Physicians face conundrum when treating bone loss

Washington -- Women in the earliest years of menopause -- those most in danger of rapid bone loss -- present a challenge to doctors who weigh the risks and benefits of available therapies.

The bisphosphonates and hormone therapies have long been the mainstays, but each has taken a hit, and their risk profiles have changed.

After the 2002 results of the Women's Health Initiative, hormone therapy fell from favor with the news that it caused increased risks for breast cancer, strokes and heart attacks. More recently, reports of osteonecrosis of the jaw among some bisphosphonate users raised concerns about those drugs.

Still, the fracture risks are fueling the need to protect bone health. Each year, about 1.5 million men and women have an osteoporosis-related fracture, according to a 2004 surgeon general's report. As many as 10 million Americans are estimated to have osteoporosis -- 8 million women and 2 million men, according to the National Osteoporosis Foundation.

And, although treatment remains a dilemma for physicians treating women in early menopause, the pendulum may be swinging back toward estrogen, said Wulf Utian, MD, PhD, executive director of the North American Menopause Society.

"There is certainly continued interest in hormone use for bones," he said. Debate at the society's recent conference indicated that there may be two camps forming: one that favors estrogen use and the other that favors bisphosphonates.

"Both are wrong," Dr. Utian said. "The truth lies in the middle."

Findings, presented Oct. 12 as a poster at the society's conference, revealed that the number of osteoporotic fractures among women rose by 44% after the precipitous decline in the use of hormones, particularly among women in early menopause, or perimenopause.

"We wanted to see what happened to women's bone health after the mass discontinuation of hormone therapy that occurred after WHI," said Dr. Syed Islam, director of safety, surveillance and epidemiology at Wyeth Research, and lead author on the poster. Wyeth makes estrogen products.

The findings signal the need for additional studies to see whether the women who had fractures were prescribed bone-building medications or had taken any actions to lower their risks, said Dr. Islam, who also has a doctorate in public health.

The study also hints at a head-to-head comparison of hormone use and bisphosphonates. Since sales data indicated that bisphosphonates' star was rising as estrogen's was falling, the fracture rate should have been stable or decreasing, Dr. Islam said. Instead it rose.

Questions have been raised about the usefulness of the WHI findings for younger women. The mean age of participants in that trial was 63. What about women ages 50 to 60, many have asked? Do the same results apply, or could those women benefit from a continued course of estrogen?

"What it means to me is, in the first few years after menopause, the symptomatic woman would do very well on hormones, and later, if she has a reduction in bone mass, start her on the bisphosphonates," Dr. Utian said. "Both drugs are valuable, they have specific places in the treatment or reduction of risk of osteoporotic fractures. I think, from what I've heard from people, that's the direction many are taking."