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Stephanie Halloran
Kelsey Corcoran
Anthony Lisi


Osteoporosis, Osteopenia, Premenopausal, Nutrition, Prevention


Objective: In the United States, Doctors of Chiropractic (DCs) are healthcare providers who may manage patient with osteoporosis or osteopenia. Many physicians are familiar with management approaches pertaining to post-menopausal osteoporosis, but the evidence available for premenopausal osteoporosis and osteopenia are limited. This review aims to provide an overview of prevalence, diagnostic strategies, risk factors and management considerations for premenopausal females as relevant to DCs.

Methods: A search of the PubMed database from January 1, 2003 to December 31, 2019, was conducted using search terms osteoporosis, osteopenia, and premenopausal women. Additional searches were performed as necessary for supplementary information regarding interventions. Data were synthesized based on content relevant to chiropractic practice and presented as a narrative review.

Results: Dual-energy x-ray absorptiometry (DXA) screening is indicated in cases of fragility fracture or significant secondary causes of low bone mineral density in the premenopausal population. For women that are 30-40 years old, perhaps 0.5% have DXA scores consistent with osteoporosis and 15% with osteopenia. Of these cases, 50-90% are influenced by genetic predisposition, increased age, low weight and body mass index, malnourishment, medication use, and related systemic diseases impacting nutrient metabolism, hormone regulation, and autoimmune inflammatory conditions. Management of osteoporosis and osteopenia in at-risk premenopausal women includes referral for primary systemic diseases requiring medical intervention, conservative management targeting nutritional treatment and lifestyle recommendations critical to bone health, and referral for DXA screening and pharmacological interventions as indicated.

Conclusion: There is currently limited evidence regarding osteoporosis and osteopenia in premenopausal women. DCs can employ diagnostic strategies and conservative management strategies, some of which may decrease the risk of development or progression of osteoporosis and osteopenia in this population. The use of conservative strategies for co-managing secondary causes may have the potential to improve long-term management of these conditions.


