Premenopausal Bone Health: Osteoporosis in Premenopausal Women Original paper

What was reviewed?

This review article comprehensively addresses the diagnosis, evaluation, and management of osteoporosis in premenopausal women, emphasizing the unique considerations in this population compared to postmenopausal women. The authors discuss the significance of low-trauma fractures and low bone mineral density (BMD) in premenopausal women, the limitations of using standard BMD diagnostic thresholds (T-scores), and recommend the use of age-matched Z-scores for assessment. The review explores special circumstances, such as pregnancy- and lactation-associated osteoporosis, and highlights the rarity but clinical importance of idiopathic osteoporosis (IOP) in younger women. The article also provides an extensive overview of secondary causes of osteoporosis in this population, including endocrine disorders, inflammatory diseases, nutritional deficiencies, and medication effects, as well as detailing appropriate laboratory evaluations and management strategies, both non-pharmacological and pharmacological.

Who was reviewed?

The review covers premenopausal women, particularly those presenting with low-trauma fractures and/or low BMD, as well as subgroups affected by unique physiological states like pregnancy and lactation. The article references studies involving diverse cohorts of premenopausal women, including those with idiopathic osteoporosis, women with secondary causes of bone loss (such as glucocorticoid excess, anorexia nervosa, estrogen deficiency, and celiac disease), and women exposed to risk-modifying medications. Certain referenced studies focus on women with specific conditions, but the review synthesizes findings broadly applicable to the general premenopausal female population at risk for or diagnosed with osteoporosis.

Most important findings

The review underscores that osteoporosis in premenopausal women is uncommon and often secondary to underlying conditions rather than being primary. The most frequent secondary causes include glucocorticoid excess, anorexia nervosa, estrogen deficiency, and celiac disease, all of which can disrupt bone formation and turnover through mechanisms such as chronic inflammation, malnutrition, hormonal derangements, and malabsorption. The article notes that low-trauma fractures in premenopausal women are strong predictors of future fracture risk, but the direct relationship between BMD (measured by DXA) and fracture risk in this group is less clear than in postmenopausal women. For diagnosis, the review recommends using Z-scores (not T-scores), with a Z-score below −2.0 indicating bone density below the expected range for age. Management should focus on treating underlying causes, optimizing nutrition and lifestyle, and reserving pharmacological therapy for women with major or multiple fractures or ongoing bone loss. Limited data support the use of bisphosphonates and teriparatide in select high-risk cases, but caution is warranted due to potential risks, especially regarding future pregnancies. The review also lists a broad array of secondary causes and outlines a structured laboratory assessment to identify them.

Key implications

For clinicians, the review highlights the importance of a thorough diagnostic workup to uncover secondary causes of osteoporosis in premenopausal women, as management often hinges on addressing these root issues. The findings justify a conservative approach to pharmacotherapy in most cases, with primary reliance on lifestyle modification, nutritional support, and targeted treatment of underlying conditions. The recommendations emphasize individualized care and caution regarding medication use in women of childbearing potential, given the possible long-term skeletal and fetal risks. Recognizing and managing secondary causes not only improves bone health but may also address broader metabolic and reproductive health concerns. The review provides practical guidance for clinical evaluation, risk stratification, and safe management, bridging the gap between research findings and day-to-day clinical practice.