About 20 years ago HRT was the only real effective treatment for osteoporosis but following the bad news from the 2002 WHI study – now totally discredited and retracted even by the investigators, most physicians who are virtually always poorly trained in hormone therapy happily resorted to use of bisphosphonates, strontium, parathyroid hormone or worse. These may be appropriate for the older patient but for the younger woman there are major side effects such as epigastric pain, osteonecrosis of the jaw and femoral mid-shaft fractures there is also a suggestion of an increase in oesophageal cancer.
The evidence is now clear that the safest and most effective way to increase bone density in women under the age of 60 years is by oestrogens. The denial of oestrogens to these younger women is tragic when we consider the younger 30-40 year old women with premature menopause with a history of anorexia and amenorrhea, also the thin exercise/marathon addicts or even healthy thin women who think that they are having enough exercise walking the dog for 2 hours a day. For these women, who are deficient of oestrogen because of premature ovarian failure or amenorrhea or simply because they are thin and not producing enough oestradiol in their body fat transdermal oestrogens must be regarded as the correct choice. Similarly premenopausal women are at risk if they have a hysterectomy and bilateral oophorectomy without appropriate hormone replacement.
With ovarian failure regardless of age there is a decrease in skin collagen which can be replaced by oestrogen therapy thus improving the skin thickness and skin elasticity. This same loss of collagen appears in the bone matrix, the vital scaffolding of the bone. Oestrogen replaces the missing collagen in the matrix of osteopenic bone. This same anabolic effect upon the collagen protects the intervertebral discs which make up one quarter of the length of the spinal column and serve as a cushion protecting the woman from developing vertebral fractures if they have osteopenia or of course osteoporosis. Oestrogens protect the intervertebral discs but bisphosphonates do not.
Anxiety about safety of HRT should have disappeared by now but a major problem remains that the spurious ‘side effect’ of HRT in women is now in the undergraduate textbooks and it will take a generation to get rid of this misinformation. Women may also have regular or even troublesome periods or may develop breast discomfort on HRT. These are minor problems that a gynaecologist can deal with but it is outside of the training of bone physicians hence the continued reluctance to use the most logical and the most beneficial treatment for low bone density.
All the current information is that HRT is safe and is associated with removal of most climacteric symptoms including loss of libido and depression as well as the more obvious hot flushes and sweats. It is safer to use transdermal oestrogens as this route does not stimulate coagulation factors from the liver and does not encourage deep vein thrombosis, stroke or pulmonary embolisus. It does seem that the risk factor in HRT is the cyclical or continuous progestogen. Following hysterectomy women can have oestrogens probably with the addition of testosterone without progestogen and data now from two large studies confirm that this is associated with less breast cancer and fewer heart attacks and cardiac deaths.
There seems no reason to deny women particularly under the age of 50 years relief of symptoms and protection of osteoporosis by denying them the transdermal oestrogens. This is an important lesson that physicians have yet to learn.