ESCEO/IOF 2019 postmenopausal osteoporosis guidance: key points

Official guidelineEuropean guidance for the diagnosis and management of osteoporosis in postmenopausal women. IOF/ESCEO, 2019.
Read the official guideline · Checked for a newer edition on 2026-10-20
We do not reproduce the guideline text — this page is an independent summary.

Who it applies to

Postmenopausal women being assessed or treated for osteoporosis and fracture risk in primary and secondary care.

Key recommendations

Fracture risk should be estimated using FRAX, ideally incorporating femoral neck BMD, rather than BMD alone.
Patients can be stratified into low, high, and very high fracture risk categories to guide treatment intensity.
Very high risk patients (e.g., recent vertebral fracture, multiple fractures, very low BMD, or very high FRAX score) should be considered for anabolic therapy first, such as teriparatide, rather than starting with an antiresorptive.
Oral bisphosphonates remain reasonable first-line therapy for most patients at high but not very high risk.
Denosumab and zoledronic acid are alternative options, particularly where adherence to oral therapy is a concern.
After stopping denosumab, antiresorptive follow-on therapy is recommended to prevent rebound bone loss and vertebral fracture risk.
After a course of anabolic therapy, an antiresorptive agent should follow to consolidate bone density gains.
Vertebral fracture assessment or imaging is recommended in patients with risk factors for vertebral fracture, since many are asymptomatic.
Adequate calcium and vitamin D intake should be ensured as an adjunct to pharmacologic therapy, correcting deficiency where present.
Treatment decisions should take into account patient preference, comorbidities, and renal function when selecting among available agents.

What is new in this edition

Introduction of a 'very high fracture risk' category directing clinicians toward anabolic-first treatment strategies.
Greater emphasis on sequential therapy concepts, including appropriate transitions after stopping denosumab or anabolic agents.

Practice points for students

Remember that stopping denosumab without follow-on antiresorptive therapy can lead to rapid bone loss and vertebral fracture risk, a key exam point.
FRAX alone without BMD can underestimate risk in some patients, so combine both when available.
Anabolic agents like teriparatide are generally used before antiresorptives in very high risk patients, not after.
A recent fragility fracture, especially vertebral, is a strong signal to consider the very high risk pathway.

Condition

Osteoporosis