Prevention of postmenopausal bone loss with minimal uterine bleeding using low dose continuous estrogen/progestin therapy: a 2-year prospective study

Impact of calcium, vitamin D, vitamin K, oestrogen, isoflavone and exercise on bone mineral density for osteoporosis prevention in postmenopausal women: a network meta-analysis

The aim of this network meta-analysis is to compare bone mineral density (BMD) changes among different osteoporosis prevention interventions in postmenopausal women. We searched MEDLINE, Embase and Cochrane Library from inception to 24 February 2019. Included studies were randomised controlled trials (RCT) comparing the effects of different treatments on BMD in postmenopausal women. Studies were independently screened by six authors in three pairs. Data were extracted independently by two authors and synthesised using Bayesian random-effects network meta-analysis. The results were summarised as mean difference in BMD and surface under the cumulative ranking (SUCRA) of different interventions. A total of ninety RCT (10 777 participants) were included. Ca, vitamin D, vitamin K, oestrogen, exercise, Ca + vitamin D, vitamin D + vitamin K and vitamin D + oestrogen were associated with significantly beneficial effects relative to no treatment or placebo for lumbar spine (LS). For femoral neck (FN), Ca, exercise and vitamin D + oestrogen were associated with significantly beneficial intervention effects relative to no treatment. Ranking probabilities indicated that oestrogen + vitamin D is the best strategy in LS, with a SUCRA of 97·29 % (mean difference: +0·072 g/cm2 compared with no treatment, 95 % credible interval (CrI) 0·045, 0·100 g/cm2), and Ca + exercise is the best strategy in FN, with a SUCRA of 79·71 % (mean difference: +0·029 g/cm2 compared with placebo, 95 % CrI –0·00093, 0·060 g/cm2). In conclusion, in postmenopausal women, many interventions are valuable for improving BMD in LS and FN. Different intervention combinations can affect BMD at different sites diversely.

Hormone therapy in postmenopausal women and risk of endometrial hyperplasia

BACKGROUND

Reduced circulating estrogen levels around the time of the menopause can induce unacceptable symptoms that affect the health and well-being of women. Hormone therapy (both unopposed estrogen and estrogen/progestogen combinations) is an effective treatment for these symptoms, but is associated with risk of harms. Guidelines recommend that hormone therapy be given at the lowest effective dose and treatment should be reviewed regularly. The aim of this review is to identify the minimum dose(s) of progestogen required to be added to estrogen so that the rate of endometrial hyperplasia is not increased compared to placebo.

OBJECTIVES

The objective of this review is to assess which hormone therapy regimens provide effective protection against the development of endometrial hyperplasia or carcinoma.

SEARCH METHODS

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched January 2012), The Cochrane Library (Issue 1, 2012), MEDLINE (1966 to January 2012), EMBASE (1980 to January 2012), Current Contents (1993 to May 2008), Biological Abstracts (1969 to 2008), Social Sciences Index (1980 to May 2008), PsycINFO (1972 to January 2012) and CINAHL (1982 to May 2008). Attempts were made to identify trials from citation lists of reviews and studies retrieved, and drug companies were contacted for unpublished data.

SELECTION CRITERIA

Randomised comparisons of unopposed estrogen therapy, combined continuous estrogen-progestogen therapy, sequential estrogen-progestogen therapy with each other or placebo, administered over a minimum period of 12 months. Incidence of endometrial hyperplasia/carcinoma assessed by a biopsy at the end of treatment was a required outcome. Data on adherence to therapy, rates of additional interventions, and withdrawals owing to adverse events were also extracted.

DATA COLLECTION AND ANALYSIS

In this update, 46 studies were included. Odds ratios (ORs) were calculated for dichotomous outcomes. The small numbers of studies in each comparison and the clinical heterogeneity precluded meta-analysis for many outcomes.

MAIN RESULTS

Unopposed estrogen is associated with increased risk of endometrial hyperplasia at all doses, and durations of therapy between one and three years. For women with a uterus the risk of endometrial hyperplasia with hormone therapy comprising low-dose estrogen continuously combined with a minimum of 1 mg norethisterone acetate (NETA) or 1.5 mg medroxyprogesterone acetate (MPA) is not significantly different from placebo at two years (1 mg NETA: OR 0.04; 95% confidence interval (CI) 0 to 2.8; 1.5 mg MPA: no hyperplasia events).

AUTHORS' CONCLUSIONS

Hormone therapy for postmenopausal women with an intact uterus should comprise both estrogen and progestogen to reduce the risk of endometrial hyperplasia.

Dose effects of oral estradiol on bone mineral density in Japanese women with osteoporosis

OBJECTIVES

This 2-year study compared 0.5 and 1.0 mg oral estradiol (E(2)), with or without levonorgestrel (LNG), for the treatment of postmenopausal osteoporosis in Japanese women.

METHODS

Japanese women with osteoporosis after natural menopause or bilateral oophorectomy were randomized to receive E(2) 0.5 or 1.0 mg/day with LNG 40 microg as required, or placebo, for 52 weeks. Women treated with E(2) in the first year continued therapy at the same doses in the second year. Efficacy, safety and pharmacokinetics were assessed.

RESULTS

There were 73 women randomized to E(2) 0.5 mg, 157 to E(2) 1.0 mg and 79 to placebo. Lumbar bone mineral density at 52 weeks increased significantly more with E(2) 1.0 mg (p < 0.001) and 0.5 mg (p < 0.001) than with placebo (no change). After 2 years, a 10% increase in bone mineral density with E(2) 1.0 mg was significantly greater than with E(2) 0.5 mg (8%; p = 0.008). E(2) was associated with an acceptable safety and tolerability profile, with slightly more adverse events with E(2) 1.0 than 0.5 mg. Serum E(2) concentration increased in a dose-dependent manner.

CONCLUSION

This study showed that E(2), at both 1.0 mg and 0.5 mg doses, was effective in increasing bone mineral density with an acceptable safety and tolerability profile in Japanese postmenopausal women with osteoporosis but that the bone mineral density response was higher with the 1.0 mg dose.

Effects of low-dose hormone therapy on menopausal symptoms, bone mineral density, endometrium, and the cardiovascular system: a review of randomized clinical trials

OBJECTIVES

First, to determine the extent of the effects of low-dose hormone therapy (HT) on menopausal symptoms, bone mineral density, endometrium, and the cardiovascular system, and, second, to determine the adverse effects of low-dose HT.

METHODS

A literature review of electronic databases was conducted to identify all prospective, randomized trials comparing the effects of low-dose HT with placebo or standard-dose therapy, using key words such as: hormone replacement therapy (HRT), low-dose HRT/conjugated equine estrogens (CEE)/estradiol, lower-dose HRT/CEE/estradiol, ultra-low-dose HRT/CEE/estradiol, menopause, cardiovascular risk, bone metabolism.

