Osteoporosis Prevention & Treatment (cont.)
MedicineNet: Do you
mean that all postmenopausal women are candidates for
estrogen replacement therapy, regardless of whether they
are at risk of developing osteoporosis?
Dr. Truong: Yes, the benefits of improving blood fats, preventing heart attacks, and preventing and
actually improving osteoporosis makes a strong case for
using estrogen replacement for all postmenopausal women who
do not have risk factors from long term estrogen. In the
United States, ERT is the standard of care for the
prevention and treatment of postmenopausal bone loss. This
treatment should be considered for all women after
menopause unless there are risk factors from long term
MedicineNet:Please tell me about the risks
of estrogen replacement therapy (ERT).
Dr. Truong: The risks of ERT include:
MedicineNet:Who should not receive
stimulation of the inner lining of the uterus, increasing the risk of cancer
of the uterus. This risk of
cancer of the uterus can be reduced by simultaneous use of
stimulation of the breast tissue, increasing
the risk of breast cancer. This breast cancer risk is not reduced by progesterone. This risk is significantly increased if there is a family history of breast cancer.
- Slight increase in the risk of blood clot formation in the deep veins of the pelvis and the legs (deep vein thrombosis). Blood clots in the deep veins can break off and travel to obstruct the arteries in the lungs (pulmonary embolism). The symptoms of pulmonary embolism include chest pain, shortness of breath, and even life threatening shock.
- Rarely estrogen can promote gallstone formation and aggravate existing liver disease.
I would not routinely prescribe
ERT to the following groups of postmenopausal women:
- Post menopausal women with a prior history of estrogen
dependent cancer (such as breast).
- Postmenopausal women with a strong family history of
- Postmenopausal women with a prior history of deep
vein thrombosis or pulmonary embolism.
- Postmenopausal women with liver disease.
- Postmenopausal women with unexplained uterine bleeding.
I am not saying doctors should absolutely withhold ERT
from patients who have higher risks from estrogen. It is
important for patients to have a clear understanding of the
risks as well as alternative options before making a
MedicineNet:What is your approach to ERT for
postmenopausal women in preventing osteoporosis?
Dr. Truong: I will ask my patients to quit
smoking cigarettes, exercise regularly, and moderate their
alcohol and caffeine consumption. They should have balanced
nutrition and adequate calcium intake (and vitamin D in
In postmenopausal women who have had removal of their
uterus (hysterectomy), I will prescribe long term estrogen
(such as Premarin or Estrace) if they have no risk factors
In postmenopausal women who have an intact uterus, I
will add progesterone (such as Provera or Cycrin) to
estrogen. Progesterone counteracts the increased risk of
cancer of the uterus from long term estrogen. But
progesterone has no effect on the risk of breast cancer
with long term estrogen.
In postmenopausal women who have had uterine cancer or
breast cancer, who have a strong family history of breast
cancer, low dose Fosamax (5 mg/day) is a reasonable
alternative. In postmenopausal women who are unwilling to
take long term estrogen, raloxifene (Evista) or low dose
Fosamax are alternatives.
Evista is an alternative that works somewhat like estrogen for the prevention of osteoporosis in postmenopausal women. Evista belongs to a class of new drugs called selective estrogen receptor
modulators (SERMs). Evista is selective
because it acts like estrogen in certain tissue
(strengthens bones) but not like estrogen in other tissues
(it does not stimulate the uterus lining like estrogen).
Human studies have shown that daily therapy with Evista
increases bone mineral density, lowers serum concentrations of total and
low-density lipoprotein (LDL) cholesterol, and
does not stimulate the uterus lining. Evista also does not
stimulate breast tissue. Preliminary studies indicate
Evista may have beneficial effects on the risk of breast
cancer, but doctors are waiting for confirmatory longer-
The FDA has approved alendronate (Fosamax) at a dose of
10 mg/day for the treatment of osteoporosis. Recently, the
FDA has also approved low dose Fosamax (5 mg/day) for
preventing osteoporosis in postmenopausal women.
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Last Editorial Review: 12/11/2006