The 2017 Hormone Therapy Position Statement of The North American Menopause Society

The North American Menopause Society 2017 Hormone Therapy Position Statement Advisory Panel

Disclosures

The North American Menopause Society (NAMS). 2018;24(7):728-753. 

In This Article

Osteoporosis

Standard-dose ET and HT prevent bone loss in postmenopausal women by inhibition of osteoclast-driven bone resorption and a reduced rate of bone remodeling.[117–120] Randomized, controlled trials and observational studies show that standard-dose HT reduces postmenopause osteoporotic fractures, including hip, spine, and all nonspine fractures, even in women without osteoporosis.[24,25,121–124]

In the WHI intervention phase, the CEE-alone and the CEE + MPA groups combined had statistically significant reduced hip fracture incidence of 33% (P = 0.03), with 6 fewer fractures per 10,000 person-years overall (Figure 1).[14,25,124] Bone mineral density response to estrogen is dose related, with less protection from bone loss at lower doses, particularly for women aged younger than 40 years. Neither low-dose (oral CEE 0.3 mg; oral 17β-estradiol ≤ 0.5 mg; or estradiol patch 0.025 mg) norultralow-dose (estradiol patch 0.014 mg) therapy has been shown to reduce fracture risk, although no studies have been adequately powered for this endpoint. Bone protection dissipates rapidly after treatment discontinuation.[14,125–128]

Although persistent benefit was found with CEE + MPA for reduced fractures in the WHI cumulative data (intervention plus 13 years' follow-up),[14] postintervention data showed that after 5 years' discontinuation, residual benefit was seen for total fractures in the CEE-alone arm but no reduction in total or hip fractures with CEE + MPA, and no rebound fracture risk was found for either.[129] There are no prospective fracture studies comparing the efficacy of HT in preventing fractures with other approved pharmacologic therapies.

Key Points

• Hormone therapy prevents bone loss in healthy postmenopausal women, with dose-related effects.

• Unless contraindicated, women with premature menopause who require prevention of bone loss are best served with HT or oral contraceptives (which are less effective than HT) rather than other bone-specific treatments until the average age of menopause, when treatment may be reassessed.

• Hormone therapy effectively prevents postmenopause osteoporosis and fractures, and some formulations of ET, EPT, and CEE combined with bazedoxifene are approved for this indication.

   - Women in the ET and EPT cohorts in the WHI intervention trial overall had significant reductions in hip fracture.

   - Bone protection dissipates rapidly after HT discontinuation, but no rebound in fracture risk has been found.

• For women with VMS aged younger than 60 years or who are within 10 years of menopause onset, HT (ET, EPT, or CEE combined with bazedoxifene) is probably the most appropriate bone-active therapy in the absence of contraindications.

• When alternate osteoporosis therapies are not appropriate or cause AEs, the extended use of HT is an option for women who are at high risk of osteoporotic fracture.

• The decision to stop HT should be made on the basis of extraskeletal benefits and risks.

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