RESULTS

Low-dose HT has been shown to improve menopausal and vulvovaginal atrophic symptoms, compared to placebo, and is less likely to give rise to unacceptable side-effects, including irregular bleeding and/or breast tenderness. When compared to standard-dose HT, the low-dose HT has comparable effects on a range of menopausal symptoms and on bone density and has similar beneficial effects on surrogate end-points of coronary heart disease.

CONCLUSIONS

A change to low-dose HT has been advocated following adverse findings in recent trials of standard-dose HT. Although a literature review has shown low-dose HT to alleviate menopausal symptoms and maintain or improve bone density with fewer side-effects than standard-dose therapy, further research is required to determine what effect the lower-dose therapy will have on fracture, cardiovascular and breast disease.

Hormone therapy in postmenopausal women and risk of endometrial hyperplasia

BACKGROUND

Declining circulating estrogen levels around the time of the menopause can induce unacceptable symptoms that affect the health and well being of women. Hormone therapy (both unopposed estrogen and estrogen/progestogen combinations) is an effective treatment for these symptoms, but is associated with risk of harms. Guidelines recommend that hormone therapy be given at the lowest effective dose and treatment should be reviewed regularly. The aim of this review is to identify the minimum dose(s) of progestogen required to be added to estrogen so that the rate of endometrial hyperplasia is not increased compared to placebo.

OBJECTIVES

The objective of this review is to assess which hormone therapy regimens provide effective protection against the development of endometrial hyperplasia and/or carcinoma.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched January 2008), The Cochrane Library (Issue 1, 2008), MEDLINE (1966 to May 2008), EMBASE (1980 to May 2008), Current Contents (1993 to May 2008), Biological Abstracts (1969 to 2008), Social Sciences Index (1980 to May 2008), PsycINFO (1972 to May 2008) and CINAHL (1982 to May 2008). Attempts were made to identify trials from citation lists of reviews and studies retrieved, and drug companies were contacted for unpublished data.

SELECTION CRITERIA

Randomised comparisons of unopposed estrogen therapy, combined continuous estrogen-progestogen therapy and/or sequential estrogen-progestogen therapy with each other or placebo, administered over a minimum period of twelve months. Incidence of endometrial hyperplasia/carcinoma assessed by a biopsy at the end of treatment was a required outcome. Data on adherence to therapy, rates of additional interventions, and withdrawals due to adverse events were also extracted.

DATA COLLECTION AND ANALYSIS

In this substantive update, forty five studies were included. Odds ratios were calculated for dichotomous outcomes. The small numbers of studies in each comparison and the clinical heterogeneity precluded meta analysis for many outcomes.

MAIN RESULTS

Unopposed estrogen is associated with increased risk of endometrial hyperplasia at all doses, and durations of therapy between one and three years. For women with a uterus the risk of endometrial hyperplasia with hormone therapy comprising low dose estrogen continuously combined with a minimum of 1 mg norethisterone acetate or 1.5 mg medroxyprogesterone acetate is not significantly different from placebo (1mg NETA: OR=0.04 (0 to 2.8); 1.5mg MPA: no hyperplasia events).

AUTHORS' CONCLUSIONS

Hormone therapy for postmenopausal women with an intact uterus should comprise both estrogen and progestogen to reduce the risk of endometrial hyperplasia.

Care of the menopausal patient: A nurse practitioner?s view

PURPOSE

To evaluate the benefits and risks of hormone therapy (HT) and other treatment options for early postmenopausal women.

DATA SOURCES

Published clinical trials, selected peer-reviewed literature, and recent clinical practice guidelines.

CONCLUSIONS

Results of the Women's Health Initiative (WHI) studies on HT may not be directly applicable to healthy, early postmenopausal women suffering from hot flushes. HT is the most effective treatment for menopausal symptoms. The benefits of HT in relieving menopausal symptoms are likely to exceed the risks in this population.

IMPLICATIONS FOR PRACTICE

The results of the WHI reinforce the importance of individualized care based on a woman's medical history, medical needs, and desired outcomes. Nurse practitioners can help their patients put recent results into perspective. When HT is used, nurse practitioners should consider using lower doses and reevaluate the need for therapy annually.

Comparison of the effects of raloxifene and low-dose hormone replacement therapy on bone mineral density and bone turnover in the treatment of postmenopausal osteoporosis

OBJECTIVE

The aim of the present study was to compare the effects of raloxifene and low-dose hormone replacement therapy (HRT) on bone mineral density (BMD) and bone turnover markers in the treatment of postmenopausal osteoporosis.

METHODS

Forty-two postmenopausal osteoporotic women, who were randomized to receive raloxifene 60 mg or estradiol 1 mg/norethisterone acetate 0.5 mg daily for 1 year, were studied. All women received calcium 600 mg/day and vitamin D 400 IU/day. BMD and markers of bone turnover were measured at baseline and at 12 months.

RESULTS

After 12 months of treatment, there were statistically significant increases in BMD in both groups at all sites (all p < 0.05). For the lumbar spine, the increase in BMD was 2.3% for raloxifene compared with 5.8% for low-dose HRT and corresponding values for total body BMD were 2.9% for raloxifene and 4.6% for low-dose HRT; the increases being significantly greater in the low-dose HRT group (p < 0.001 and p = 0.02, respectively). Although the increase in BMD at the hip was significant for both raloxifene (2.1%) and low-dose HRT (3.2%) compared with baseline, the difference between the two regimens did not reach statistical significance. The decrease in serum C-terminal telopeptide fragment of type I collagen and serum osteocalcin levels for the low-dose HRT group (-53% and -47%, respectively) was significantly greater than for the raloxifene group (-23% and -27%, respectively; both p < 0.01).

CONCLUSIONS

In postmenopausal women with osteoporosis, low-dose HRT produced significantly greater increases in BMD of the lumbar spine and total body and greater decreases in bone turnover than raloxifene at 12 months.

Benefits and risks of long-term low-dose oral continuous combined hormone therapy

OBJECTIVES

Current recommendations for hormone therapy (HT) are mainly based on findings from studies using standard dose regimens in older women who had a different health profile from those who start HT soon after the onset of menopause.

METHODS

We, therefore, reviewed controlled trials assessing the efficacy, safety and tolerability of low-dose oral continuous combined HT (cc-HT) started for treatment of climacteric symptoms. This review is limited to oral cc-HT regimens over sequential regimens as most postmenopausal women prefer not to have a return of uterine bleeding, and to studies of at least 2 years in duration.

RESULTS

Low-dose cc-HT is effective in alleviating climacteric symptoms and in maintaining bone density over prolonged periods, although no data were available regarding fracture risk. No increased risk of coronary heart disease, venous thrombo-embolism or stroke during the use of low-dose cc-HT was reported in the long-term studies and no definitive evidence for an increased risk of breast cancer was found. Breakthrough bleeding during the first months of use is less common than with standard dose HT and amenorrhoea is achieved in most women over time. These regimens are safe for the endometrium and are well tolerated, with a low incidence of adverse events compared with standard doses.

