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Hormone Therapy

Hormone therapy (HT) used to be the “gold standard” for the treatment and prevention of post-menopausal osteoporosis. However, newer medications, such as bisphosphonates and SERMs have been studied more extensively, with positive results, and are associated with fewer side effects. These drugs have been proven to maintain and sometimes increase bone density, and reduce the incidence of fractures in the spine and hip. Because of this, bisphosphonates and SERMs are now considered "first-line" agents for the treatment of osteoporosis.

Nevertheless, HT continues to be prescribed, typically to relieve menopausal symptoms in women between the ages of 50 and 59, and to preserve their bone mass. Although there has been much debate and conflicting evidence about the efficacy and safety of HT, an international panel at the First Global Summit on Menopause-Related Issues concluded, in March 2008, that HT is safe when taken by healthy women for a few years in the early post-menopausal period, and that it can prevent bone fractures.

The hormones in hormone therapy

Hormone therapy consists of estrogen with progesterone, or estrogen alone for women who have had a hysterectomy. Women who still have their uterus should take progesterone in addition to estrogen, to protect them from uterine cancer.

Hormone therapy to treat osteoporosis: weighing the pros and cons

If you and your doctor are considering hormone therapy (HT) to treat osteoporosis, you will want to weigh the benefits against the potential risks. Learning as much as you can about HT, and discussing HT and other treatment options with your health-care professionals will help you make an informed decision.

Benefits

Prevention and treatment of osteoporosis
For women with osteoporosis, hormone therapy

  • slows the rate of bone loss
  • helps the body absorb calcium from the gut (bowel)
  • reduces the amount of calcium lost in urine
  • decreases the risk of hip fractures due to osteoporosis

In addition to its role in preventing and treating osteoporosis, HT can also have other benefits for menopausal and post-menopausal women.

Other benefits
HT can relieve moderate to severe menopausal symptoms, including:

  • hot flashes
  • night sweats
  • insomnia
  • mood swings
  • vaginal dryness
  • bladder incontinence

The Society of Obstetricians and Gynaecologists of Canada advises that HT is a safe and effective option for the treatment of moderate to severe menopausal symptoms when taken for up to five years.

Several studies have also shown that the use of HT may reduce the incidence of colon cancer.

Side-effects and risks

Side-effects
Temporary side-effects of HT can include:

  • breast swelling and tenderness
  • bloating
  • headaches
  • mood changes

These side-effects usually occur in the first three to six months of therapy, then decrease over time. Changing the dose, HT schedule or products used may reduce these side-effects.

HT can also cause you to have your period or experience spotting, depending on the nature of the HT prescribed. If your doctor prescribes estrogen to be taken every day with progesterone, for 10 to 14 days per month, you will have monthly periods. If you are prescribed estrogen and progesterone (at a low dose) to be taken every day, you will not have a monthly period but you may experience light bleeding (or spotting) during the first year. Speak to your doctor about these HT options and possible bleeding patterns.

Risk of blood clots
HT may increase your risk of blood clots, although this is a rare side-effect.

Risk of breast cancer
Some studies have shown a small increase in risk in women who have taken HT for five years or more. However, many other factors may contribute to the risk of breast cancer (for example, alcohol use, lack of exercise, late menopause, weight gain after menopause) to a greater degree than long-term estrogen use.

Risk of heart disease
At one time, it was believed that HT might lower a woman's risk of having a heart attack or stroke. We now know that HT does not protect women from cardiovascular disease and should not be recommended for the sole purpose of preventing heart disease. Studies show that it may slightly increase your risk of blood clots, heart attack and stroke.

Who should not take HT
You should NOT use HT if are pregnant or if you have a history of blood clots, stroke, heart disease, liver disease or breast cancer.

Making a decision

If you are considering taking HT to treat osteoporosis, discuss all of the benefits and risks with your doctor before starting any therapy.

If you are postmenopausal, you should also have routine mammograms, physical and pelvic exams, to monitor your health.

Starting and stopping hormone therapy

Starting hormone therapy

Estrogen can prevent the accelerated bone loss that occurs in the early years of menopause. If you and your doctor decide that hormone therapy (HT) is appropriate for you, the best time to start HT is at the beginning of menopause or shortly afterwards.

Stopping hormone therapy

If you expect to have a surgery, talk to your doctor about temporarily stopping your HT. Women should stop taking the hormones 72 hours prior to surgery. Similarly, HT should be stopped during prolonged periods of bedrest or stretches of time when you will be immobile. The therapy can be restarted once you are mobile again.

You may decide to continue taking HT, if you are tolerating it well and if your risk factors for cardiovascular disease and breast cancer are minimal. If you decide to discontinue HT, it is best to taper off the hormones gradually instead of stopping them suddenly.

Withdrawal symptoms, which are similar to menopausal symptoms (and include hot flashes, effects on mood and sleep), may occur as a result of the decreased amount of estrogen. Temporary withdrawal "spotting" (i.e. light vaginal bleeding) may also occur when stopping a combined HT regimen. To minimize these potential withdrawal effects, your doctor may suggest tapering off your HT over a period of two to four weeks (or longer).

 

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Treatment

Bisphosphonates (BPs)

Selective estrogen receptor modulators (SERMs)

Hormone therapy (HT)

Calcitonin

Parathyroid hormone

Other medications

Monitoring treatment response

  • A publication of:
  • Women's College Hospital