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1. Qaseem A, Forciea MA, McLean RM, Denberg TD. Treatment of low bone density or osteoporosis to prevent fractures in men and women: Aa clinical practice guideline update from the American College of Physicians. Ann Internal Med 2017;166(11):818–839
2. National Board of Chiropractic Examiners. Practice analysis of Cchiropractic: A project report, survey analysis, and summary of the practice of chiropractic within the United States. (2015)
3. Ji, M, Yu, Q. Primary osteoporosis in postmenopausal women. Chronic Disease Translational Med 2015;1:9-13
4. Ferrari S, Bianchi ML, Eisman JA et al. Osteoporosis in young adults: pathophysiology, diagnosis, and management. Osteoporosis International 2012;23(12):2735–2748
5. Weaver CM, Gordon CM, Janz KF, Kalkwarf HJ, Lappe JM, Lewis R, et al. The National Osteoporosis Foundation’s position statement on peak bone mass development and lifestyle factors: a systematic review and implementation recommendations. Osteoporosis International 2016;27(4):1281–1386
6. Gourlay ML, Brown SA. Clinical considerations in premenopausal osteoporosis. Arch Internal Med 2004;164(6):603–614
7. Akkawi I, Zmerly H. Osteoporosis: current concepts. Joints 2018;6(2):122–127
8. Sharma M, Dhakad U, Wakhlu A, Bhadu D, Dutta D, Das S. Lean mass and disease activity are the best predictors of bone mineral loss in the premenopausal women with rheumatoid arthritis. Indian J Endocrinology Metabolism. 2018;(2)
9. Ili? K, Obradovi? N, Vujasinovi?-Stupar N. The relationship among hypertension, antihypertensive medications, and osteoporosis: a narrative review. Calcified Tissue International 2013;92(3):217–227
10. Hudec SMD, Camacho PM. Secondary causes of osteoporosis. Endocrine Practice 2013;19(1):120–128
11. Hacker-Thompson A, Robertson TP, Sellmeyer DE. Validation of two food frequency questionnaires for dietary calcium assessment. J Am Dietetic Assoc 2009;109(7):1237–1240
12. Ross AC, Manson JE, Abrams SA et al. The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know. J Clin Endocrinol Metabolism 2011;96(1):53–58
13. Islam MZ, Shamim AA, Viljakainen HT et al. Effect of vitamin D, calcium and multiple micronutrient supplementation on vitamin D and bone status in Bangladeshi premenopausal garment factory workers with hypovitaminosis D: a double-blinded, randomised, placebo-controlled 1-year intervention. Br J Nutrition. 2010;104(S2):241–247
14. Karaguzel G, Holick MF. Diagnosis and treatment of osteopenia. Rev Endocrine Metabolic Disorders 2010;(4):237
15. Shams-White MM, Chung M, Du M et al. Dietary protein and bone health: a systematic review and meta-analysis from the National Osteoporosis Foundation. Am J Clin Nutrition 2017;105(6):1528–1543
16. Morin P, Herrmann F, Ammann P, Uebelhart B, Rizzoli R. A rapid self-administered food frequency questionnaire for the evaluation of dietary protein intake. Clin Nutrition 2005;24(5):768–774
17. Grossman JM, Gordon R, Ranganath VK et al. American College of Rheumatology 2010 recommendations for the prevention and treatment of glucocorticoid-induced osteoporosis. Arthritis Care Res 2010;62(11):1515–1526
18. Cohen A, Shane E. Evaluation and management of the premenopausal woman with low BMD. Current Osteoporosis Reports 2013;11(4):276–285
19. Lange HLH, Manos BE, Gothard MD, Rogers LK, Bonny AE. Bone mineral density and weight changes in adolescents randomized to 3 doses of depot medroxyprogesterone acetate. J Pediatric Adolescent Gynecol 2017;30(2):169–175
20. Lado F, Spiegel R, Masur JH, Boro A, Haut SR. Value of routine screening for bone demineralization in an urban population of patients with epilepsy. Epilepsy Res 2008;78(2):155–160
21. Poly TN, Islam MM, Yang H-C, Wu CC, Li Y-CJ. Proton pump inhibitors and risk of hip fracture: a meta-analysis of observational studies. Osteoporosis International 2019;30(1):103–114
22. Stenson WF, Newberry R, Lorenz R, Baldus C, Civitelli R. Increased prevalence of celiac disease and need for routine screening among patients with osteoporosis. Arch Internal Med 2005;165(4):393–399
23. Targownik LE, Bernstein CN, Nugent Z, Leslie WD. Inflammatory bowel disease has a small effect on bone mineral density and risk for osteoporosis. Clin Gastroenterol Hepatol 2013;11(3):278–285
24. Lima CA, Lyra AC, Mendes CMC et al. Bone mineral density and inflammatory bowel disease severity. Brazilian J Med Biological Res 201;50(12):e6374
25. Chew CK, Clarke BL. Causes of low peak bone mass in women. Maturitas 2018;111:61–68
26. Vestergaard P, Mosekilde L. Hyperthyroidism, bone mineral, and fracture risk--a meta-analysis. Thyroid 2003;13(6):585–593
27. Polovina S, Mici? D, Milji? D, Mili? N, Mici? D, Popovi? V. The Fracture Risk Assessment Tool (FRAX score) in subclinical hyperthyroidism. Vojnosanitetski Pregled 2015;72(6):510–516
28. Bilezikian JP, Potts JT Jr, Fuleihan GE-H et al. Summary statement from a workshop on asymptomatic primary hyperparathyroidism: a perspective for the 21st century. J Clin Endocrinol Metabolism 2002;87(12):5353–5361
29. Willemsen RH, Arends NJT, Bakker-van Waarde WM et al. Long-term effects of growth hormone (GH) treatment on body composition and bone mineral density in short children born small-for-gestational-age: six-year follow-up of a randomized controlled GH trial. Clin Endocrinol 2007;67(4):485–492
30. Shah VN, Harrall KK, Shah CS et al. Bone mineral density at femoral neck and lumbar spine in adults with type 1 diabetes: a meta-analysis and review of the literature. Osteoporosis International 2017;28(9):2601–2610
31. Maddaloni E, D’Onofrio L, Lauria A et al. Osteocalcin levels are inversely associated with Hba1c and BMI in adult subjects with long-standing type 1 diabetes. J Endocrinol Investigation 2014;37(7):661–666
32. Walker-Bone K. Recognizing and treating secondary osteoporosis. Nature Reviews Rheumatol 2012;(8):480
33. Mendoza-Pinto C, García-Carrasco M, Sandoval-Cruz H et al. Risks factors for low bone mineral density in pre-menopausal Mexican women with systemic lupus erythematosus. Clin Rheumatol 2009;28(1):65–70
34. Cramarossa G, Urowitz MB, Su J, Gladman D, Touma Z. Prevalence and associated factors of low bone mass in adults with systemic lupus erythematosus. Lupus 2017;26(4):365–372
35. Williams LJ, Pasco JA, Jackson H et al. Depression as a risk factor for fracture in women: A 10 year longitudinal study. J Affective Disorders 2016.
36. Cizza G, Mistry S, Nguyen VT, Eskandari F, Martinez P, Torvik S, et al. Do premenopausal women with major depression have low bone mineral density? A 36-month prospective study. PLOS One 2012;7(7):e40894
37. Khan AA, Bachrach L, Brown JP et al. Standards and guidelines for performing central dual-energy x-ray absorptiometry in premenopausal women, men, and children: a report from the Canadian Panel of the International Society of Clinical Densitometry. J Clin Densitometry. 2004;7(1):51–63
38. Cosman F, de Beur SJ, LeBoff MS et al. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporosis International 2014;25(10):2359–2381
39. Langsetmo L, Barr SI, Berger C et al. Associations of protein intake and protein source with bone mineral density and fracture risk: A population-based cohort study. J Nutrition Health Aging 2015;(8):861
40. McLendon AN, Woodis CB. A review of osteoporosis management in younger premenopausal women. Women’s Health 2014;(1):59
41. Holick MF. Optimal vitamin D status for the prevention and treatment of osteoporosis. Drugs Aging 2007;24(12):1017–1029
42. Aspray TJ, Bowring C, Fraser W et al. National Osteoporosis Society vitamin D guideline summary. Age Ageing 2014;43(5):592–595
43. Nikander R, Sievänen H, Heinonen A, Daly RM, Uusi-Rasi K, Kannus P. Targeted exercise against osteoporosis: A systematic review and meta-analysis for optimising bone strength throughout life. BMC Med 2010;8:47
44. Mohr M, Helge EW, Petersen LF et al. Effects of soccer vs swim training on bone formation in sedentary middle-aged women. European J Applied Physiol 2015;15(12):2671–2679
45. Bhalla AK. Management of osteoporosis in a pre-menopausal woman. Best Practice Res Clin Rheumatol 2010;24(3):313–327