"Generation WHI" Bones Have Been Put At Risk

When large numbers of menopausal women were on hormone therapy bones were protected against ostoporosis and bone loss. Now that fewer women use hormone therapy in menopause, they have some benefits in terms of long term risks of blood clots and other side effects, but we have not necessarily always done a good job replacing the therapy with bone protective strategies. Estrogen menopausal treatment used to be ubiquitous, even for completely asymptomatic women, who thought they were being prescribed treatment for all manner of health benefits including their hearts. And in fact some women were protecting their hearts if they began hormone treatment early enough and took it through the menopause transition. Risks of post menopausal hormone therapy are mostly limited to small increases in breast cancer and blood clots. We are trying to put those risks and benefits into better perspective.. The Women's Health Initiative (WHI) proved that there were flaws in the thinking of many physicians. It was discovered that treatments that were initially approved for short term symptom relief were being given to women into the last decades of their life. When the Women's Health Initiative (WHI) came through and looked at long term use, and use in older women who were not currently on therapy by the time they got to their early 60s, or within 10 years of the beginning of menopause, they discovered that heart protection could not be put in the benefit list for these women, but in fact in the risk column. In May of 2012 the USPTF also cautioned women who have no menopausal symptoms to not take estrogen as their analysis of WHI showed limited evidence for bone protection, no evidence of heart protection, and some evidence that there would be greater risk of dementia with aging. Suddenly, faster than they ripped their bras off in the 60s, they stopped their hormones. But the effects of estrogen in the treatment form wears off, just as significantly as if your own ovaries stop producing estrogen. The average patient, after the WHI results came out, was more likely to stop her estrogen and young women entering menopause were less likely to seek treatment. For those not seeking treatment, they were also less likely to take a bone test. The consequences of that radical shift in hormone use after WHI now first being studied. It's a fact that bone loss proceeds at the most rapid pace right as a woman goes through menopause. In fact menopausal women can lose 2-3% of their bone per year. During these high loss times, bones are more susceptible to breakage.  Results from a Southern California Kaiser Permanente health management organization have now shown that lower bone mass and 55% greater rates of hip fracture occurred in that group. The effects of estrogen are thought to wear off the bone as fast as a year, but in the study if took about 2 years to really see higher hip fracture rates. Women who used hormone therapy had about a 3.9/1000 rate of hip fracture vs about a 5.7/1000 rate in women who did not. To my reading of this study we have not yet assessed the impact of using lower dosing of hormone therapy. It's difficult problem. We lose more bone in menopause, this can be proven in so many ways. In a 2013 Study of Women's Health Across the Nation (SWAN) they show great loss of bone during early menopause with markers of bone turnover. But early  menopause is not our high fracture time. We have to prevent bone loss in youth, to prevent fractures during aging. At Women's Health Practice we are concerned that patients who only seek menopausal counseling from those using saliva methods of hormone testing are not getting enough bone scanning recommendations as part of patient care, and that inadequate bone health monitoring and testing will lead to more women with fractures. At Women's Health Practice we advocate both BMD testing vertebral fracture assessment (VFA) testing for fractures in appropriate patients. Women who were switched to bone protecting medicines, bisphosphonates like Actonel, Atelvia, Boniva, Fosamax or Reclast did not have the increased risk of hip fracture in this study.  And the newest data is that you have double protection against uterine endometrial cancer if you are on a bisphosphonate for your bones! It's more important than ever that women try to get balance in their life: stopping or declining hormone therapy may absolutely be the best thing for your health, but be sure to have a discussion with your gyno so that you can get the best treatment for all aspects of your health.


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