Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 3. Effects of ovarian hormone therapy on skeletal and extraskeletal tissues in women

Abstract

OBJECTIVE: To present recent evidence on the use of ovarian hormone therapy (OHT) for osteoporosis and outline safe and effective regimens. OPTIONS: Estrogen alone, estrogen and progestins, progestins alone; various treatment regimens. OUTCOMES: Fracture and loss of bone mineral density in osteoporosis; increased bone mass, prevention of fractures and improved quality of life associated with OHT. EVIDENCE: Relevant clinical studies and reports, including the Nurses' Health Study and the Post-menopausal Estrogen/Progestin Interventions (PEPI) Trial, were studied with emphasis on recent prospective, randomized, controlled trials. Current clinical practice was determined by survey. VALUES: Reducing fractures, increasing bone mineral density and minimizing side effects of treatment were given a high value. BENEFITS, HARMS AND COSTS: Proper management of osteoporosis minimizes injury and disability, improves quality of life and reduces the personal and social costs associated with the condition. OHT is the front-line pharmaceutical therapy for prevention and treatment of osteoporosis in post-menopausal women. In those who are able and willing to comply with therapy, OHT prevents bone loss and fractures. Hormone therapy may also decrease risk of coronary artery disease. Cyclic progestin protects against endometrial cancer in patients receiving estrogen. Potential harms include breast cancer and endometrial cancer related to dosage and duration of therapy. Mastalgia and especially resumption of menstrual bleeding affect compliance. RECOMMENDATIONS: Use of OHT should be considered as early as possible in the perimenopausal period for women at increased risk of osteoporosis. Guidelines are provided for assessment of osteoporosis risk. Physicians and their patients should take into account the absolute and relative contraindications to OHT. Women with a uterus should be given estrogen in combination with a progestin. Ideally, therapy would be continued for a minimum of 10 years beyond menopause for maximum bone protection. Women using OHT should be carefully monitored and evaluated for possible adverse events. This should include regular screening mammography, breast examination and, for some, endometrial surveillance. Specific dosages and treatment regimens are outlined.