Hormone replacement therapy or SERMS in the long term treatment of osteoporosis

Replacement therapy with estrogen and progestogen (HT) or estrogen alone (ET) and selective estrogen receptor modulators (SERMS) still constitute valuable additions to the range of osteoporosis treatments available. Due to the diverse action on a wide variety of organs, HT/ET has the capacity to improve quality of life in most postmenopausal women,- more than other more specific osteoporosis treatments. The initial optimism associated with HRT 20-30 years ago was reduced considerably after the HT arm of WHI was stopped prematurely due to safety concerns. Later analyses of the WHI study have, however, tempered the negative messages emerging from the first publication in 2002. HT/ET still constitutes a first line choice for prevention of bone loss and fracture in the early postmenopausal period for a period of 5 years. However, in women with low risk of adverse events classically associated with HT/ET newer analyses show that treatment can be continued with an acceptable risk benefit ratio. These analyses have also highlighted the negative impact of progestogens on breast cancer risk an adverse effects on the cardiovascular system. Newer guidelines therefore suggest that a combination of a progestogen IUD and transdermal estrogen seems to be the best alternative for long term treatment. This combination minimizes cardiovascular safety concerns by avoiding the negative impact of first pass metabolism in the liver seen with oral compounds and minimizes exposure to progestogens. SERMS are valuable alternatives, particularly in osteopenic women (t-score -1,0 to -2,5) at increased risk of breast cancer, but their general lack of anti fracture efficacy towards non vertebral fractures limits their use in women at high risk of osteoporotic fracture.