Menopausal Hormone Therapy and Osteoporosis

Andrew M. Kaunitz, MD

Disclosures

May 27, 2003

Question

In light of the new concerns regarding menopausal hormone therapy (HT) and cardiovascular disease, for asymptomatic postmenopausal women, is HT still justified for the prevention of osteoporosis? By the same token, would estrogen replacement therapy be justified for prevention of osteoporosis in women who have undergone hysterectomy and oophorectomy?

Marcia Angle, MD, MPH

Response from Andrew M. Kaunitz, MD

It is ironic that the Women's Health Initiative (WHI), the study that alerted us to concerns regarding risks with long-term combination HT, also represents the study that has most persuasively demonstrated HT's skeletal benefits. In the summer of 2002, the combination (estrogen-progestin vs placebo) HT arm of the WHI was prematurely terminated because risks (more myocardial infarctions, strokes, thrombotic episodes, and breast cancer) outweighed benefits (fewer cases of colon cancer and fractures). As the dust continues to settle in this area, the message that clinicians are left with is to restrict the use of combination HT to those menopausal women with vasomotor symptoms (HT continues to represent the most effective therapy for these symptoms).

Although combination HT clearly is effective for fracture prevention, therapy to prevent or treat osteoporosis needs to be long-term. Given the risks associated with long-term HT and given that the nonhormonal agents known as bisphosphonates (alendronate and risedronate) effectively prevent osteoporotic fractures, bisphosphonates represent an appropriate first-line approach to fracture prevention in women with osteoporosis or severe osteopenia.

In the patient Dr. Angle describes who has recently undergone hysterectomy and oophorectomy, the first approach to skeletal health should focus on lifestyle and nutritional issues (adequate weight-bearing exercise, adequate calcium and vitamin D intake, and avoidance of smoking). If estrogen therapy is not being used for vasomotor symptoms, measuring bone mineral density would certainly be appropriate. If T scores of the spine or femur indicate severe osteopenia (T ≤ -2.0) or osteoporosis (T ≤ -2.5), bisphosphonate therapy should be considered. Keep in mind that the excess risks found with HT in the WHI reflect the use of combination HT. Given that long-term use of estrogen-only therapy appears effective for fracture prevention and may have a more favorable risk-benefit profile than combination HT, use of either bisphosphonate or estrogen therapy can be considered in the posthysterectomy patient with low bone density.

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