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 estrogen.

MedicineNet:Please tell me about the risks of estrogen replacement therapy (ERT).

Dr. Truong: The risks of ERT include:

  1. Estrogen 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 progesterone.
  2. Estrogen 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.
  3. 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.
  4. Rarely estrogen can promote gallstone formation and aggravate existing liver disease.
MedicineNet:Who should not receive ERT?

Dr. Truong: I would not routinely prescribe ERT to the following groups of postmenopausal women:
  1. Post menopausal women with a prior history of estrogen dependent cancer (such as breast).
  2. Postmenopausal women with a strong family history of breast cancer.
  3. Postmenopausal women with a prior history of deep vein thrombosis or pulmonary embolism.
  4. Postmenopausal women with liver disease.
  5. 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 decision.

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 certain individuals).

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 for estrogen.

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- term data.

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