Osteoporotic fractures occur in one third of women, principally the hip (neck of femur), the vertebral bodies and the wrist. Apart from the life-threatening fracture of the hip which occurs in the older age group of women, the collapse fractures of the lumbar and thoracic vertebra produce pain, loss of height and the deformity of the dowager's hump. The capacity of the chest is diminished and women have their heart and lungs squashed up into small volume producing greater distress.
The tragedy is that osteoporotic fractures should be preventable as it is, for the most part, a product of post-menopausal oestrogen loss and can be prevented by oestrogen replacement. There are other causes such as anorexia as these women can have several years without periods and hence oestrogen production. Similarly, a previous hysterectomy with removal of ovaries produce profound, prolonged oestrogen deficiency. Steroid therapy, renal disease, thyroid disease, malnutrition as a growing child and, of course, family history are all important risk factors.
It is also important to realise that oestrogens can substantially increase bone density (not just prevent bone loss) particularly in the over 60's with low bone density. Hence it is never too late, nor the patient too old to start oestrogen therapy. Oestrogens will not, of course, correct the deformities that have occurred through osteoporotic fractures.
Unfortunately many women find it difficult to take oestrogens for a long period of time because of the side-effects of bleeding, breast discomfort, PMS-type symptoms as well as the fear of breast cancer and weight gain.
The acceptability of oestrogen therapy can be improved by using the correct dose, i.e. the dose that makes women feel better without producing side-effects, perhaps using a non-bleeding combination so that the woman does not experience unwanted cycles and perhaps the addition of testosterone in the woman who has loss of energy, loss of libido and depression.
It is clearly important to use a dose that works and use an oestrogen where the blood levels can be measured in the case of an inadequate or inappropriate response. Oestradiol is the most satisfactory oestrogen to use, either by tablets, patches, creams or implants in a dose which produces an oestradiol level of at least 300 pmol/l . Tibolone, a more complex oestrogen, which allows non-bleeding treatment is also effective in the post-menopausal woman.
- Studd, JWW., Arnala, I., Kicovic, PM., Zamblera, D., Kroger, H., Holland,
EFN. (1998) A randomised study of Tibolone on bone mineral density in osteoporotic
post-menopausal women with previous fractures. Obstetrics & Gynecology 92,
- Studd, J., Zamblera, D. (1994) Estrogen therapy in women over 60 years
og age. Gynecol. Endocinol. 8, 191-196.
- Studd, J., Holland, EFN., Leather,
A., Smith, R. (1994). The dose-response of percutaneous oestradiol implants
on the skeletons of post-menopausal women. BJOG 101, 787-791.
- Holland, EFN.,
Studd, JWW., Mansell, JP., Leather, AT., Chambers, TJ (1994) Histomorphometric
changes in the skeleton of post-menopausal women with low bone mineral density
treated with percutaneous estradiol implants. Obstet. & Gynecol
83, (3), 387-391.
- Holland, EFN., Leather, AT., Studd, JWW., Garnett, TJ. (1993). The effect of a new sequential oestradiol valerate and levonorgestrel preparation on the bone mineral density of post-menopausal women. BJOG, 100, 966-967.