In the summer of 2002, the Women’s Health Initiative prospective study on the effectiveness of estrogen replacement therapy was stopped early because results seemed to indicate more risk than benefit from estrogen replacement therapy.  In the August 1st issue of the Gettysburg Medical News, this topic was discussed at some length.  In fact, the Women’s Health Initiative did not indicate that there was a greater risk from taking estrogen replacement therapy.  Rather it proved that there was no benefit in preventing heart disease from taking estrogen replacement therapy.  In my opinion, the issue is still unsettled and I think each patient needs to make their own decision after obtaining as much information as possible from both the media and their healthcare professional.  Since the publication of the findings of the Women’s Health Initiative, there have been additional studies demonstrating that estrogen replacement therapy decreases the incidence of both Alzheimer’s disease and diabetes.

 The purpose of this column is not to advocate for or against estrogen replacement therapy.  Rather, it is to alert women that stopping estrogen replacement therapy should not mean doing nothing more.  If estrogen replacement therapy is stopped, there still needs to be address of osteoporosis through some other means.

 In a recently published study, it was shown that within one year after stopping estrogen replacement therapy, women had a major loss in bone mineral.  Another group of women using a group of medications called the bisphosphonates (Fosamax, Actonel) had a much slower loss of bone mineral if they stopped their drug.  The reason for this is that the bisphosphonates incorporate into the bone mineral matrix and slow the loss of bone mineral through that mechanism.  Hormone replacement therapy slows the rate of bone mineral degradation and as soon as the hormone is stopped the effectiveness of the drug is also stopped.  The most rapid loss of bone occurs in the first six months after hormone replacement therapy has been discontinued.

 To that end, it is strongly recommended that women who discontinue estrogen replacement therapy make another choice to prevent bone mineral loss and the osteoporosis leading to the dowagers hump, broken hips, compression fractures, and broken wrists.

 The first line of treatment for osteoporosis would be the group of drugs called the bisphosphonates.  These drugs are best taken on a once a week basis.  Specifically, the medications are taken on an empty stomach with a glass of water only.  Not coffee, not orange juice, not milk, because each of these products would stop the absorption of the drug.  A half an hour after the drug has been taken the person must remain erect so that there is not a reflux bubble back of the drug into the swallowing pipe (esophagus).  By washing back into the esophagus, irritation can occur.  This is prevented if the person remains erect (this means not going back to bed).  The disadvantage of this treatment is the price at about $15.00 per pill or $60.00 per month.  The advantage is the convenience of once a week treatment and the effectiveness of the medication.
 There is an old drug etidronate (Didronel).  This was one of the first bisphosphonates that came ever came out and was used to treat a disease called Paget’s disease.  It turns out that it is really very effective in treating osteoporosis when used for two weeks every three months.  This is a tremendous advantage of not having to take anything for 2 ½ out of 3 months in addition to a significant price advantage.

 The second drug that can be used to replace estrogen is raloxifene (Evista).  This is a medication that has been modified to take away the feminizing effects of estrogen and yet leave the bone mineral protective effect of estrogen replacement therapy.  The major advantage of this treatment is its better protection of spinal bone mineral, the absence of side effects and perhaps most importantly for many women, it seems to prevent breast cancer.  If there are any disadvantages to this product, it would be the price and the need for a daily pill.

 There is a new product called teriparatide (Forteo).  This the first product on the market that actually increases bone mineral density significantly as opposed to simply slowing the rate of loss of bone mineral that the other products do.  It has a tremendous disadvantage in that it requires a daily injection and they are quite expensive.  Nonetheless it seems to be very effective in re-establishing bone mineral in individuals who have severe advanced disease.  Fortunately, it is only necessary to use for 2 years and then can be replaced with Fosamax, Actonel or Evista.

 The last drug treatment used for osteoporosis is called calcitonin (Miacalcin).  This drug has the advantage of stopping the pain when a person breaks a vertebral (back) bone from osteoporosis.  There is significant relief using this product.  It is very useful in the case of an individual having severe back pain from a bone fracture.  It is not as effective as  Fosamax, Actonel, or Evista in preventing bone fractures.

 Regardless of which medication might be chosen (or not) it is important to maintain 1200 to 1500 mg a day of calcium intake along with weight-bearing exercise.  In addition, the calcium intake is of very little use unless the person gets a full 800 Units of Vitamin D daily.  This is the amount of Vitamin D in 2 standard vitamin pills.  Calcium/Vitamin D, weight-bearing exercise, and a medication for osteoporosis are like the three legs on a three-legged stool.  It takes all three legs for the stool to stay upright.

 In summary, estrogen replacement therapy remains a very controversial topic.  I am in no way a believer that estrogen replacement therapy causes strokes or heart attacks.  By the same token, claims that were made that estrogen replacement therapy prevents strokes or heart attacks is not true.  The drug seems to be neutral in this arena.  Estrogen replacement therapy probably does increase the risk of breast cancer from 10 chances in 100 to 13 chances in 100 in the general population.  There are so many considerations on whether a woman should or should not use estrogen replacement therapy, that this is a very individual decision.  But if estrogen replacement therapy is not chosen, there needs to be other protection for women in their menopausal years to prevent osteoporosis.