Pregnancy- and lactation-associated osteoporosis: a position statement of the IAPM, IOF, ECTS, ESCEO, IMS, and EMAS

Pregnancy- and lactation-associated osteoporosis (PLO) is a syndrome characterized by fragility fractures (most commonly vertebral, often multiple) occurring in late pregnancy or the early postpartum period. This position statement summarizes the current knowledge of PLO, and the recommended procedure for assessment, diagnosis and treatment based on a review of published evidence. As PLO is a rare condition, controlled, comparative clinical studies are limited. Individual studies were reviewed, focusing on design, size, follow-up, evaluation of safety, and factors that impact PLO outcomes. Diagnosis of PLO should include a detailed clinical examination, a review of medical and treatment history, and laboratory tests to rule out secondary osteoporosis. Imaging techniques can be used to inform the appropriate treatment pathway, which will depend on whether the patient is antepartum or postpartum. Management of PLO and fractures includes calcium/vitamin D intake/supplementation, considering stopping breastfeeding, and analgesia, if necessary. Treatment with bone-specific agents should be evaluated on an individual basis to reduce subsequent fracture risk, noting that their use in PLO patients is off label. If pharmacological treatments are used, they must be given alongside effective contraceptive measures. Bisphosphonates can pass the placental barrier and are detectable in bone for years, so adverse effects on future pregnancies, although not yet reported, cannot be excluded. Preferred treatment options are teriparatide/abaloparatide or romosozumab. Second-choice treatments are denosumab followed by bisphosphonates or bisphosphonates alone. This position statement includes a pragmatic approach for identifying women with PLO and suggests developing an individualized treatment plan that might include pharmaceutical intervention.