Is there any evidence that HRT will strengthen my bones?

Is there any evidence that HRT will strengthen my bones (reduce osteoporosis)?

The density of bones can be measured accurately by special scans. Serial bone density scans can be used to follow progress of treatment.

A 50-year old patient was found to have a polyp on her cervix and was referred to me by her general practitioner. Her periods had stopped ten years earlier and she had never considered HRT. Bone density scans of her spine and left hip showed that she was at risk of fractures. She was commenced on HRT and remains happily on her regimen. Serial bone density scans have demonstrated the benefit of her treatment (Figure 27.1).

In the Framingham Study, the relative risk (Q33.27) of hip fracture was 0.65 for those who had taken HRT at some time and dropped further to 0.34 for those who had been taking HRT within the last two years. The earlier HRT is commenced the better and it should be continued for at least ten years. There is evidence that bone density remains higher for some years after HRT has been discontinued but the benefit may not be sustained indefinitely.

Following the publication of the Women's Health Initiative (WHI) and the Million Women Study (MWS), regulatory authorities issued an urgent safety restriction on HRT use in preventing post-menopausal osteoporosis, recommending that it now be considered a second-line treatment. Are such recommendations justified? Treatments for osteoporosis, in women with increased future risk for fractures but who have not yet developed the disease, should prevent all types of osteoporotic fractures. Of the available therapies, none other than HRT has been clearly demonstrated to prevent hip fractures in such women. Thus, HRT should be recommended as first-line treatment for osteoporosis prevention. Potential risks of HRT, such as increased development of breast cancer and increased thromboembolism, have long been known. The WHI showed risks in less than 0.3% of women studied, and the MWS appears to have overestimated the risk of breast cancer. Thus, no new safety issues have been identified, and the regulatory authorities may have misinterpreted the data from these recent studies. When given for the correct indications, HRT is of major benefit to many women.

Low dose HRT may be effective for preventing osteoporosis.⁰⁸⁰¹

Calcium supplementation in healthy postmenopausal women is associated with upward trends in cardiovascular event rates. This potentially detrimental effect should be balanced against the likely benefits of calcium on bone.⁰⁸⁰²

Few studies have directly compared different agents or classes of agents used to treat osteoporosis. Although good evidence suggests that many agents are effective in preventing osteoporotic fractures, the data are insufficient to determine the relative efficacy or safety of these agents. Raloxifene, estrogen, and estrogen-progestin increased the risk for thromboembolic events, and etidronate increased the risk for esophageal ulcerations and gastrointestinal perforations, ulcerations, and bleeding.0801

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