Estrogens as first-choice therapy for osteoporosis prevention and treatment in women under 60

A case is made for estrogens to be the first-choice therapy for the prevention and treatment of osteoporosis in women below the age of 60 years. Estrogens produce a dose-related increase in bone density and also, by their effect on collagen, have a beneficial effect not only on the bone matrix but the intravertebral disc. Bisphosphonates do not have that effect upon the disc. Estrogens are also associated with other beneficial effects upon mood, vasomotor symptoms, pelvic atrophy, sexuality and quality of life. The data from the Women's Health Initiative (WHI) study are used as a justification for not using estrogens but the neglect of estrogen therapy by physicians antedated this and other studies by many years. Subsequent publications from the WHI study show that hormone replacement therapy, particularly estrogens alone, is not associated with the excess side-effects found in the older population. The substantial but non-significant decrease in heart attacks, breast cancer and mortality in women under the age of 60 taking estrogens alone should persuade the advisory bodies to revise their judgment on the benefits and safety of hormone replacement therapy in this population.