CONCLUSIONS

Current evidence from controlled trials indicates that low-dose oral cc-HT appears effective and safe. This makes it a good choice for the alleviation of climacteric symptoms, and for this purpose long-term administration of low-dose cc-HT does not seem to impose serious health risks. However, more long-term study data and direct head-to-head comparisons between various low-dose preparations are needed to support or rectify the safety aspects.

Low dose estrogens inhibit coronary artery atherosclerosis in postmenopausal monkeys

OBJECTIVES

To determine if low dose conjugated equine estrogens (CEE) result in a reduction of coronary artery atherosclerosis progression, and to relate these findings to previous studies using the traditional dose.

METHODS

Adult female monkeys (Macaca fascicularis) were fed an atherogenic diet for 10 months, to induce fatty streaks and small plaques comparable to those present in early postmenopausal women, and then ovariectomized and treated orally with: CEE (0.30 mg/day women's equivalent dose, n=28) or placebo (n=25) daily for 24 months. Body weight and estradiol were measured at 3, 6, 12 and 18 months and plasma lipids were measured at baseline and every 6 months.

RESULTS

Despite the lack of effect on plasma lipid profiles, monkeys treated with low dose CEE had marked reductions in coronary artery atherosclerosis plaque extent (intimal area) in all three main coronary arteries: left anterior descending artery (52% less, 0.044 mm(2) versus 0.091 mm(2), p=0.04); left circumflex artery (62% less, 0.045 mm(2) versus 0.119 mm(2), p=0.006) and right circumflex artery (42% less, 0.018 mm(2) versus 0.031 mm(2), p=0.20). The overall mean coronary atherosclerosis extent was 52% lower in CEE treated animals (0.042 mm(2) versus 0.088 mm(2), p=0.02).

CONCLUSION

Low dose CEE (0.30 mg/woman/day equivalent) was effective in reducing coronary atherosclerosis and the magnitude of the protection was comparable to previously reported studies using doses equivalent to 0.625 mg/woman/day. This study provides an experimental basis for the assumption that low dose CEE may be as effective as the traditional dose in inhibiting coronary atherosclerosis progression in early postmenopausal subjects.

Randomized trial comparing low-dose hormone replacement therapy and HRT plus 1alpha-OH-vitamin D3 (alfacalcidol) for treatment of postmenopausal bone loss

We conducted a prospective, randomized, multicenter, open-label 2-year trial with 76 postmenopausal women aged > or =60 years with low (T-score less than -1) lumbar bone mineral density (BMD). The hormone replacement therapy (HRT) group received a low dose of conjugated estrogen (CEE) at a dose of 0.31 mg/day +/- medroxyprogesterone acetate (MPA) 2.5 mg/day. Group HRT/D received the same dose of HRT together with alfacalcidol in a daily dose of 1.0 microg/day. Changes in lumbar BMD measured by dual energy X-ray absorptiometry (DXA) were followed every 6 months for 2 years. The lumbar BMD of group HRT increased 3.37% [95% confidence interval (CI) 1.6%-5.2%], 4.00% (95%CI 1.6%-6.4%), and 2.32% (95%CI -0.7% to 5.3%) at 12, 18, and 24 months, respectively, when the baseline value was taken as 0%. Lumbar BMD of group HRT/D showed a significant increase beyond 6 months. The percent increases for this group at 6, 12, 18, and 24 months were 6.18 (95%CI 1.3%-6.6%), 6.18% (95%CI 3.9%-8.5%), 7.17% (95%CI 4.3%-10.0%), and 8.75% (95%CI 6.0%-11.5%), respectively. In addition, there was a significant difference in the changes of the lumbar BMD between the two groups at 24 months, suggesting that the combination of HRT and alfacalcidol is more effective than HRT alone in terms of the BMD effect. This study is the first prospective trial demonstrating an additive effect of alfacalcidol on lumbar BMD in postmenopausal women receiving low-dose HRT. It suggests that the combination therapy can be considered to be a promising mode of treatment for bone loss after menopause.

Appropriate use of hormones should alleviate concerns of cardiovascular and breast cancer risk

Since the publication of several recent randomized trials in the United States, prescriptions for hormonal therapy have dropped precipitously. This has been due, in large part, to the concerns about the increased risk of cardiovascular (CV) disease and breast cancer among the hormone users. This review takes the perspective that the appropriate use of hormones largely alleviates these concerns. The appropriate use of hormones pertains to treating younger, healthy women who have menopausal symptoms as well as using low-doses of hormones. In the randomized trials, suggesting an increased CV risk, the older women were largely asymptomatic and had other CV risk factors. Data are presented to suggest that there is no increased CV risk with hormonal therapy in younger, healthy women within 5 years of menopause. Moreover, a model is presented to attempt to explain the potential of preventing CV disease when estrogen is begun early, and the relative hazard associated with later use. The risk of breast cancer with hormonal therapy is put into perspective with the realization that this risk is related to hormonal dose and duration of use, and that the absolute risk remains small. Use of progestogens, in particular, appears to enhance this risk. The appropriate use of hormones also pertains to using lower-doses. Here data are presented showing efficacy with lower-doses and improved safety. With the use of lower-doses of estrogens, the progestogen dose, as required in women with a uterus, can be minimized.

Human races and pharmacogenomics of effective bone treatments

Osteoporosis and its complications represent one of the most important causes of morbidity and mortality around the world. Moreover, its management presents an important economic problem. Although osteoporosis is a worldwide health problem, there are many differences in ethnic groups regarding disease morbidity and drug treatment efficacy. This review analyzed clinical response data of two major osteoporotic treatments (vitamin D and estrogens) regarding four major human races (Asian, Caucasian, Hispanic and Negroid). From clinical studies, Asians seem to be more vitamin-D-sensitive while Caucasians appear more estrogen-sensitive than other human races. Different drug responses may be related to allelic variants in their signaling genes such as those for the vitamin D receptor (VDR) and estrogen receptor-alpha (ER alpha). Some polymorphisms of VDR and ER alpha loci appear to be genetic determinants of osteoporotic risk: ApaI-BsmI-TaqI, FokI variants and poly(A) repeats in VDR; PvuII-XbaI variants and (TA) repeats in ER alpha. Also, because of specific ethnic allele distributions, these VDR and ER alpha polymorphisms may be involved in race differences of osteoporosis treatment responses. Future studies and preventive strategies for the management of osteoporosis need to take into account these racial and genetic factors.

Serum Estradiol Concentration as Measured by HPLC-RIA and Bone Mineral Density in Postmenopausal Women during Hormone Replacement Therapy

OBJECTIVE

To determine the relationship between the serum estradiol concentration and bone mineral density (BMD) of the lumbar spine in postmenopausal women treated with conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA) every other day and every day.

