mg ethinyl estradiol) oral contraceptives on bone mass in very young women/adolescents.575859 Selective estrogen receptor modulators, such as raloxifene and tamoxifen, should not be used to treat bone loss in menstruating women because they block estrogen action on bone and lead to further bone loss.6061
- Bisphosphonates have been shown to improve BMD or prevent bone loss in young adults with several conditions, including:
- Pregnancy and lactation–associated fractures
- Breast cancer therapy
- Glucocorticoid therapy
- Anorexia nervosa
- Cystic fibrosis
- Thalassemia62636465666768697071
- In some cases, premenopausal women were studied specifically6263646566677071
- Two oral bisphosphonates, alendronate and risedronate, have been approved by the US Food and Drug Administration (FDA) for use in premenopausal women receiving glucocorticoids.
- Even though trials show favorable short-term BMD outcomes, fracture data are rarely available and long-term risks in premenopausal women are unknown.
- Bisphosphonates carry a category C rating for safety in pregnancy from the FDA because they accumulate in the skeleton, cross the placenta, and accumulate in the fetal skeleton in a rat model and have been reported to cause toxic effects in pregnant rats72
- Although a majority of published case reports have documented no adverse maternal and fetal outcomes,62737475 effective contraception should be encouraged during bisphosphonate use, and there is also the potential for adverse effects after stopping bisphosphonates, because they remain in the skeleton for years.
- The choice of bisphosphonates in younger women must also take into account increasing concerns about the potential risks of long-term use of these agents.7677
- In young women, plans for duration of bisphosphonate use must be discussed as part of the process of initiation of this therapy, and the goal should be for the shortest possible duration of bisphosphonate use.
- Denosumab is currently approved for the treatment of osteoporosis in postmenopausal women and men at high risk for fracture.
- Although denosumab may have some advantages in premenopausal populations because of its shorter half-life relative to bisphosphonates and lack of skeletal accumulation, the efficacy and safety of this medication have not been defined in premenopausal women.
- Denosumab, as marketed for osteoporosis, has been assigned a designation of pregnancy category X; animal studies indicate that denosumab may cause fetal harm.
- Teriparatide, or parathyroid hormone [PTH (1–34)], has been used successfully in clinical trials to prevent bone loss or increase BMD in:
- Premenopausal women on gonadotropin-releasing hormone (GnRH) agonists for the treatment of endometriosis78
- Premenopausal women taking glucocorticoids4853
- Premenopausal women with IOP7980
- Those with anorexia nervosa81
- In premenopausal women, FDA approval for use of teriparatide is currently encompassed under the FDA approval for the treatment of those with osteoporosis associated with sustained systemic glucocorticoid therapy at high risk for fracture.
- Because the long-term effects of teriparatide in young women are not known, use this medication should be reserved for those at highest risk for fracture or those who are experiencing recurrent fractures.
- In young women less than 25 years of age, documentation of fused epiphyses is recommended prior to consideration of teriparatide treatment.
Special Considerations
- Premenopausal women with idiopathic low bone density without fracture history. The currently available data suggest that young women with idiopathic low bone density and no fracture history are likely to have abnormal bone microarchitecture that is consistent with osteoporosis; this does not mean that such a finding should be used to make therapeutic decisions in premenopausal women as in postmenopausal women.
- This is because:
- Currently available data do not allow using BMD by DXA to predict fracture risk in premenopausal women
- Fracture risk depends greatly on age
- Few studies have addressed risks and benefits of osteoporosis medications in premenopausal women. Risks and benefits of osteoporosis medications are likely to differ in premenopausal women compared with postmenopausal women
- 3-D bone imaging and transiliac bone biopsy studies performed by the authors’ group, however, have shown that healthy, normally menstruating, premenopausal women with unexplained low BMD and no fractures (idiopathic low BMD) have micro architectural disruption and decreased estimated bone strength that is similar to a comparable cohort of premenopausal women with idiopathic low trauma fractures, even after correcting for bone size14082
- Data from a group of premenopausal women with constitutional thinness (very low body mass index, normal menses, and no known systemic disease), were found to have low BMD, smaller bone size, and decreased estimated breaking strength in comparison to normal women.83
- These studies are limited by their small sample size as well as the possibility of referral/ascertainment bias. Although these results may not be generalizable to all premenopausal women with low aBMD by DXA, they suggest that very low BMD may represent a presymptomatic phase of osteoporosis in premenopausal women.
- This is because:
Physiologic Changes Associated With Pregnancy and Lactation
- Changes in bone mass in association with both pregnancy and lactation have been reported in several studies.
- At the lumbar spine, longitudinal studies document losses of 3% to 5% during a pregnancy and 3% to 10% over a 6-month period of lactation,84 with recovery of bone mass demonstrated over 6 to 12 months thereafter, even in the setting of continued lactation.8586
- At the hip, bone loss of 2% to 4% has been documented over 6 months of lactation.84
- The amount of bone loss during lactation is directly associated with longer durations of lactation and postpartum amenorrhea.85868788
- Both human and rodent studies suggest that patterns of recovery of bone mass after weaning are site specific, with full recovery at the spine but only partial recovery at the femur.878990
- To date, however, longitudinal studies of BMD recovery in humans extend 12 months to 20 months postpartum.
- Longer duration of follow-up may be required to document the true degree of recovery.
- A majority of epidemiologic studies in humans suggest that the net effect of the loss and regain of bone mass during and after lactation does not affect postmenopausal bone mass or long-term fracture risk.919293
- Because of these physiologic bone mass changes associated with reproduction, interpretation of BMD results in premenopausal women must take into account the timing of any recent pregnancy or lactation.
- Based on available data, BMD at the lumbar spine is likely to have returned to that individual’s premenopausal baseline by 12 months’ postweaning.87
Pregnancy and Lactation-Associated Osteoporosis
- In some women, premenopausal osteoporosis may first present with low trauma fracture(s), usually at trabecular sites, such as the vertebrae, occurring in the last trimester of pregnancy or during lactation.62889495
- Given the physiologic bone mass changes described previously, pregnancy and lactation may represent particularly vulnerable times for the premenopausal woman’s skeleton, particularly if low BMD is present before pregnancy.
- Premenopausal fractures, however, including those associated with pregnancy and lactation, remain rare, suggesting that additional factors contribute to bone fragility in women who present with fractures during this time.
- Women with low trauma fractures sustained during pregnancy and/or lactation require the same thorough evaluation for secondary causes as do young women with fractures that are not associated with reproductive events.
Follow-up
Monitoring
- In premenopausal women with isolated low BMD, no fractures, and no known secondary cause after thorough evaluation.
- BMD should be measured at 1-year to 2-year intervals to identify women with declining BMD.
- Evidence of declining BMD in a premenopausal woman should lead to continued evaluation for secondary causes and, in rare cases, consideration of therapeutic options.
- Few data are available to guide treatment options for premenopausal women after teriparatide cessation.
- One study documented BMD gain in premenopausal women who resumed menses after cessation of both long-acting GnRH analog and PTH(1–34).96
- In a study of 13 premenopausal women with IOP and normal gonadal function followed for 2.0 years +/- 0.6 years after teriparatide cessation, BMD declined 4.2+/- 3.9% at the spine and remained stable at the hip.97
- This finding suggests that women with IOP require antiresorptive treatment to prevent bone loss after teriparatide.
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