Menopausal Hormone Therapy for Bone Health: Balancing Benefits and Risks

Announcer: 
You’re listening to On the Frontlines of Osteoporosis on ReachMD. On this episode, we’ll hear from Dr. Risa Kagan, who’s a Clinical Professor in the Department of Obstetrics, Gynecology, and Reproductive Sciences at the University of California San Francisco and a consulting gynecologist with Sutter Health. She’ll be talking about the potential benefits and risks of hormone therapy for postmenopausal patients who are at risk of osteoporosis. Here’s Dr. Kagan now.

Dr. Kagan:
Until the 1990s, the treatment for osteoporosis for people even who had fractures and for people for preventing bone loss, high-risk women, we often used hormone therapy. That was all we had. And in the 1990s, we finally had the approval with good studies, good RCTs, and large studies with women with osteoporosis versus placebo, and we got the approval of the bisphosphonates, raloxifene, and then down the road many other newer agents, as you may know. The standard by the FDA changed, and in order to get an approval for women with established osteoporosis, whether by history of fracture or by BMD, you must have large randomized controlled trials versus placebo in these high-risk women and prove a reduction in both vertebral and nonvertebral hip fractures compared to placebo, and we don’t have that data for menopausal hormone therapy officially with women with osteoporosis. That’s why it does not have the official indication, but yet many of us will use it based on older studies and also the Women’s Health Initiative, which did not recruit women with osteoporosis. These were women who were low-risk. They showed in a large RCT, as you may know, huge numbers of women, both in the estrogen-alone arm and the estrogen and progestogen-alone arm, a reduction in vertebral, hip, and total fracture combined of about 34 percent versus placebo. So we have that, but that wasn’t the official trial done recruiting women with osteoporosis, so that is why we don’t have the official indication to use estrogen any longer for treatment. Yet many of us in clinical practice, if somebody is young, healthy, they have never had a fracture, and they are not very high risk, but they have had bone density—that is maybe their T score is -2.6, just over the line, whereas when we could use estrogen if it was a minus T score of -2.4, which is just below the 2.5 threshold. So what’s the difference? Many of us will counsel women about the benefits and risks and will go on estrogen initially and then later on, as they get older, use another agent. 

I think many people are afraid to use hormone therapy, but there is an enormous amount of data now to show the benefits for symptomatic women, and in this case even nonsymptomatic women for the prevention of bone loss, since the majority of your bone loss does occur with the perimenopausal transition and continues on in those first few years postmenopausal. So it’s important to preserve your bone mass, and if this is another option for women, I think that is something that should be done with shared decision-making and consider menopausal hormone therapy for the prevention of fractures and bone loss. 

Announcer:
That was Dr. Risa Kagan talking about the benefits and risks of hormone therapy for osteoporosis prevention. To access this and other episodes in our series, visit On the Frontlines of Osteoporosis on ReachMD.com, where you can Be Part of the Knowledge. Thanks for listening!