How can I assess the risk of osteoporosis in a patient with Premature Ovarian Insufficiency, and what preventive measures should I consider?

Assessing osteoporosis risk in a patient with premature ovarian insufficiency (POI):

• Recognise that untreated premature menopause (POI) is a major secondary cause of osteoporosis and increases fragility fracture risk.
• Assess fracture risk in women under 50 with POI as they have a major risk factor for osteoporosis; use fracture risk tools such as FRAX® or QFracture® to estimate 10-year absolute fracture risk, with or without bone mineral density (BMD) values.
• Consider offering a dual-energy X-ray absorptiometry (DXA) scan to measure BMD, especially if fracture risk is high or close to treatment thresholds.
• Exclude other secondary causes of osteoporosis and fragility fractures during assessment.

Preventive measures to consider:

• Discuss and consider hormone replacement therapy (HRT) with transdermal oestrogen and cyclical oral progesterone as recommended by specialists, as HRT reduces fragility fracture risk in POI by addressing oestrogen deficiency.
• Provide lifestyle advice to support bone health, including smoking cessation, limiting alcohol intake, ensuring adequate calcium and vitamin D intake, and encouraging weight-bearing exercise.
• Review treatment and fracture risk at least annually in liaison with specialists.
• Consider referral to osteoporosis specialists if BMD is low or fracture risk is high despite preventive measures.

These steps align with NICE and UK clinical guidelines on osteoporosis risk assessment and management in secondary osteoporosis due to hypogonadism such as POI, and on menopause management.