Withdrawal of hormone replacement therapy is associated with significant vertebral bone loss in postmenopausal women

Antiosteoporosis therapy after discontinuation of menopausal hormone therapy: a systematic review

OBJECTIVE

Menopausal hormone therapy (MHT) has consistently shown a bone protective effect by reducing the risk of vertebral, non-vertebral, and hip fractures in postmenopausal women regardless of baseline fracture risk. However, the optimal sequential treatment after MHT discontinuation has not been determined. This systematic review aimed to obtain the best evidence regarding the effect of antiresorptive or osteoanabolic treatment on bone mineral density (BMD) and/or fracture risk following MHT.

METHODS

A comprehensive search was conducted in the PubMed, Scopus, and Cochrane databases up to October 31, 2023. Randomized-controlled trials (RCTs) and observational studies conducted in postmenopausal women were included.

RESULTS

After the exclusion of duplicates, 717 studies were identified. Two were eligible for qualitative analysis, one RCT and one retrospective cohort study. The RCT showed that alendronate 10 mg/day for 12 months further increased lumbar spine (LS) BMD by 2.3% following MHT and maintained femoral neck (FN) BMD in postmenopausal women (n = 144). It also decreased bone anabolic and resorption markers by 47 and 36%, respectively. In the retrospective study (n = 34), raloxifene 60 mg/day increased both LS and FN BMD at 12 months by 3 and 2.9%, respectively. No fractures were reported.

CONCLUSIONS

Antiresorptive therapy with either a bisphosphonate (i.e., alendronate) or raloxifene could be considered a sequential antiosteoporosis therapy after MHT withdrawal since they have been shown in studies to further increase BMD. However, no safe conclusions can be drawn from the existing literature.

Temporal patterns of osteoclast formation and activity following withdrawal of RANKL inhibition

Rebound bone loss following denosumab discontinuation is an important clinical challenge. Current treatment strategies to prevent this fail to suppress the rise and overshoot in osteoclast-mediated bone resorption. In this study, we use a murine model of denosumab treatment and discontinuation to show the temporal changes in osteoclast formation and activity during RANKL inhibition and withdrawal. We show that the cellular processes that drive the formation of osteoclasts and subsequent bone resorption following withdrawal of RANKL inhibition precede the rebound bone loss. Furthermore, a rise in serum TRAP and RANKL levels is detected before markers of bone turnover used in current clinical practice. These mechanistic advances may provide insight into a more defined window of opportunity to intervene with sequential therapy following denosumab discontinuation.

Discontinuation of hormone therapy and bone mineral density: does physical activity modify that relationship?

OBJECTIVE

Hormone therapy can positively impact bone mineral density after menopause. We explored bone mineral density change in postmenopausal women who discontinued hormone therapy after the Women's Health Initiative landmark 2002 trial results were published. We secondarily explored whether usual physical activity modified the results.

METHODS

Postmenopausal women participating in the Buffalo OsteoPerio study with information on hip bone density, hormone therapy use, and self-reported physical activity at two time points (1997-2001; 2002-2007) were included (N = 961). Hormone therapy included three groups according to use at baseline and year 5 (non/non; current/non; current/current).

RESULTS

At baseline (mean age, 65.9 years; SD, 6.7 years), 480 women were not using hormone therapy, while 481 were current users. Between the baseline and 5-year visits, 336 women using hormone therapy discontinued. Baseline total hip bone density was highest in current users. After 5 years, those who continued hormone therapy exhibited no bone loss; those who discontinued exhibited the greatest loss at the total hip of -0.021 gm/cm2. Women who never used hormone therapy exhibited some loss of -0.012 gm/cm2. Usual physical activity did not appreciably impact change in bone density in any group.

CONCLUSIONS

This prospective observational study explored the 5-year change in bone mineral density among older postmenopausal women after the landmark 2002 hormone therapy trial findings were released. We found bone density decreased in never-users and in women who discontinued use. Bone density was maintained in current users. Although usual physical activity did not mitigate bone loss, targeted physical activity regimens should be investigated.

Effects of Hormone Therapy and Exercise on Bone Mineral Density in Healthy Women-A Systematic Review and Meta-analysis

CONTEXT

There is some evidence that an adequate "anabolic hormonal milieu" is essential for the mechanosensitivity/transduction/response of bone tissue.

OBJECTIVE

This work aimed to determine whether enhancing hormone therapy (HT) with exercise increases the isolated effect of HT on bone mineral density (BMD) at the lumbar spine (LS) and femoral neck (FN).

METHODS

A comprehensive search of 6 electronic databases according to the PRISMA statement up to April 28, 2021, included controlled trials longer than 6 months with 3 study arms: (a) HT, (b) exercise, and (c) HT plus exercise (HT + E). Apart from HT, no pharmaceutic therapy or diseases with relevant osteoanabolic or osteocatabolic effect on bone metabolism were included. The present analysis was conducted as a random-effects meta-analysis. Outcome measures were standardized mean differences (SMD) for BMD changes at the LS and FN.