METHODS

Eighty-four postmenopausal women were randomly treated with hormone replacement therapy (HRT) every other day and every day. Forty-seven women received oral administration of 0.625 mg CEE and 2.5 mg MPA every other day, and 37 women received oral administration of 0.625 mg CEE and 2.5 mg MPA every day. BMD of the lumbar spine at 12 months and serum concentrations of estradiol and estrone at 6 and 12 months after treatment were examined.

RESULTS

The estradiol concentration in subjects treated every other day showed a significant (p < 0.001) positive correlation with the percentage change in lumbar BMD, while that in subjects treated every day was not correlated with the percentage change in BMD. The differences between serum estradiol concentrations after 12 months of treatment and initial serum estradiol values in women treated every other day and every day also showed a significant (p < 0.01 and 0.05, respectively) positive correlation with percentage changes in BMD. In women treated every other day, body mass index (BMI) in the subjects in whom BMD did not increase was significantly (p < 0.01) lower than that in the subjects in whom BMD did increase.

CONCLUSIONS

The serum estradiol concentration in women treated every other day has a strong positive correlation with the percentage change in lumbar BMD, but a higher estradiol concentration may be needed for women in whom BMD did not increase with HRT every other day after due consideration of individual characteristics such as BMI.

Hormone replacement therapy in postmenopausal women: endometrial hyperplasia and irregular bleeding

BACKGROUND

The decline in circulating oestrogen around the time of the menopause often induces unacceptable symptoms that affect the health and well being of women. Hormone replacement therapy (both unopposed oestrogen and oestrogen and progestogen combinations) is an effective treatment for these symptoms. In women with an intact uterus, unopposed oestrogen may induce endometrial stimulation and increase the risk of endometrial hyperplasia and carcinoma. The addition of progestogen reduces this risk but may cause unacceptable symptoms, bleeding and spotting which can affect adherence to therapy.

OBJECTIVES

The objective of this review is to assess which hormone replacement therapy regimens provide effective protection against the development of endometrial hyperplasia and/or carcinoma with a low rate of abnormal vaginal bleeding.

SEARCH STRATEGY

We searched the Cochrane Menstrual Disorders and Subfertility Group trials register (searched January 2003), The Cochrane Library (Issue 2, 2003), MEDLINE (1966 to January 2003), EMBASE (1980 to January 2003), Current Contents (1993 to January 2003), Biological Abstracts (1969 to 2002), Social Sciences Index (1980 to January 2003), PsycINFO (1972 to February 2003) and CINAHL (1982 to January 2003). The search strategy was developed by the Cochrane Menstrual Disorder and Subfertility Group. Attempts were also made to identify trials from citation lists of review articles and drug companies were contacted for unpublished data. In most cases, the corresponding author of each included trial was contacted for additional information.

SELECTION CRITERIA

The inclusion criteria were randomised comparisons of unopposed oestrogen therapy, combined continuous oestrogen-progestogen therapy and sequential oestrogen-progestogen therapy with each other and placebo administered over a minimum treatment period of six months. Trials had to assess which regimen was the most protective against the development of endometrial hyperplasia/carcinoma and/or caused the lowest rate of irregular bleeding.

DATA COLLECTION AND ANALYSIS

Sixty RCTs were identified. Of these 23 were excluded and seven remain awaiting assessment. The reviewers assessed the thirty included studies for quality, extracted the data independently and odds ratios for dichotomous outcomes were estimated. Outcomes analysed included frequency of endometrial hyperplasia or carcinoma, frequency of irregular bleeding and unscheduled biopsies or dilation and curettage, and adherence to therapy.

MAIN RESULTS

Unopposed moderate or high dose oestrogen therapy when compared to placebo was associated with a significant increase in rates of endometrial hyperplasia with increasing rates at longer duration of treatment and follow up. Odds ratios ranged from (1 RCT; OR 5.4, 95% CI 1.4 to 20.9) for 6 months of treatment to (4 RCTs; OR 9.6, 95% CI 5.9 to 15.5) for 24 months treatment and (1 RCT; OR 15.0, 95% CI 9.3 to 27.5) for 36 months of treatment with moderate dose oestrogen (in the PEPI trial, 62% of those who took moderate dose oestrogen had some form of hyperplasia at 36 months compared to 2% of those who took placebo). Irregular bleeding and non adherence to treatment were also significantly more likely under these unopposed oestrogen regimens that increased bleeding with higher dose therapy. Although not statistically significant, there was a 3% incidence (2 RCTs) of hyperplasia in women who took low dose oestrogen compared to no incidence of hyperplasia in the placebo group. The addition of progestogens, either in continuous combined or sequential regimens, helped to reduce the risk of endometrial hyperplasia and improved adherence to therapy. At longer duration of treatment, continuous therapy was more effective than sequential therapy in reducing the risk of endometrial hyperplasia. There was evidence of a higher incidence of hyperplasia under long cycle sequential therapy (progestogen given every three months) compared to monthly sequential therapy (progestogen given every month). No increase in endometrial cancer was seen in any of t in any of the treatment groups during the duration (maximum of six years) of these trials. During the first year of therapy irregular bleeding and spotting was more likely in continuous combined therapy than sequential therapy. However, during the second year of therapy bleeding and spotting was more likely under sequential regimens.

REVIEWERS' CONCLUSIONS

There is strong and consistent evidence in this review that unopposed oestrogen therapy, at moderate and high doses, is associated with increased rates of endometrial hyperplasia, irregular bleeding and consequent non adherence to therapy. The addition of oral progestogens administered either sequentially or continuously is associated with reduced rates of hyperplasia and improved adherence to therapy. Irregular bleeding is less likely under sequential than continuous therapy during the first year of therapy but there is a suggestion that continuous therapy over long duration is more protective than sequential therapy in the prevention of endometrial hyperplasia. Hyperplasia is more likely when progestogen is given every three months in a sequential regimen compared to a monthly progestogen sequential regimen.

Overview on the effects of progestins on bone

In view of the fact that fractures are the clinically relevant events, risk factors for fractures are discussed first. Bone mineral density (BMD) appears to be a much less important risk factor for the most severe hip fractures than the risk of falling. No results of experimental studies on hormones and fractures at advanced age are available. An overview of the effects of progestins on bone is given. Effects of progestins on bone have been studied by in vitro experiments using cell lines and by more relevant clinical observations. Prospective studies have been conducted following the use of progestins contained in oral contraceptives, alone or in combination with oestrogens; long-term contraception by injection of depot preparations; so-called "add-back" hormonal therapy attempting to reverse the adverse effects of gonadotropin releasing hormone agonists on bone and after different regimens of hormone replacement therapy (HRT) in postmenopausal women. From the data there are no indications that the various progestins, used in clinical practice, have either a bone-protective or an oestrogen antagonistic activity. Progestins do not add or subtract much of the protective action of oestrogens on the bones.

