Preventing Osteoporosis with Hormone Therapy: How to Select Appropriate Patients

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 sharing her insights on how we can determine if hormone therapy is an appropriate option for a postmenopausal patient who’s at risk of osteoporosis. Here’s Dr. Kagan now.

Dr. Kagan:
Some of the key factors that clinicians need to consider when thinking about using menopausal hormone therapy for the prevention of bone loss or osteoporosis in a menopausal woman is most of the time what the person’s desire is. Many women will come in very concerned about their bone health. They either have a family history or they already were able to get a bone density at or around the time of menopause. Even though that doesn’t go along with the official guidelines, there are many women that have risk factors that allow them to get that bone density. The first thing we have to do is try to go over and explain what it means when they have a low T score. It’s not necessarily that they’ve lost all that bone, but it’s possible that they never reached anything better in their peak bone mass or they did start losing some bone mass over the perimenopausal transition. 

Many women don’t realize that they start losing bone mass—we learned this from the study of women across the nation—prior to their final menstrual period. So somebody comes in; they have a discussion about their bone health; they are concerned; and they’re worried about their bone health, and they happen to be menopausal and also having menopausal symptoms. That’s an easy question and answer. We’ve learned a lot over the last 20 years since the Women’s Health Initiative about the benefits versus risks of menopausal hormone therapy, and without a doubt, there are many more benefits than risks for women who initiate therapy under the age of 60 and within the first 10 years since her final menstrual period. So if that woman is symptomatic and they have low bone mass, to prevent further bone loss, we for sure have a long discussion about the benefits and risks, and that’s an easy answer. 

The big question here is for women who are at high risk, have low bone mass, and even if you don’t have a bone density but they’re concerned because their mother or their sister have osteoporosis or they’re concerned that they are going to be at risk for fractures due to family history or prior history of some issue that led to them to having concern around low bone mass, we then have to weigh the pros and cons of going on menopausal hormone therapy. Most of the guidelines—Endocrine Society and the previous North American Menopause Society, now called The Menopause Society—they all endorse the use of menopausal hormone therapy for the prevention of bone loss, especially in perimenopause—the early years of menopause—for women who are at high risk for fracture—there’s no question—who are symptomatic; but none of them really endorse the use of menopausal hormone therapy for women who are not symptomatic. I think the caveat is that in real clinical practice with shared decision-making, women are very low risk in this age group but want to preserve their bone mass independent of symptoms; many women will choose with their clinician—if they are healthy, have had a full medical evaluation, and there’s no contraindications to use menopausal hormone therapy, which is estrogen, estradiol of some sort or conjugated estrogens. If you have a uterus, we need an estrogen and a progestogen to protect against endometrial hyperplasia and cancer. 

So that is basically the overview of looking at one’s health, weighing the pros and cons, and making sure that women understand the benefits versus risks. So I would say in the newly menopausal women, this is something that many women are starting to even ask more about because they want to preserve their bone mass for certain. 

Announcer:
That was Dr. Risa Kagan discussing hormone therapy for postmenopausal women at risk of osteoporosis. 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!