Is Prolia (denosumab) an Option to Treat Osteoporosis in Early Menopause?

Osteoporosis usually affects older people, but it can also impact younger individuals, like women in their 20s, 30s, and 40s who still have regular periods. According to the Office on Women’s Health, “Early menopause occurs when a woman’s periods stop before the age of 45, and premature menopause occurs when her periods stop before the age of 40.” A small but significant percentage of these women can develop osteoporosis in early menopause without early signs of this.

My mother could have been one such case of osteoporosis in early menopause. While she is now in her mid-60s, her bones are pretty much in their 90s. Her doctor suspects she has had very low bone density probably for years, but it was not identified until she was old enough to qualify for bone density tests. Would earlier intervention have helped? It would likely have, but with the lack of research into osteoporosis in pre-menopausal women, even identifying it is a challenge, let alone finding a physician willing to treat it. Let’s examine why that is and what treatment options are within reach.

How is Early Onset Osteoporosis Diagnosed

Spotting osteoporosis in younger women can be tricky, as bone tests aren’t usually recommended. Here’s why:

• Some young women with low bone density may not be at immediate risk of fractures, so testing could cause unnecessary stress or may not be financially worthwhile.
• Certain individuals inherit low bone density from their families, which is something they cannot control.
• Bone density tests may inaccurately assess petite women’s bone health, potentially indicating risk when they are actually fine.
• Osteoporosis medications are generally not designed for young women, making a long-term treatment plan somewhat challenging.

Treatments for Osteoporosis

The main treatments for osteoporosis in women are designed for postmenopausal women, not those who are still having periods. Most medications for osteoporosis work by stopping the breakdown of bones. Little information exists on how well these work for more than ten years or how safe it is to use them together, though most include calcium and vitamin D supplementation alongside treatment.

The main osteoporosis treatments include: 

1. Hormone Replacement Therapy (HRT) – Usually with estrogen, as this hormone is needed to build bones.
2. Bisphosphonates, which slow down the breakdown of bones.
3. Prolia/Denosumab – works by slowing down bone breakdown and increasing bone density.
4. Evista – is used to treat and prevent osteoporosis in postmenopausal women. It belongs to a class of drugs called selective estrogen receptor modulators (SERMs) and helps to reduce the risk of bone fractures.
5. Parathyroid hormone peptides – are used to treat osteoporosis by stimulating bone formation, increasing bone density, and reducing the risk of fractures.
6. Evenity – works by increasing bone formation and decreasing bone breakdown, helping strengthen bones and reducing the risk of fractures.
7. Calcium and vitamin D – help strengthen bones and improve bone density.
8. Exercise –  helps strengthen bones and muscles, reducing the risk of osteoporosis.

The majority of these medications are typically prescribed for individuals with significantly low bone density, those who have experienced fractures, or individuals whose osteoporosis stems from steroid medication use. For women with early menopause, estrogen therapy is the preferred treatment. There is no solid evidence about the safety or effectiveness of non-estrogen treatments like bisphosphonates, Prolia/Denosumab, or Evista for these women.

Some women may choose to stay on HRT for life to manage osteoporosis, while others might opt for different treatments like bisphosphonates due to a slight increase in breast cancer risk with long-term HRT use.

Currently, most osteoporosis medications are not FDA-approved for use in women before menopause.

Treatment Options for Pre Menopausal Osteoporosis

There are currently no FDA-approved treatments for idiopathic premenopausal osteoporosis in women, and there’s ongoing debate about if and when treatment is necessary. Treatment decisions often depend on how severe the condition is, with women experiencing fractures or low bone density being potential candidates for medication. However, not all women diagnosed with osteoporosis in early menopause need drug therapy and they can still slow the breakdown of bone with a calcium-rich diet, adequate vitamin D levels, and exercise. 

