Host: Welcome to today’s podcast Long-term benefits of MHT – Osteoporosis perspective. This episode is part of a podcast series supported by Abbott. The content is solely the responsibility of EMAS, the European Menopause and Andropause Society. All our episodes are available in English, Spanish, Mandarin, and Russian and you can find them on any of the most popular podcast platforms.
In today’s episode Dr. Sanjay Kalra, endocrinologist at Bharti Hospital, Karnal, India; President of the South Asian Federation of Endocrine Societies; and Chairperson of the Education Working group of the International Society of Endocrinology, will help us understand the usage of MHT as a preventive and therapeutic intervention for osteoporosis. He will describe a woman-centric approach so as to ensure optimal benefits of MHT for bone health.
Dr. Sanjay Kalra: Good day, friends, and welcome to this podcast on menopausal hormone therapy and osteoporosis.
Now, more than 75 years ago, in 1947, Albright demonstrated that exogenous estrogen therapy led to improvement in bone mass and reduction in the risk of fracture. This led to frequent usage of estrogen-based therapy as a routine intervention in post-menopausal women. Unfortunately, in the year 2002, the Women’s Health Initiative reported their results, where they found that there was an increase in the risk of cerebrovascular events, cardiovascular accidents and breast cancer with estrogen therapy. This led to a disinclination amongst physicians towards prescribing this drug. Even in women who needed it for symptom relief, or who needed it for bone health. This change in prescribing habits has actually led to an increase in the risk of fractures. Especially in women with a relatively short experience of living with menopause.
Now, what does estrogen do and what does lack of estrogen do in peri- and post-menopausal women? In menopause, in fact, two to three years before menopause begins, there is an increase in osteoclastic recruitment and an increase in osteoclastic activity in the bone. This leads to a reduction in bone mass. Initially, around menopause, more fractures are seen in the wrist, the humerus and the ribs. In women who are 10 to 15 years post-menopausal, vertebral fractures are more common. And in the more elderly ladies, it is hip fractures which predominate. All these occur because of estrogen openia, estropenia. Exogenous insulin is able to inhibit the osteoclastic recruitment and activity in a very swift, steady and sustained manner. There is a swift reduction in bone resorption seen within three to six months. Steady state is achieved in 6 to 12 months and then BMD remains sustained. The increase in BMD, bone mineral density, is sustained beyond one year. This increase in bone mineral density and in bone quality occurs mainly at the lumbar spine, which is rich in metabolically active trabecular bone. There is an improvement in the cortical bone seen in the femoral neck, but it’s not so visible. And when you look at data from meta-analysis across the world, you find that exogenous insulin therapy is able to reduce the risk of fractures by 20 to 30%. Reduce the risk of femoral fractures by 30% and that of vertebral fractures by up to 40%. This is as compared to women who are only on calcium and vitamin D supplementation. The beneficial effect of estrogen is more pronounced in younger women. And also, it is more pronounced if women take oral estrogen. These are data that we get from the million women study and from the E3N study.
Now, what does this mean for us as physicians? Should we prescribe estrogen to every post-menopausal woman, from an osteoporosis prevention and management point of view? Or should we take an individualized approach? The answer is: there should be a women centric approach to MHT usage, to menopausal hormone therapy usage. This should be based upon the individual risk benefit ratio, and it should also be accompanied by informed decision making. And it should be based upon shared decision making. We should be able to explain the physiology of menopause, the anticipated changes that may occur after menopause, and we should be able to tell the patient about the various options that are available to prevent decline in bone mass, to improve bone mass and quality, and to optimize bone health. Once we have done that, we find that we should consider MHT as not only therapeutic, but also as a preventive intervention. In women with swift menopause, that’s early menopause, short duration of menopause, less than 10 years or aged less than 60 years. Not only swift and short menopause, but also women who are slim built. Smoking, a history of smoking. Women who have had undergone surgical menopause. Those who may have specific genes that promote estrogen metabolism clearance or enhanced bone resorption. Sibling or family history of osteoporosis and its complications, like falls and fractures. MHT should also be considered as preventive and therapeutic intervention in women with symptoms of estrogenopenia, vasomotor symptoms, genitourinary symptoms. Even otherwise they would deserve estrogen, and also women with specific concerns about their bone and muscle health.
So let’s repeat. Consider MHT as preventive and therapeutic intervention in women with swift menopause, short duration of menopause, those who are slim built, have a history of smoking, a history of surgical menopause, those who may have specific genes that promote estrogenopenia, those with a sibling or family history of osteoporosis and its complications, and especially those with symptoms of osteopenia and those who have specific concerns about bone and muscle health. This is one group of women who would benefit from MHT as an anti-osteoporosis therapy. Another group of patients would be those in whom anti-osteoporotic therapy is not indicated. We want improvement in bone health, but the anti-osteoporotic therapy is not indicated because the T score is less, not less than -2.5. So, these would be women with a clinical picture of osteopenia, or osteosarcopenia, osteopenia, sarcopenia, or osteosarcopenia. Women with comorbid conditions that have a high risk of fracture or fall, like postural hypotension, neurological disorders and substance abuse. So clinical picture of osteosarcopenia comorbid conditions that increase the risk of fracture and fall, concomitant medications that may worsen bone health, like corticosteroids and pioglitazone. Concerns we’ve already mentioned, women who are concerned about their bone health and another is cuisine. Women who enjoy a low protein diet, a low calcium vitamin D diet, or a restricted diet which predisposes them to osteoporosis. In all such women, traditional anti-osteoporotic therapy may not be indicated, but MHT will certainly help improve bone health. A third group of women would be those where anti-osteoporotic therapy is not tolerated or is not safe. Maybe there are contraindications to other drugs or there are complications of other drugs, that have occurred in the past or that are suspected or anticipated. So, anyone with the various contraindications, the various concerns, caveats related to bisphosphonates, related to denosumab, related to teriparatide. In all such women where you cannot use these drugs, MHT would be a very pragmatic option. MHT can also be used along with other drugs along with other anti-osteoporotic drugs. If even after giving adequate therapy or supposedly adequate therapy, there is still a fracture or fracture risk or low BMD that persists. You may use estrogen simultaneously with other anti-osteoporotic therapy or in a sequential manner, based upon the patients’ needs.
Today, dear friends, we’ve been speaking about menopausal hormone therapy as an anti-osteoporotic preventive and therapeutic measure. Let’s revise what we have done. Estrogen improves bone mass, it reduces the risk of fracture at various sites in the body, especially in the vertebrae. Consider MHT as a preventive and therapeutic option after informing the patient and following shared decision making. Especially in women with swift and short duration of menopause, those who are slim build, smokers, those who have gone through surgical menopause, may have specific genes, a sibling or family history, and especially those with symptoms of estrogenopenia and specific concerns about bone health. Considered in women where the clinical picture, the comorbid conditions, concomitant medications and culinary habits predisposed to osteoporosis and falls and fractures. Consider MHT where other anti-osteoporotic therapy is contraindicated, causes complications, or is deemed insufficient.
We look forward to being with you on future podcasts like this and we look forward to sharing opinions, sharing experiences and these will help us make all the women who lived through menopause much healthier and much happier.
Good day, friends.
Host: Today, Dr. Sanjay Kalra discussed the effect of MHT on bone health and shared tips on how to identify the right person for this therapy, in a simple, listener-friendly manner. Thank you for listening to today’s episode. We hope it will be valuable for your clinical and research practice. Stay safe!
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