Hormone Therapy for the Prevention of Bone Loss in Menopausal Women with Osteopenia
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CURRENT OPINION
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Hormone Therapy for the Prevention of Bone Loss in Menopausal Women with Osteopenia Is it a Viable Option? Mary H. Hohenhaus,1 Kelly A. McGarry2 and Nananda F. Col3 1 2 3
Department of Medicine, Brown University, The Miriam Hospital, Providence, Rhode Island, USA Department of Medicine, Brown University, Rhode Island Hospital, Providence, Rhode Island, USA Center for Outcomes Research and Evaluation, Maine Medical Center, Portland, Maine, USA
Abstract
Osteopenia is a state of low bone mass, the appropriate clinical management of which is not always clear. The use of hormone therapy for postmenopausal bone loss has become controversial given recent data regarding the risks of therapy. Fragility fractures are common, and result in substantial morbidity and mortality. Although the fracture rate is higher among osteoporotic women, the substantially larger population of osteopenic women accounts for a higher absolute number of fractures. Osteopenia is defined solely according to the statistical properties of the distribution of bone mineral density (BMD) values, which limits its usefulness in clinical care. BMD, although inversely related to fracture risk, should not be used as the sole criterion for fracture risk. Limited data suggest that benefits of treatment seen in women with documented osteoporosis may not extend to osteopenic women. Although estrogen prevents postmenopausal bone loss, preservation of BMD does not necessarily translate into reduced fracture risk. In making decisions about whether to treat a woman with osteopenia, it is critical to estimate how treatments will affect the individual’s risk of fracture. Treatment decisions should be based on whether the net benefits of treatment outweigh the anticipated risks, which will depend on the age of the patient and her risk profile. In our opinion, there is insufficient evidence to support treatment for women with a BMD in the osteopenic range in the absence of fragility fracture. For osteopenic women with higher risk, the availability of other treatments with a more favourable risk-benefit profile eliminates the role of hormone therapy for fracture prevention.
Osteoporosis is a common but preventable disease characterised by low bone mass and microarchitectural deterioration of bone tissue. Osteoporosis increases skeletal fragility and the suscepti-
bility to fracture.[1] Osteopenia is also a state of low bone mass that represents part of a continuum with osteoporosis, the appropriate clinical management of which is not always clear. Is osteopenia a statisti-
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cal byproduct, or is it a premorbid condition that warrants treatment to prevent progression to osteoporosis and fracture, much as treating hypertension prevents progression to overt cardiovascular disease? As screening for osteoporosis by dual-energy absorptiometry (DXA) has become more readily available, more women and their physicians face the dilemma of how to respond to DXA results that fall in the osteopenic rang
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