Treating premenopausal women with osteoporosis involves more than just prescribing medication; it requires a long-term plan. Conducting research on the best treatments is difficult due to the rarity of the disease, which limits the size and power of clinical trials. There is also some debate over whether to treat women with weak bones who haven’t had fractures versus those who have. While pre-menopausal women with osteoporosis who present with fractures are likely to receive treatment, the question is what to do for those with low bone density and no fractures yet. It’s unclear if treating them early can prevent fractures due to insufficient data. 

Despite this, some physicians do recommend treatment for those with very weak bones with or without fractures. The key is finding a physician knowledgeable and experienced in treating osteoporosis to discuss the individual risk factors and determine the best course of action.

Prolia/Denosumab for Osteoporosis

While denosumab for osteoporosis is not likely to be a first-line treatment for a pre-menopausal woman, it may be prescribed for women who are under 60 but post-menopausal and have fractures. Without treatment, an excess of bone-removing cells can cause bones to weaken faster than they can repair, increasing the risk of fractures. Denosumab injection collaborates with the body to inhibit the formation of these cells, aiding in bone health. It is administered via injection and can be used long-term.

Side Effects of Denosumab

Denosumab for osteoporosis is effective, but it can cause serious side effects in some people. It might lead to very low calcium levels in the blood, especially in people with low calcium or advanced kidney disease. A doctor might suggest taking calcium and vitamin D to help prevent this. Contact the doctor immediately if muscle spasms, tingling in the fingers or toes, or around the mouth are felt. It can also cause severe allergic reactions, so seek immediate medical attention if there are symptoms like swelling, difficulty breathing, or hives.

Other side effects may include serious infections in the skin or abdomen, bone or joint pain, and unusual breaks in a thigh bone. After stopping use of this medication, there might be a higher risk of broken bones, so always consult a doctor before making changes to the treatment.

Lifestyle Changes to Support Osteoporosis Treatment

Instead of feeling frustrated about having to wait until there is a fracture due to osteoporosis in early menopause or until being old enough to qualify for treatment of osteoporosis, there are plenty of ways to support bone health in the meantime. Lifestyle changes for bone health focus on diet and exercise to help ensure that bone density is maintained or increased as much as possible. 

Key Nutrients for Bone Health

Calcium: This mineral is crucial for strong bones. However, during normal aging or when osteoporosis develops, the body might extract calcium from the bones, making them weaker. To prevent this, eat plenty of calcium-rich foods or take supplements if needed.

Vitamin D: It helps the body absorb calcium. Without enough vitamin D, bones can become fragile. A person can get vitamin D from sunlight and foods like fish, eggs, and fortified products like milk and cereals.

Foods to Include:

• Dairy: Milk, cheese, and yogurt are great sources of calcium.
• Leafy Greens: Vegetables like broccoli and spinach.
• Fish: Salmon and sardines are excellent for both calcium and vitamin D.
• Fortified Foods: Look for calcium and vitamin D-fortified products like orange juice and cereals.

Foods to Avoid:

• Salty Foods: These can cause the body to lose calcium.
• Sugary Drinks and Snacks: These can be bad for bone health.
• Wheat Bran and Colas: These can interfere with calcium absorption.

Exercise for Strong Bones

Regular weight-bearing exercise is key to maintaining bone strength. Mix in activities that are easy on the joints but help build bone density. Consider exercises like:

• Walking or hiking
• Dancing
• Climbing stairs
• Lifting light weights
• Swimming and biking

High-impact activities like running can be risky, so check with a doctor before starting them.

Lifestyle Changes

• Limit Alcohol and Caffeine: Too much can weaken bones.
• Quit Smoking: Smoking increases the risk of bone problems.

Preventing Falls

Falls can be dangerous when osteoporosis in early menopause causes bones to be weakened. Here’s how to reduce the risk of falling:

• Improve Balance: Activities like yoga or tai chi can help a person stay steady.
• Home Safety: Remove tripping hazards like loose rugs and ensure good lighting at home.
• Use Support: Don’t hesitate to use a cane or walker if one will help.
• Work with a trained healthcare provider.

A doctor should help create a plan that includes medication and lifestyle changes to manage osteoporosis effectively. Regular check-ups and open communication about issues or questions are important for maintaining bone health.