Low-Dose Estrogen Therapy for Menopausal Women: A Review of Efficacy and Safety

BACKGROUND

Recent adverse events involving research of traditional estrogen therapy have led to interest in lower-than-standard doses of menopausal estrogen therapy.

METHOD

The Medline (1966-present) database was searched for randomized controlled trials (keywords: low-dose estrogen, minimum dose AND estrogen, menopause, and osteoporosis) regarding hot flashes, endometrial hyperplasia, vaginal bleeding, breast tenderness, and bone density. Studies are only a few years in duration.

RESULTS

The decrease in hot flashes with half-strength estrogens, range 60%-70%, is less than the 80%-90% reduction with standard dosing. Some low-dose preparations preserve lumbar and femoral bone density (although the degree of effect and quality of evidence vary among preparations). Bone density effects are dose dependent for conjugated equine estrogen (CEE), transdermal estradiol ethinyl (E(2)), norethindrone acetate (E(2)/NETA), oral E(2), and esterified estrogens. Bone preservation is likely to be less efficacious with low-dose estrogens than with traditional doses. Low-dose estrogen alone may not protect bone unless adequate calcium is given. Breast tenderness and skeletal effects are likely dose dependent. The longest endometrial safety data are 2-year data, reported for 5 microg/1 mg EE(2)/NETA and for 0.3 mg/day esterified estrogens. Some low-dose preparations have better vaginal bleeding profiles than do higher dose preparations. Breast tenderness is not totally averted with new lower-dose preparations. There are no fracture, breast cancer, or cardiovascular outcome data and a general lack of direct head-to-head comparisons involving low-dose preparations.

CONCLUSIONS

Serious adverse effects linked with traditional doses of estrogens may not be averted with lower-dose preparations, and low-dose preparations should not yet be emphasized as being safer than traditional (e.g., 0.625 mg/day CEE doses).

Lipid profiles and endothelial function with low-dose hormone replacement therapy in postmenopausal women at risk for coronary artery disease: a randomized trial

AIMS

To compare the effect of low (0.3 mg) and commonly prescribed (0.625 mg) doses of conjugated equine estrogens (CEE) on brachial artery flow-mediated dilation and lipid profiles.

METHODS AND RESULTS

Twenty-five postmenopausal women (mean age, 65+/-6 years) at risk for coronary artery disease (CAD) (> or =2 established risk factors) entered a double-blind crossover study. Brachial artery endothelial function was evaluated by means of high-resolution vascular echography. Both CEE doses significantly decreased total cholesterol (-13%, 0.3 mg; -15%, 0.625 mg), low-density lipoprotein-cholesterol (LDL-C) (-15%, 0.3 mg; -16%, 0.625 mg), and lipoprotein(a) (-28%, 0.3 mg; -39%, 0.625 mg) values from baseline levels. Both treatments increased high-density lipoprotein-cholesterol (HDL-C) (5%, 0.3 mg; 7%, 0.625 mg) and triglycerides (3%, 0.3 mg; 8%, 0.625 mg). There was no dose effect for changes in the LDL-C/HDL-C ratio (-21%, 0.3 mg; -23%, 0.625 mg). Both doses improved brachial artery dilation during reactive hyperemia by 63% over baseline.

CONCLUSION

In women at risk for CAD, low-dose hormone replacement treatment (HRT) improves lipid profiles and brachial artery endothelial function comparably to the most commonly prescribed dose. The benefit:risk ratio of low-dose HRT provides an attractive option for postmenopausal women at risk for CAD.

Hormone replacement therapy: optimising the dose and route of administration

Several new products and regimens for estrogen replacement in the postmenopausal woman have recently been introduced, giving physicians and patients greater choice not only in dose but also in route of administration. Estrogen treatment in the postmenopausal woman has several proven benefits for those who have vasomotor symptoms or problems related to urogenital atrophy. However, the most controversial area is in the long-term preventive benefits of estrogen against the development of osteoporosis and cardiovascular disease, particularly in women older than 60 years. It is in these areas that decisions on the dose and optimal route of administration of estrogen replacement therapy (ERT) must be made. Although adding a progestogen to an ERT regimen is mandatory, particularly in a woman with an intact uterus, discussion now focuses on which progestogen least attenuates the beneficial effects of estrogen. Emerging trends suggest that lower doses of estrogen (i.e. ethinylestradiol 5 microg/day, estradiol 0.25 mg/day or conjugated estrogens [CEE] 0.3 mg/day) continuously combined with lower doses of medroxyprogesterone (MPA) are equally effective at relieving vasomotor symptoms as the most commonly prescribed regimen in the US (CEE 0.625mg/MPA 2.5mg daily), with fewer adverse events, leading to greater patient acceptance and likelihood for continuation of therapy. This is especially important when therapy is initiated at an older age.

Meta-analyses of therapies for postmenopausal osteoporosis. V. Meta-analysis of the efficacy of hormone replacement therapy in treating and preventing osteoporosis in postmenopausal women

OBJECTIVE

To review the effect of hormone replacement therapy (HRT) on bone density and fractures in postmenopausal women.

DATA SOURCE

We searched MEDLINE and EMBASE from 1966 to 1999, the Cochrane Controlled Register, citations of relevant articles, and proceedings of international meetings for eligible randomized controlled trials. We contacted osteoporosis investigators to identify additional studies, and primary authors for unpublished data.

STUDY SELECTION

We included 57 studies that randomized postmenopausal women to HRT or a control (placebo or calcium/vitamin D) and were of at least 1 yr in duration. Seven of these studies reported fractures.

DATA ABSTRACTION

For each study, three independent reviewers assessed the methodological quality and abstracted the data.

DATA SYNTHESIS

HRT showed a trend toward reduced incidence of vertebral fractures [relative risk (RR) 0.66, 95% confidence interval (CI) 0.41-1.07; 5 trials] and nonvertebral fractures (RR 0.87, 95% CI 0.71-1.08; 6 trials). HRT had a consistent effect on bone mineral density (BMD) at all sites. The difference between HRT and control in the percent change in bone density at 2 yr was 6.76 (5.83, 7.89; 21 trials) at the lumbar spine and 4.53 (3.68, 5.36; 14 trials) and 4.12 (3.45, 4.80; 9 trials) at the forearm and femoral neck, respectively.

CONCLUSIONS

HRT has a consistent, favorable and large effect on bone density at all sites. The data show a nonsignificant trend toward a reduced incidence in vertebral and nonvertebral fractures.

