Taking HRT to Decrease Osteoporosis Risk: Yes, No… or Maybe?

PJ Hamel Health Guide
  • Betty is a relatively healthy woman in her 70s. She suffers from minor angina. A family history of osteoporosis – plus her own small, slight frame – puts her at risk for osteoporosis. While she hasn’t yet reached that diagnosis, her doctor, who’s been tracking her T-scores, says she’s definitely heading that way. Is Betty a candidate for hormone replacement therapy (HRT)?

    Jennifer is 43 years old. Uterine fibroids, with their accompanying heavy bleeding, resulted in Jen having a complete hysterectomy last month. Now she’s starting to have hot flashes… oh, right, she’s going through menopause. Hmmm, menopause… bone loss... Is Jennifer a candidate for HRT?

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    Diane is 51 years old, and has had just one period in the past year. Her mom was diagnosed with breast cancer at age 60; she recovered. Her grandmother died of complications from a broken hip at age 80. Diane doesn’t live a healthy lifestyle; she’s a heavy smoker, and regular drinker. Her PMS has been tough lately; she’s even had a few hot flashes. Is Diane a candidate for HRT?

    Prior to 2002, hormone replacement therapy was the menopausal woman’s best friend. Doctors prescribed it to millions of patients, believing that estrogen (or an estrogen/progestin combination) not only slowed the symptoms of aging, but protected against cardiovascular disease, colorectal cancer, and fractures due to decreased bone density.

    HRT did indeed help menopausal and post-menopausal women look better and feel healthier. It lowered their risk for colorectal cancer; hip fracture risk was reduced by 40%, and other fractures by 30%. It also quelled the hot flashes and other miserable side effects of menopause. 

But the massive Women’s Health Initiative (WHI) study, completed in 2002, showed that HRT actually increased a woman’s risk of heart attack, stroke, blood clots, and breast cancer. And, after results of the study were finally released in 2006, HRT use dropped by two-thirds.

    Now, doctors are reconsidering HRT. Current thinking is that HRT might be effective and relatively safe for some women, and should be considered for relief of severe menopausal symptoms; or for those at high risk of osteoporosis, without existing cardiac/stroke issues, and with normal risk of breast cancer.

    Moreover, HRT might be the best choice for women who’ve gone the bisphosphonate route to curtail bone loss; and either couldn’t stomach the medicine (literally!), or for whom the drugs didn’t work.

    Why the change in thinking? Bone density decreases most rapidly during the first 2 years of full menopause, then slows considerably thereafter. And, studies show that HRT builds bone mass very effectively for about 3 years, then seems to lose its effectiveness.

    In addition, it’s been shown that HRT, taken for just 2 to 3 years, carries considerably less risk than when it’s taken for long periods of time.

    Thus, for women experiencing severe menopausal symptoms; or at significantly increased risk of osteoporosis; and without underlying risks that would prevent taking it, a low dose of HRT for the first 2 to 3 years after menopause starts* would seem to be the safest, most effective way to lower osteoporosis risk.

  • *And how do you know when menopause starts? Your doctor can tell with a simple blood test; so if you’ve missed a few periods, you might want to get tested.

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    So, back to Betty, Jennifer and Diane.

    Is Betty, the woman in her 70s, a candidate for HRT?

    No. Her 2-year window of opportunity during menopause is long past. Plus, her angina already elevates her risk of cardiac issues – which HRT exacerbates in older women. And HRT has been shown to increase the risk for Alzheimer’s and dementia in women over age 65.

    Betty’s best bet to ensure bone health would be exercise, healthy eating, and a bisphosphonate drug, if necessary.

    Is Jennifer a candidate?

    Yes. Early menopause (before age 50) increases her osteoporosis risk considerably. In Jennifer’s case, estrogen alone might be her best choice; studies have shown that estrogen increases the risk of uterine cancer, but doesn’t raise the risk of breast cancer or heart disease. Thus, since Jennifer’s had a hysterectomy and her risk of uterine cancer has disappeared, estrogen on its own would be both safe and effective.

    How about Diane – should she try HRT?

    Probably. While drinking raises her risk of breast cancer slightly, alcohol use – especially combined with smoking – raises her osteoporosis risk considerably, as does her family history. Meanwhile, her mom’s breast cancer diagnosis increases her risk of breast cancer only slightly. And if hot flashes and PMS are already bothering her, they’ll no doubt become worse once she’s in full-blown menopause.

    Bottom line: Diane should stay in touch with her doctor to determine when she’s in menopause, then consider taking a low dose of HRT for 2 to 3 years.

    How about you? Determine your risks for osteoporosis, heart issues, breast cancer, and stroke (your doctor will help you). Weigh them against HRT’s known risks. The choice should become clear.

Published On: July 23, 2010