Postmenopausal Hormone Replacement Therapy for Osteoporosis

Evidence for Efficacy

The American College of Physicians suggests that hormone replacement therapy (HRT) increases bone mineral density at the hip, lumbar spine, and peripheral sites in postmenopausal women, with a significant reduction in fracture risk 1, 4, 5
A meta-analysis of 22 trials showed a 27% reduction in nonvertebral fractures (RR 0.73, 95% CI 0.56-0.94) with HRT use 1, 7, 4
The Women's Health Initiative (WHI) found a significant 24% reduction in total fracture risk (RH 0.76, 95% CI 0.63-0.92) among healthy women taking combined estrogen/progestin 1, 7, 4

The U.S. Preventive Services Task Force recommends against using HRT routinely for the specific purpose of preventing chronic disease, including osteoporosis, in postmenopausal women, due to increased risks of breast cancer, cardiovascular disease, stroke, and venous thromboembolism 1, 2, 3
HRT use is associated with a 26% increased risk of breast cancer (RH 1.26, 95% CI 1.00-1.59) and a 41% increased risk of stroke (RH 1.41, 95% CI 1.07-1.85) 7, 5

The American College of Obstetricians and Gynecologists and the North American Menopause Society suggest that HRT should be considered primarily for women requiring treatment of moderate-to-severe menopausal vasomotor symptoms who also have osteoporosis risk 2, 3
The National Osteoporosis Foundation recommends that HRT be used at the lowest effective dose for the shortest duration consistent with treatment goals, and that patients be reevaluated at 3-6 month intervals to determine if treatment is still necessary 2, 3

The American Heart Association advises against prescribing HRT solely for osteoporosis prevention or treatment when safer alternatives exist (bisphosphonates, denosumab, selective estrogen receptor modulators) 1, 2, 3
The U.S. Preventive Services Task Force recommends that HRT not be used in women with intact uterus without progestin, as this dramatically increases endometrial cancer risk, and that cardiovascular and breast cancer risks be discussed with patients, particularly in women over 60 or more than 10 years post-menopause 2, 3