Menopause and osteoporosis: Epidemiology, pathophysiology, screening and diagnosis.

Menopause and osteoporosis: Non-pharmacological and pharmacological management.

BACKGROUND Once osteoporosis has been identified, risk stratification is followed by non- pharmacological and, where needed, pharmacological management, which may include menopausal hormone therapy (MHT) where indicated. OBJECTIVE This article will build on general practitioners' skills in stratifying fracture risk, supporting their patients to maintain bone health and preventing osteoporotic fracture by instigating lifestyle changes along with appropriate pharmacotherapy. DISCUSSION Risk stratification entails integrating fracture history, bone density and FRAX risk into The Royal Australian College of General Practitioners' official modified flowchart. Non-pharmacological treatments, such as ensuring adequate calcium intake and vitamin D sufficiency, form the basis of bone health maintenance. MHT should be considered in women aged <65 years with T-scores between -1.8 and -2.5. Pharmacotherapy is integral to fracture prevention in osteoporosis. Those at very high fracture risk may need a referral to a consultant physician for consideration of bone anabolic therapy.

Male osteoporosis: pathophysiology, risk assessment, and evidence-based management

Effective care in cases of male osteoporosis requires an integrated risk-based approach that extends beyond BMD to include clinical risk factors, secondary causes, and functional status, and improved recognition and sex-specific management strategies are essential to reduce the fracture burden and improve long-term outcomes in men.

Osteoporosis screening in diabetic postmenopausal women: a neglected priority

Madam, Osteoporosis screening is widely recommended for postmenopausal women; however, its implementation remains suboptimal in many developing countries, including Pakistan. In most cases, diagnosis is only made after the occurrence of a fracture. The coexistence of type 2 diabetes mellitus (T2DM) further complicates this situation, presenting a clinical paradox: despite normal or elevated bone mineral density (BMD) in diabetic patients, fracture risk remains significantly increased.1 Evidence suggests that between 20% and 49.3% of women in Pakistan suffer from osteoporosis post menopause.2 On the other hand, a meta-analysis of 21 studies comprising 11,603 patients with T2DM recorded an overall osteoporosis prevalence of 27.67%.3 Additionally, a cross-sectional study carried out in Karachi showed that 41.5 % of the women diagnosed with osteoporosis had concomitant T2DM.4 In patients with T2DM, relative hyperinsulinemia may exert anabolic effects on bone, contributing to higher BMD. Despite this, chronic hyperglycaemia ensues leading to accumulation of advanced glycation end products within collagen, compromising bone microarchitecture and mechanical strength. Additionally, diabetes-associated microvascular disease and an increased propensity for falls further contribute to skeletal fragility.3 This apparent contradiction is precisely what limits the use of Dual- Energy X-ray Absorptiometry (DXA) scan as a sole diagnostic tool in this subgroup.3 Moreover, the conventional Fracture Risk Assessment Tool (FRAX) does not include diabetes as a risk factor, potentially underestimating fracture risk, and the chances of early detection. 3 In a country where osteoporosis screening is already inadequate, following a pragmatic and targeted approach by focusing on high-risk subgroups such as postmenopausal women with T2DM may be more practicable. Early risk counselling at the time of menopause or diabetes diagnosis, patient education regarding fracture susceptibility, encouraging weight-bearing exercise and adequate nutrition, and routine fall risk assessment may prove to be cost-effective first steps. For those identified as at higher risk, timely referral for DXA scanning, with careful interpretation of FRAX scores, and adjunctive tools such as trabecular bone score where available, may help reduce fracture-associated morbidity.

Osteoporosis Diagnosis and Management: A Review from an Orthopedic Perspective

This review synthesizes international guidelines and recent literature to provide a practical framework for DEXA interpretation, laboratory integration, and holistic management aimed at reducing refracture risk, improving functional outcomes, and lowering healthcare costs.

Treatment of osteoporosis in clinical practice: when, whom, how, and for how long.

Osteoporosis is a highly prevalent chronic disease associated with an increased risk of fragility fractures and a substantial clinical and socioeconomic burden. Its management is based on fracture risk stratification, integrating clinical risk factors, bone mineral density, and tools such as FRAX®. Previous fragility fracture is the strongest predictor of future fractures and, in most cases, indicates the need for pharmacological treatment. In patients at high risk, antiresorptive agents remain the cornerstone of therapy, whereas in those at very high risk, an initial anabolic strategy followed by antiresorptive treatment should be considered. Treatment duration and sequencing require periodic reassessment, particularly with bisphosphonates and denosumab, whose discontinuation must be carefully planned to avoid rebound effects. This practical approach allows individualized clinical decision-making and aims to optimize fracture prevention, treatment adherence, and long-term outcomes in patients with osteoporosis in routine clinical practice settings.

Prioritizing the heart, neglecting the bones: The hidden impact of diabetes on skeletal health