despite various studies , osteoporosis is one of the most major health problems , especially among elderly women . there are two major categories in managing osteoporosis : bone resorption inhibition and bone formation stimulation . recently , more attention has been focused on teriparatide as a stimulator of bone formation . teriparatide is a genetically engineered recombinant human parathyroid hormone ( pth ) which acts as a bone anabolic drug in treating osteoporosis . the mechanism of this drug is similar to that of endogenous human pth.168 ) human pth and teriparatide binds to the same receptor on osteoblasts and stimulates osteoblastic effects on bone.4 ) daily injection of teriparatide stimulates osteoblast activity improving bone architecture . this drug is approved by the united states food and drug administration as a treatment for osteoporosis.3 ) bisphosphonate , estrogen , selective estrogen receptor modulators ( serm ) , calcitonin and calcitriol are representative bone resorption inhibitors . of these , bisphosphonate is the first line treatment and is among the most popular and cost - effective for osteoporosis . bisphosphonate acts by inhibiting the digestion of bone encouraging osteoclasts to undergo apoptosis . regulating calcium and bone metabolism , other therapies utilize the human monoclonal antibody denosumab and , in hypogonadal men , testosterone . we compared the combination of teriparatide and serm with bisphosphonate to treat osteoporosis for menopausal women and its effect on bone mineral density ( bmd ) in lumbar spine and femur neck . between november 2008 and january 2015 , we retrospectively reviewed postmenopausal female patients at 52 - 88 years of age ( mean 70.259.03 years ) diagnosed with compression fracture diagnosed by spine x - ray and spine magnetic resonance imaging . osteoporotic patients were divided into two groups based upon treatment : teriparatide ( forsteo ) plus serm ( evista ) ( ts group , n=26 ) and bisphosphonate ( alend ; b group , n=59 ) . patients who agreed to use teriparatide , were indicated ts group , and b group patients refused to inject teriparatide . after the discontinuation teriparatide treatment , 26 patients were treated via continuous oral serm drug . the teriparatide therapy was discontinued mainly due to its expensive cost compared to those of other osteoporotic drugs . patients in the ts group used teriparatide during 3.231.63 months , before the change to serm . we evaluated the therapeutic outcome of patients for bmd indirectly by measuring bone strength and fracture risk . bmd was measured twice ( at the start of medication therapy and following therapy ) in the femur and lumbar spine region via dual x - ray absorptiometry using a hologic discovery - wi model . outcome was evaluated by comparing bmd changes and calculating the bmd ratio as follows : bmd ratio=(postmedication bmd - premedication bmd)100/premedication bmd numerical data were presented in terms of the mean range , and tested for statistical significance using the student t - test . categorical data were indicated as frequencies and percentages , and then compared using the pearson chi - square test , or fisher 's exact test . the difference was considered to be statistically significant when the p value was less than 0.05 . all statistical analyses were conducted using ibm spss statistics version 22 ( spss inc . , chicago , il , usa ) . numerical data were presented in terms of the mean range , and tested for statistical significance using the student t - test . categorical data were indicated as frequencies and percentages , and then compared using the pearson chi - square test , or fisher 's exact test . the difference was considered to be statistically significant when the p value was less than 0.05 . all statistical analyses were conducted using ibm spss statistics version 22 ( spss inc . , chicago , il , usa ) . mean age was 70.259.03 years , mean body mass index was 23.903.30 kg / m . the ts group was treated during 3.231.63 months and then with teriparatide , and the b group was treated for 19.037.76 months . in the ts group , there was no change bmd of femur neck ( 0.540.12 vs. 0.540.11 ) , but the t - score was marginally increased from -2.471.11 to -2.451.00 . in contrast , in the b group , bmd of femur neck and t - score decreased from 0.600.11 to 0.540.10 , and from -2.260.87 to -2.381.00 , respectively . bmd and t - score of the lumbar spine increased in the ts group , whereas the b group displayed a decrease l1 bmd and total bmd in b group ( table 2 ) . especially , in the ts group , all of lumbar spine t - score was increased significantly . bmd ratio of femur neck increased in the ts group ( 2.0016.29 ) but decreased in the bisphosphonate group ( -8.3913.08 ) ( p=0.002 ) . in lumbar spine , the bmd ratio of the ts group was statistically higher than those of b group except lumbar total bmd significantly ( table 3 ) . we studied the outcomes of osteoporosis treatment among postmenopausal females with compression fracture using teriparatide and serm treatments comparison with bisphosphonate using bmd . the world health organization 1994 recommendation for measuring bmd is via dual - energy x - ray absorptiometry , which is a gold standard for diagnosing osteoporosis and monitoring treatment results in bone strength and a determinant in fracture risk.10 ) today , the treatment outcome has been measured by bmd and t - score of femur and lumbar spine , since it is supposed that bmd reflects both bone strength and fracture risk . several studies demonstrated 20 ug of daily subcutaneous teriparatide injection decreases vertebral fracture risk . in one of study , bmd of the lumbar spine and femur neck was determined 4 , 12 , and 24 months after using 21 months of teriparatide injection ; then compared to those of a control group of patients under placebo.7 ) teriparatide decreased the fracture risk compared to those of the placebo group . teriparatide increased cancellous bone volume and cortical bone thickness , and improved trabecular morphology . in these data , lumbar spine bmd of the ts group was significantly higher than those of the b group . in another study , 6 months of teriparatide use decreased pain and promoted healing of femoral fractures . in the five patients using teriparatide for 6 months , bone remodeling markers were increased.2 ) our study also improved femur neck bmd ratio showing that the value 2.0016.29 ( p=0.002 ) , but that is less than lumbar spine bmd ratio . teriparatide is especially effective in the elderly and in those with low initial bmd.9 ) our results showed that mean age of ts group and b group was 71.658.74 and 69.649.16 as old age representative . another study showed vertebral fracture reduction effects persisted for at least 18 months after the end of teriparatide treatment.5 ) but there was no long term follow up bmd after termination of using teriparatide . however , recent trials show teriparatide has been effective for elderly patients with osteoporosis diagnosed compression fracture . almost articles described that teriparatide was used during at least 6 months . but patients in the ts group used teriparatide for a mean of 3.231.63 months , after only oral serm treatment . in the korea , osteoporosis patients tend to stop teriparatide medication due to its high cost with regard to medical insurance compensation , and prefer cost effective or generic drugs . keep this limitation , although not patients used teriparatide for long - term , we got the results that using teriparatide combination with serm make better bmd compared to those using bisphosphonate . in this retrospective study , the ts group showed improvements in lumbar spine bmd and t - score , and increased width of the bmd ratio , compared to those of b group . teriparatide used in combination with serm can reduce fracture risk , especially in the lumbar spine more so than the femur neck region . using teriparatide and serm can be effective in increasing bmd in postmenopausal women with compression fracture within a short time frame of treatment . further long term study is needed for improvement of bmd reflects clinical good outcome included recurrent fracture . additionally , bone turnover markers are also important evaluation factors and should be evaluated for further studied . comparison of ts group and b group was performed in postmenopausal women of compression fracture by bmd and in lumbar spine region , bmd ratio of ts group was comparatively higher than those of b group . in summary , the results are shown to be significantly effective increasing bmd through treatments using serm after using teriparatide within a short period of time among menopausal women .