HRT and Osteoporosis.
1st June 2019
Professor of Gynaecology, The London PMS Menopause Centre, London.
I am surprised that physicians seem to be reluctant to use estrogen treatment for low bone density. The Royal Osteoporosis Society literature suggests a link between hormones heart attacks, strokes and breast-cancer which isn’t true but is hardly encouraging for women to start estrogen therapy Fortunately these risks have been exaggerated and are probably non-existent.
Let us start with the most obvious age-group who needs estrogen replacement. That would be premature menopause, anorexia as anorectics lose their periods, thin ballet dancers and exercise addicts without periods who are frequent sufferers of osteoporosis although they believe that they are healthy. We then have the more frequent menopausal group of women who may have low bone density many years before cessation periods later with amenorrhoea and estrogen deficiency that go on until late old-age. There is no age limit of being too young or too old to start estrogen therapy if it is required for very low bone density.
There is every reason to use oestrogens as the primary treatment in all these women. Not only is a very effective but also treats other frequent problems of vasomotor symptoms, vaginal dryness and pain, insomnia, depression and loss of libido. It often helps the “brain fog” all too well-known to peri menopausal women. There is also some less convincing evidence that there is possibly a decreased incidence of Alzheimer’s disease.
Where have these scare stories about side effects come from? This is essentially the result of the 2004 WHI Study from America in which the wrong combination of hormones in the wrong dose using the wrong route in the wrong hypertensive overweight and often diabetic women. These faults were recognised and published within weeks of original publication (by me!) Even now authors of this dreadful study are lecturing around the world apologising for the errors in this study which has affected the lives and health of many millions of women around the world
Of course if the woman is a severely overweight women, one must be cautious about treatment. The most important information is that all oestrogens taken by mouth produce liver clotting agents and there is certainly a small risk of strokes and heart attacks with all oral oestrogens whether it is or older women taking HRT or the younger woman taking the birth control pill. The transdermal route should be used either by gels or patches or occasionally by hormone implants. Occasionally it is necessary to add testosterone (yes it is female hormone) for problems of libido, depression and mood. It's also good for increasing bone density but less effective than oestrogens.
The breast-cancer fear is more important. Every study of estrogen alone shows a decrease or no change in breast-cancer. The culprit is in women having continuous synthetic progestogen. By using 7 to 10 days of the natural progesterone, such as utrogestin, that is avoided.
The ideal hormonal treatment should be transdermal estrogen gel such as estrogel with occasional addition of testosterone gel testogel and with utrogestin if the woman still has a uterus.
Women can be reassured that estrogens are a very effective and safe way of increasing bone density. They do not have to take non-hormonal medications would all have their own severe side-effects and none of the added symptomatic and health benefits of HRT.