Endometrial safety of hormone replacement therapy: review of literature

Unopposed estrogens for treating menopausal symptoms were extensively used when epidemiological findings associated them with an increased endometrial cancer risk. Adding progestogens reverse this side effect efficiently but patient, dose, type and especially time during which the progestogen is administered are important. Long-term uterine safety of the long cycle HRT with administration of the progestogen every 3 months remains unclear. Because regular bleeding lowers compliance, continuous combined estrogen-progestogen treatment has become popular. Many different regimens are now available using oral, transdermal, subcutaneous, intravaginal or intra-uterine application of the estrogen and/or progestogen. Available but inadequate studies seem to point towards a slightly decreased endometrial cancer risk with continuous combined preparations compared with non-HRT-users and an increased risk with long-term oral but not vaginal treatment with low-potency estrogen formulations such as estriol. Newer compounds for menopausal health such as tibolone and raloxifene seem to be safe. As for any women with abnormal vaginal bleeding, those on HRT must have an intra-uterine evaluation. Transvaginal ultrasound (TVU) is very accurate in predicting a normal uterine cavity but inaccurate in predicting endometrial pathology because of a low specificity and positive predictive value of a thick echogenic endometrium. In all such cases a three-dimensional visualisation of intra-uterine lesions is more accurate. Periodic examination with TVU and/or endometrial biopsy of HRT exposed endometrium in asymptomatic women is not cost-effective. The available limited data on the use of HRT in hysterectomised women for early stage endometrial cancer show little evidence in terms of recurrence.

Biological effects of hormone replacement therapy in relation to serum estradiol levels

OBJECTIVE

Tissues in various parts of the body have different sensitivities to estradiol. However, it is very difficult to measure the serum estradiol levels precisely in women receiving oral conjugated equine estrogen, which is a mixture of estrogens. In the present study, we precisely measured the serum levels of estradiol in postmenopausal women undergoing hormone replacement therapy (HRT), and we clarified the relationships between serum estradiol levels and the effects of HRT on the Kupperman index, bone mineral density (BMD), serum gonadotropin, lipid metabolism and unscheduled bleeding as the clinical endpoints.

METHODS

Sixty-eight postmenopausal or bilaterally ovariectomized women, aged 30-64 years, who had been suffering from vasomotor symptoms such as hot flush or atrophy of the vagina were randomly assigned to two groups: one group of 34 patients who received oral administration of 0.625 mg conjugated equine estrogen (CEE, Premarin, Wyeth) and 2.5 mg medroxyprogesterone acetate (MPA, Provera, Upjohn) every other day, and another group of 34 patients who received oral administration of 0.625 mg CEE and 2.5 mg MPA every day. All subjects were re-classified into three groups according to the serum estradiol level after 12 months of treatment: (1) low estradiol group (<15 pg/ml, n = 25); (2) middle estradiol group (> or =15 and <25 pg/ml, n = 27), and (3) high estradiol group (> or =25 pg/ml, n = 16). We examined the relationships between serum estradiol level and the effects of estradiol on the Kupperman index, BMD, serum gonadotropin levels, lipid profile and unscheduled bleeding in these three groups.

RESULTS

RESULTS obtained by using our newly developed high-performance liquid chromatography (HPLC)-radioimmunoassay (RIA) system clearly showed that the effects on each tissue in postmenopausal women receiving oral CEE and MPA is closely related to estradiol level. The effects of HRT on BMD, serum gonadotropin levels and lipid profile were shown to be clearly dependent on the serum estradiol levels, while the effect of HRT on the Kupperman index was independent of the serum estradiol level. Furthermore, it was also found that a very low concentration of estradiol (<15 pg/ml) was sufficient to suppress the serum LH and FSH levels and to relieve vasomotor symptoms, and that the minimum concentration of estradiol required to increase BMD was 15 pg/ml. On the other hand, the level of estradiol required to reduce total cholesterol, low density lipoprotein-cholesterol (LDL-C) and apolipoprotein B (Apo B) was found to be more than 25 pg/ml, while the level required to increase high density lipoprotein-cholesterol (HDL-C) and apolipoprotein A1 (Apo A1) was at least 15 pg/ml. The incidence of unscheduled bleeding was also lower in the low estradiol group than in the other estradiol level groups.

CONCLUSION

These results suggest that the different clinical endpoints have different response thresholds and thus reflect tissue sensitivity to estradiol levels achieved by HRT.

The effect of low-dose conjugated equine estrogens and cyclic MPA on bone density

OBJECTIVE

to compare the effect of 0.3 and 0.625 mg conjugated equine estrogens on bone mineral density (BMD) in a private practice setting.

METHODS

postmenopausal women interested in hormone replacement therapy were prescribed either 0.3 or 0.625 mg conjugated equine estrogens daily with 10 mg medroxyprogesterone acetate days 1-12 of the month. All women were given calcium citrate 1000 mg/day and vitamin D 400 IU/day. DEXA bone mineral density studies of the spine and hip were performed at baseline and 1 year.

RESULTS

there was no significant difference in BMD at the spine, the trochanter or the femoral neck compared with baseline in either the 0.625 or 0.3 mg group. The mean percent increase in BMD for the 0.3 versus 0.625 mg group was: spine 2.6 versus 3.8%, femoral neck 1.8 versus 1.5%, and trochanter 0.5 versus 2.6%.

CONCLUSION

both the 0.625 mg dose and the 0.3 mg dose of conjugated equine estrogens preserved BMD at the spine and hip over one year in early postmenopausal women who were also given cyclic medroxyprogesterone acetate, calcium citrate and vitamin D.

Efficacy of every-other-day administration of conjugated equine estrogen and medroxyprogesterone acetate on gonadotropin-releasing hormone agonists treatment in women with endometriosis

We performed a randomized controlled study to determine the efficacy of add-backed therapy by every-other-day administration of 0.625 mg conjugated equine estrogen (CEE) and 2.5 mg medroxyprogesterone acetate (MPA) on GnRH agonists (GnRH-a) treatment in Japanese women with symptomatic endometriosis. At the end of treatment, serum estrone and estradiol levels in the add-back group (n = 11) were significantly higher than those in the control group (n = 10). The assessment of Beecham classification by bimanual examination, serum CA-125 levels, and the frequency of genital bleeding revealed no significant differences between the two groups. The add-back group showed reduced Kupperman indices relative to those of the control group, and could prevent the loss of bone density. These findings led to a conclusion that GnRH-a therapy added back by every-other-day administration of 0.625 mg CEE and 2.5 mg MPA was a safe and effective treatment for Japanese women with endometriosis.

Effects of lower doses of conjugated equine estrogens and medroxyprogesterone acetate on endometrial bleeding

OBJECTIVE

To evaluate vaginal bleeding profiles with lower doses of conjugated equine estrogens (CEE) and medroxyprogesterone acetate (MPA) as continuous combined therapy.

DESIGN

The Women's Health, Osteoporosis, Progestin, Estrogen (Women's HOPE) study, a randomized, double-blind, placebo-controlled trial.

SETTING

Study centers across the United States.

PATIENT(S)

Two thousand six hundred seventy-three healthy, postmenopausal women.

