25: Preventing Fractures: Osteoporosis Medications Explained
Ep. 25
Osteoporosis medications often get a bad rap—but the science tells a very different story. Without treatment, bone loss can quietly progress until one fall or even a simple movement leads to a fracture. And those fractures aren’t just painful—they can mean months of recovery, ongoing pain, or even the loss of independence.
Now imagine the opposite: feeling strong enough to carry your groceries, climb the stairs with ease, or scoop up your grandkids without fear. That’s the real difference effective osteoporosis treatments can make.
In this post, we’ll explore the main medication options, who they’re right for, and what you need to know about side effects, safety, and timing—so you can make confident choices about protecting both your bones and your quality of life.
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Why Medications Matter
Fragility fractures—breaks that happen from a simple fall, or even just bending over—are what make osteoporosis so serious. They don’t just cause pain; they can limit mobility, reduce quality of life, and even shorten life expectancy.
The good news? Medications can significantly lower the risk of these fractures, including in the spine and hips.
One of my patients—let’s call her Rose—always brushed off her stumbles as simple clumsiness. But one icy morning, a slip led to a hip fracture and months of recovery. Only then did she discover she’d been living with osteoporosis for years. Starting treatment earlier could have greatly lowered her risk.
Who Needs Osteoporosis Treatment?
You're likely a candidate for osteoporosis medication if you have:
A bone density T-score of -2.5 or lower (the official osteoporosis diagnosis)
A history of hip or spine fractures
High fracture risk based on your FRAX score—specifically, a 3% or higher risk of hip fracture in the next 10 years, or 20% or higher risk of major osteoporotic fracture
Even if you're in the pre-osteoporosis stage (osteopenia), treatment might be recommended based on your individual fracture risk calculation.
First-Line Defense: Bisphosphonates
Oral Options: The Weekly Pills
The most commonly prescribed osteoporosis medications are oral bisphosphonates like alendronate and risedronate. These work by slowing down the osteoclasts (the cells that break down old bone tissue).
The results are impressive:
Cut spine fracture risk in half or more
Reduce hip fracture risk by about 40%
Taking them correctly matters: These medications must be taken first thing in the morning on an empty stomach with water, and you need to stay upright for 30 minutes to an hour to protect your esophagus and stomach lining.
IV Alternative: Once-Yearly Treatment
If you have acid reflux, difficulty swallowing, or trouble with the oral medications, zoledronic acid offers an IV alternative given once yearly. You'll be monitored briefly after the infusion, then you're done for 12 months.
Important timing: Oral bisphosphonates are typically used for five years before taking a break, while the IV form is given for about three years before reassessment.
When Standard Treatment Isn't Enough: Denosumab
Denosumab works through a different pathway and is given as a shot every six months. It's an excellent option if you can't tolerate bisphosphonates due to stomach issues or IV reactions.
Warning: You cannot suddenly stop denosumab. Doing so causes rapid bone loss and potential for multiple spine fractures. Your doctor will need a specific transition plan, typically involving a dose of IV zoledronic acid six months after your last denosumab injection to "seal in" the effects.
The Bone Builders: Anabolic Therapies
For patients with very severe osteoporosis—particularly those with T-scores below -3.5, multiple fractures, or vertebral fractures—there are medications that actually build new bone.
Teriparatide and Abaloparatide
These synthetic parathyroid hormones are the first medications proven to build bone rather than just slow breakdown. They require daily self-administered injections for two years and can only be used once in your lifetime.
Romosozumab
This once-monthly injection works in two ways: building bone and slowing breakdown. However, studies suggest it may increase heart disease risk, so it's avoided in patients with recent heart attacks or strokes.
All these bone-building medications require a dose of zoledronic acid afterward to maintain their effects.
Specialized Options
For Breast Cancer Survivors: Raloxifene
This selective estrogen receptor modifier offers a "two-for-one" benefit: it protects against spine fractures while reducing breast cancer risk. However, it doesn't help prevent hip fractures and increases blood clot risk.
Hormone Therapy: An Interesting Case
While only FDA-approved for preventing osteoporosis progression in osteopenia, studies show menopause hormone therapy can reduce fracture risk by 20-40% in postmenopausal women with osteoporosis. The challenge is that benefits disappear if you stop the therapy.
Addressing Safety Concerns
Many fears about osteoporosis medications stem from how they were used when first introduced—often for 10-15 years without breaks, leading to complications like atypical fractures.
Modern approach focuses on:
Regular monitoring
Appropriate treatment duration (5 years for oral, 3 years for IV)
Planned drug holidays when appropriate
Proper sequencing when multiple medications are needed
About jaw problems: This rare complication primarily occurs when these medications are given more frequently than the osteoporosis regimen (as in cancer treatment). For routine osteoporosis care, coordinate any major dental work with your doctor, but don't let fear of this rare side effect prevent necessary treatment.
The Foundation: Calcium and Vitamin D
Regardless of which medication you take:
Aim for 1,000-1,200 mg of calcium daily (calcium citrate absorbs better than carbonate)
Take 1,000-2,000 IU of vitamin D3 daily
Prioritize dietary calcium—it absorbs better than supplements
Never combine osteoporosis medications (except calcium and vitamin D supplements)
Essential Lifestyle Components
Resistance and balance training
Smoking cessation
Limiting alcohol
Creating a safe home environment
Regular bone density monitoring (every 1-2 years, not more frequently)
Making Treatment Work
Consistency is crucial. Patients who start and stop medications without medical supervision often end up with fractures. If you're considering changes to your treatment, discuss this with your healthcare provider first.
Proper transitions matter. Whether taking a drug holiday or switching medications, this must be done under medical supervision by someone experienced with these treatments.
Beyond the Numbers
Osteoporosis medications aren't just about improving bone density numbers on a scan. They're about maintaining your independence and quality of life, whether that means hiking with friends, carrying groceries, lifting grandchildren, or simply walking confidently without fear of falling.
The difference between treatment and no treatment can literally be the difference between living life on your own terms or having those terms dictated by fractures and their complications.
If you're concerned about your bone health or have been offered osteoporosis treatment, have an informed discussion with your healthcare provider. With proper medical guidance, these medications can be powerful tools for protecting your future mobility and independence.
Want to dive deeper into bone health?Listen to the full podcast episode for more detailed insights and if you're interested in personalized guidance for navigating perimenopause, menopause, and metabolic health, I'd love to help. Visit eastsidemm.com to book a consultation and learn about upcoming programs designed specifically for women like you.