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Case History

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Image not available. A 56-year-old woman slipped on wet leaves whilst taking her chocolate Labrador for his walk, sustaining a Colles fracture. She had a premature menopause at the age of 38 years, but has only taken hormone replacement therapy (HRT) intermittently because of media scares about safety. She still has debilitating hot flushes. She has had a dual-energy X-ray absorptiometry (DEXA) scan and was found to be osteopenic with a T-score of –2.3 at the hip.

What hormonal treatment options would you advise?

What non-oestrogen based treatments are available?

How would you monitor treatment?

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Background

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Image not available. Osteoporosis affects one in three women (see Case 44: Osteoporosis). Her major risk factor for osteoporosis is her premature menopause with intermittent use of hormone replacement therapy. A major concern is that having had one fracture she is likely to have another.1 She also has vasomotor symptoms.

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What hormonal treatment options would you advise?

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Evidence from randomized controlled trials (including the Women's Health Initiative [WHI]) shows that HRT reduces the risk of spine and hip fractures, as well as other osteoporotic fractures.2 While some studies show that a short duration of oestrogen use has long-term preventive effects on fracture, most epidemiological studies suggest that continuous and lifelong use is required for HRT to be an effective method of preventing fracture.3 Regulatory authorities have advised that HRT should not be used as a first-line treatment for osteoporosis prevention, as the risks outweigh the benefits. This may be true for a population with no increased risk of osteoporosis (as in the WHI), but the risk–benefit ratio changes favourably when a population with increased risk of osteoporosis is targeted. Also HRT might be a first-line option for this patient since she also has hot flushes.4 The 'standard' doses of oestrogen said to be bone-protective were oestradiol 1–2 mg, conjugated equine oestrogens 0.625 mg and transdermal 25–50 μg patch. However, lower doses may be protective. The relative risk of breast cancer on combined HRT is 2.17 after 5–9 years use, but women also need to realize that there is a similar doubling of risk with obesity (body mass index >30 kg/m2) or drinking >3 units of alcohol per day.5 Tibolone is classified as HRT in the United Kingdom British National Formulary. It conserves bone mass, and preliminary data have demonstrated a reduction in vertebral fractures. From the Million Women Study, the relative risk of breast cancer with tibolone is 1.45. Before prescribing HRT the woman must be aware of the full pros and cons of HRT and make her evidence-based patient choice, and her decision either way should be documented in the medical notes.

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What non-oestrogen based treatments are available?

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A variety of treatment options are available, but most have been studied in older women, few data exist about long-term efficacy in reducing fractures ...

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