INTERVENTION(S)

Women received CEE, 0.625 mg/d; CEE, 0.625 mg/d, plus MPA 2.5 mg/d; CEE, 0.45 mg/d; CEE, 0.45 mg/d, plus MPA, 2.5 mg/d; CEE 0.45 mg/d, plus MPA, 1.5 mg/d; CEE, 0.3 mg/d; CEE, 0.3 mg/d, plus MPA, 1.5 mg/d; or placebo for 1 year.

MAIN OUTCOME MEASURE(S)

Bleeding data were analyzed in efficacy-evaluable and intention-to-treat populations.

RESULT(S)

Cumulative amenorrhea and no bleeding rates were higher with lower doses of CEE/MPA than with CEE 0.625/MPA 2.5. A linear trend between time since menopause and cumulative amenorrhea was observed (P<.05) in all CEE/MPA groups except the CEE 0.45/MPA 1.5 group. The proportion of patients who experienced no bleeding in cycle 1 was 89%, 82%, and 80% in the CEE 0.3/MPA 1.5, CEE 0.45/MPA 1.5, and CEE 0.45/MPA 2.5 groups, respectively. These values were significantly greater than the incidence of no bleeding in the CEE 0.625/MPA 2.5 group (P<.05).

CONCLUSION(S)

Lower-dose regimens of CEE and MPA produce higher rates of amenorrhea and no bleeding compared with CEE 0.625/MPA 2.5 and may be appropriate for newly menopausal patients.

Relief of vasomotor symptoms and vaginal atrophy with lower doses of conjugated equine estrogens and medroxyprogesterone acetate

OBJECTIVE

To evaluate the efficacy of lower doses of conjugated equine estrogens (CEE) plus medroxyprogesterone acetate (MPA) for relieving vasomotor symptoms and vaginal atrophy.

DESIGN

A randomized, double-blind, placebo-controlled trial (the Women's Health, Osteoporosis, Progestin, Estrogen study).

SETTING

Study centers across the United States.

PATIENT(S)

Two thousand, six hundred, seventy-three healthy, postmenopausal women with an intact uterus, including an efficacy-evaluable population (n = 241 at baseline).

INTERVENTION(S)

Patients received for 1 year (13 cycles; in milligrams per day) CEE, 0.625; CEE, 0.625 and MPA, 2.5; CEE, 0.45; CEE, 0.45 and MPA, 2.5; CEE, 0.45 and MPA, 1.5; CEE, 0.3; CEE, 0.3 and MPA, 1.5; or placebo.

MAIN OUTCOME MEASURE(S)

Number and severity of hot flushes and Papanicolaou smear with vaginal maturation index (VMI) to assess vaginal atrophy.

RESULT(S)

In the efficacy-evaluable population, reduction in vasomotor symptoms was similar with CEE of 0.625 mg/d and MPA of 2.5 mg/d (the most commonly prescribed doses) and all lower combination doses. CEE of 0.625 mg/d alleviated hot flushes more effectively than the lower doses of CEE alone. VMI improved in all active treatment groups.

CONCLUSION(S)

Lower doses of CEE plus MPA relieve vasomotor symptoms and vaginal atrophy as effectively as commonly prescribed doses.

Effects of postmenopausal hormone replacement therapy on lipid, lipoprotein, and apolipoprotein (a) concentrations: analysis of studies published from 1974-2000

OBJECTIVE

To establish reference estimates of the effects of different hormone replacement therapy (HRT) regimens on lipid and lipoprotein levels.

DESIGN

Review and pooled analysis of prospective studies published up until the year 2000.

SETTING

Clinical trials centers, hospitals, menopause clinics.

PATIENT(S)

Healthy postmenopausal women.

INTERVENTION(S)

Estrogen alone, estrogen plus progestogen, tibolone, or raloxifene in the treatment of menopausal symptoms.

MAIN OUTCOME MEASURE(S)

Serum high- and low-density lipoprotein (HDL and LDL) cholesterol, total cholesterol, triglycerides, and lipoprotein (a).

RESULT(S)

Two-hundred forty-eight studies provided information on the effects of 42 different HRT regimens. All estrogen alone regimens raised HDL cholesterol and lowered LDL and total cholesterol. Oral estrogens raised triglycerides. Transdermal estradiol 17-beta lowered triglycerides. Progestogens had little effect on estrogen-induced reductions in LDL and total cholesterol. Estrogen-induced increases in HDL and triglycerides were opposed according to type of progestogen, in the order from least to greatest effect: dydrogesterone and medrogestone, progesterone, cyproterone acetate, medroxyprogesterone acetate, transdermal norethindrone acetate, norgestrel, and oral norethindrone acetate. Tibolone decreased HDL cholesterol and triglyceride levels. Raloxifene reduced LDL cholesterol levels. In 41 studies of 20 different formulations, HRT generally lowered lipoprotein (a).

CONCLUSION(S)

Route of estrogen administration and type of progestogen determined differential effects of HRT on lipid and lipoprotein levels. Future work will focus on the interpretation of the clinical significance of these changes.

A comparison of observational studies and randomized, controlled trials

BACKGROUND

For many years it has been claimed that observational studies find stronger treatment effects than randomized, controlled trials. We compared the results of observational studies with those of randomized, controlled trials.

METHODS

We searched the Abridged Index Medicus and Cochrane data bases to identify observational studies reported between 1985 and 1998 that compared two or more treatments or interventions for the same condition. We then searched the Medline and Cochrane data bases to identify all the randomized, controlled trials and observational studies comparing the same treatments for these conditions. For each treatment, the magnitudes of the effects in the various observational studies were combined by the Mantel-Haenszel or weighted analysis-of-variance procedure and then compared with the combined magnitude of the effects in the randomized, controlled trials that evaluated the same treatment.

RESULTS

There were 136 reports about 19 diverse treatments, such as calcium-channel-blocker therapy for coronary artery disease, appendectomy, and interventions for subfertility. In most cases, the estimates of the treatment effects from observational studies and randomized, controlled trials were similar. In only 2 of the 19 analyses of treatment effects did the combined magnitude of the effect in observational studies lie outside the 95 percent confidence interval for the combined magnitude in the randomized, controlled trials.

CONCLUSIONS

We found little evidence that estimates of treatment effects in observational studies reported after 1984 are either consistently larger than or qualitatively different from those obtained in randomized, controlled trials.

The impact of estrogen replacement therapy and raloxifene on osteoporosis, cardiovascular disease, and gynecologic cancers

OBJECTIVE

To compare the clinical utility of estrogen replacement therapy (ERT) and raloxifene in osteoporosis and cardiovascular disease in postmenopausal women and to evaluate the contrasting adverse effects of these therapies.

DATA SOURCES

A MEDLINE search was performed for January 1980 through September 1998 using the key terms raloxifene, estrogen, CVD, lipoproteins, and osteoporosis.

