Menopausal hormone therapy for the management of osteoporosis

Postmenopausal osteoporosis is a frequent clinical condition which affects nearly 1 in 3 women. Estrogen deficiency leads to rapid bone loss which is maximal within the first 2-3 years after the menopause transition and can be prevented by menopause hormone therapy (MHT). Not only, MHT prevents bone loss and the degradation of the bone microarchitecture but it significantly reduces the risk of fracture at all bone sites by 20-40%. It is the only anti-osteoporotic therapy that has a proven efficacy regardless of basal level of risk, even in low-risk women for fracture. Following the publication of the WHI results, use of MHT has considerably declined due to safety concerns which raise the question as to whether it might still be used in the prevention of osteoporosis. Over the last years, subsequent re-analyses of the WHI and further trials have challenged the initial conclusions of the WHI. It is now clearer that the individual benefit-risk balance of MHT is dependent on the individual risk profile in each woman as well as whether estrogen is opposed or unopposed, the type of estrogens and progestogens or doses and routes of administration. It must be also reminded that to date osteoporosis is a chronic disease that cannot be cured. The choice of the 1st treatment option should thus always be made in the context of a more comprehensive long-term strategy. This is particular true in early postmenopausal women found to be at low/moderate risk of fragility fracture over the first 10 years after menopause but who may have a much greater lifetime risk. In the absence of contraindication, use of MHT should be considered as a 1st option for the maintenance of bone health in those women where specific bone active medications are not warranted. Subsequent reassessment of the individual benefit-risk balance of MHT is thereafter recommended, with the possibility of switching to another osteoporosis treatment if the balance is not considered as favourable as at the beginning of the menopause for women still at high risk of fracture.