STUDY SELECTION AND DATA EXTRACTION

All clinical studies assessing ERT and raloxifene in cardiovascular disease or osteoporosis were evaluated.

DATA SYNTHESIS

ERT remains the standard for prevention and treatment of osteoporosis in women. Its use increases total bone mineral density (BMD) up to 12.1% and reduces hip fracture risk by 66-73%. It reduces low-density lipoprotein (LDL) cholesterol by 15-19% and increases high-density lipoprotein (HDL) cholesterol by 6-18%. Raloxifene, an alternative to ERT in the prevention of osteoporosis, increases total BMD by 2.2%. It reduces LDL by 6.2-14.1% and increases HDL by 1.5-5.7%. Preliminary data suggest that raloxifene has contrasting effects on gynecologic cancers compared with the increased risk posed by ERT.

CONCLUSIONS

Clinical trials have illustrated greater effects on BMD with ERT than with raloxifene. Studies of significant duration assessing raloxifene and its fracture risk effects are lacking. ERT appears to have greater beneficial cardiovascular risk factor effects than raloxifene. Prospective, primary prevention studies evaluating overall cardiovascular risk reduction do not exist for either intervention. Raloxifene, while more costly, is an alternative that may have a lower associated risk of breast cancer compared with ERT.

Moderation of the daily dose of HRT: prevention of osteoporosis

INTRODUCTION AND METHODS

Osteoporosis is the most common bone disease in clinical practice. Between 30% and 50% of postmenopausal women and almost 50% of all people over the age of 75 are estimated to have osteoporosis. HRT is well known for reducing the risk of osteoporosis in postmenopausal women but compliance with long-term HRT therapy remains low. The use of low dose HRT reduces the estrogenic adverse events which often cause patients to stop therapy. In this paper, the current literature on the benefits of low dose HRT and osteoporosis prevention are reviewed.

RESULTS

Various studies have assessed the efficacy of low-dose HRT (25 mcg/day transdermally; 0.3 mg/day orally) in the prevention of osteoporosis. Low dose HRT is effective at reducing bone loss in postmenopausal and oophorectomised women. In one study of 218 postmenopausal women, a dose of 0.3 mg/day of esterified estrogen resulted in a small but significant increase in whole body BMD compared to a decrease in the placebo group. The addition of calcium supplements may have a synergistic effect on the reduction of bone loss.

CONCLUSION

Low dose estrogen, taken either orally or transdermally, can prevent or reverse postmenopausal bone loss and appears to be a useful alternative to higher dosages in the prevention and treatment of osteoporosis. The option of starting HRT at low dose gives physicians the ability to titrate doses to suit individual patients whilst ensuring adequate bone protection and the minimum of hyperestrogenic side effects.

Osteoporosis: intervention options

Osteoporosis is a systemic progressive disease with important clinical complications because of the fractures that arise and cause major morbidity in especially the aging postmenopausal women. Because of the relative not complex procedure of diagnosis and prediction the most important question to answer: is treatment possible? There are now a variety of treatments available for the management of osteoporosis. The inhibitors of bone resorption, which include calcium, the vitamin Ds, bisphosphonates, calcitonins and gonadal steroids have been variously shown to prevent bone loss or to reduce fractures. On the other hand bone formation stimulating agents as fluorides and in the near future parathyroid hormone and analogues must be considered also. However, randomized clinical trials with fractures as clinical endpoints are only few in number and not present for every suggested treatment. During the last 3 years it has become clear that besides estrogen, bisphosphonates and now perhaps the selective estrogen receptor modulators also show a good alternative as intervention option of postmenopausal osteoporosis. At this moment sodium fluoride is not the first choice in treatment of osteoporosis in general practice.

Treatment of bone loss in oophorectomized women with a combination of ipriflavone and conjugated equine estrogen

OBJECTIVE

We previously reported that 0.625 mg/day of conjugated equine estrogen (CEE) could not prevent acute bone loss in the first year after oophorectomy. The effect of additional administration of ipriflavone on bone mineral density (BMD) and biochemical indices of bone remodeling were studied to investigate whether concurrent use of CEE and ipriflavone prevent acute bone loss in the early stages following surgical menopause.

METHODS

One-hundred and sixteen oophorectomized women were randomly divided into four groups according to treatment; group 1: placebo, n = 30; group 2: CEE (0.625 mg/day), n = 29; group 3: ipriflavone (600 mg/day), n = 30; group 4: CEE (0.625 mg/day) plus ipriflavone (600 mg/day), n = 27. Vertebral BMD was measured using dual energy X-ray absorptiometry (DEXA) and two biochemical indices of bone metabolism, urinary pyridinoline (Pyr) and serum intact human osteocalcin (hOC), were also measured before, 24 weeks, and 48 weeks after initiation of treatment.

RESULTS

BMD was reduced 48 weeks after treatment by 6.1, 3.9 and 5.1% in groups 1-3, respectively, but by only 1.2% in group 4. Pyr decreased by 49.5, 32.0 and 41.5% in groups 2-4, respectively. hOC also decreased by 45.2 and 21.6% in groups 2 and 4, but increased by 40.5% in group 3, suggesting an inhibitory action of CEE and ipriflavone on the turnover of bone metabolism and stimulatory action of ipriflavone on bone formation.

CONCLUSION

Concomitant use of ipriflavone with CEE from an early stage after oophorectomy inhibited bone loss and was considered to be effective in maintaining bone mass after oophorectomy.

Differential time-related effects of conjugated equine estrogen on bone metabolism in oophorectomized women

OBJECTIVE

The effects of conjugated equine estrogen (CEE) on bone mineral density (BMD) and biochemical indices of bone remodeling in oophorectomized women were studied for 3 years during estrogen replacement therapy (ERT) to investigate whether 0.625 mg/day of CEE alone prevent acute bone loss in the early stage of surgical menopause.

METHODS

We divided the subjects into three groups according to interval between oophorectomy and the start of ERT (group 1: less than 2 years after surgery, n = 31; group 2: 2-5 years after surgery, n = 29; and group 3: more than 5 years after surgery, n = 27). Vertebral BMD was measured using dual energy X-ray absorptiometry (DEXA). Two biochemical indices of bone metabolism, urinary deoxypyridinoline (DPyr) and serum intact human osteocalcin (hOC) were also measured.

RESULTS

In group 1, continuous ERT with 0.625 mg/day of CEE could not prevent a BMD decrease within the first year. However, by the end of the second year, BMD was restored to the pre-ERT. The same dosage of CEE significantly increased BMD in groups 2 and 3 by the end of the first year. DPyr and hOC levels both decreased dramatically in the initial 6 months of therapy and were stable thereafter.

CONCLUSION

In the initial 2-year period after oophorectomy, 0.625 mg/day of CEE alone could not prevent acute bone loss suggesting that additional therapy for the prevention of osteoporosis may be needed.