RESULTS

Our search identified 6 eligible studies (n = 585). Although the effect of HT + E was more pronounced in the LS (SMD: 0.19; 95% C,: -0.15 to 0.53) and FN-BMD (0.18; -0.09 to 0.44) compared to the HT group, we did not observe significant differences between the 2 groups. We observed a low (I2: 29%) or moderate (I2: 49%) level of heterogeneity between the trials for FN or LS.

CONCLUSION

We do not observe a significant effect of HT + E vs HT alone. We largely attribute this result to varying HT supplementation and hormonal status. Bearing in mind that synergistic/additive effects between HT and mechanical stimulation can only be expected in situations of hormonal insufficiency, further clinical studies should consider baseline endogenous estrogen production but also HT dosing more carefully.

Upper-Extremity Venous Thromboembolism Following Operative Treatment of Distal Radius Fractures: An Uncommon but Dangerous Complication

PURPOSE

Distal radius fractures are the most common long bone fracture in the United States, with an estimated incidence of 640,000 cases per year. Operative fixation presents a theoretical risk factor for the development of upper-extremity venous thromboembolism (UE-VTE). Additionally, patients presenting with distal radius fracture commonly have preexisting comorbidities that further increase the risk of UE-VTE. Finally, UE-VTE is considered the highest risk for eventual development of pulmonary embolism. Despite this, scant attention has been paid to studying UE-VTE in this population. The purpose of this study was to measure the incidence of this complication and to identify possible medical factors that increased the risk of developing UE-VTE.

METHODS

We queried the Truven MarketScan Commercial Claims and Encounters Database for all patients who experienced a distal radius fracture and were subsequently treated with open reduction and internal fixation between 2012 and 2016. Patients were identified using relevant Common Procedural Terminology codes. Demographic and medical variables were tabulated. Our primary outcome was the development of ipsilateral UE-VTE or pulmonary embolism in the first 60 days after surgery.

RESULTS

The study included 24,494 patients. The mean age was 50.7 years (range, 18-91), and 58% were women. There were 79 cases (0.3%) of UE-VTE and 19 cases of pulmonary embolism in the study population (24.1% of all UE-VTE cases; 0.08% of total sample). Multivariable logistic regression showed that coexisting heart failure and estrogen use were associated with increased risk of UE-VTE.

CONCLUSIONS

Although uncommon, the development of UE-VTE after open reduction and internal fixation for distal radius fractures is a concerning complication. Coexisting heart failure and estrogen use are associated with increased risk of UE-VTE.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

[Menopause, menopause hormone therapy and osteoporosis. Postmenopausal women management: CNGOF and GEMVi clinical practice guidelines]

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 years after the menopause transition and can be prevented by menopause hormone therapy (MHT). Assessment of the individual risk of osteoporosis is primarily based on the measurement of bone mineral density (BMD) at the spine and femur by DXA. Clinical risk factors (CRFs) for fractures taken either alone or in combination in the FRAX score were shown not to reliably predict fractures and/or osteoporosis (as defined by a T-score<-2.5) in early postmenopausal women. If DXA measurement is indicated in all women with CRFs for fractures, it can be proposed on a case-by-case basis, when knowledge of BMD is likely to condition the management of women at the beginning of menopause, particularly the benefit-risk balance of MHT. MHT prevents both bone loss and degradation of the bone microarchitecture in early menopause. It significantly reduces the risk of fracture at all bone sites by 20 to 40% regardless of basal level of risk with an estrogen-dependent dose-effect. Given the inter-individual variability in bone response, individual monitoring of the bone effect of MHT is warranted when prescribed for the prevention of osteoporosis. This monitoring is based on repeated measurement of lumbar and femoral BMD (on the same DXA measurement system) after 2years of MHT, the response criterion being no significant bone loss. Discontinuation of treatment is associated with a resumption of transient bone loss although there is a large variability in the rate of bone loss among women. Basically, there is a return to the level of fracture risk comparable to that of in untreated woman of the same age within 2 to 5years. Therefore, when MHT is prescribed for the prevention of osteoporosis in women with an increased risk at the beginning of menopause, measurement of BMD is recommended when MHT is stopped in order to consider further management of the risk of fracture whenever necessary (with possibly another anti-osteoporotic treatment).

Estrogen and bones after menopause: a reappraisal of data and future perspectives

Menopausal hormone therapy (MHT) is effective in preventing menopause-related bone loss and decreasing vertebral, non-vertebral and hip fracture risk. MHT contains estrogens that exert both antiosteoclastic and osteoanabolic effects. These effects are dose-dependent, as even ultra-low doses preserve or increase bone mineral density. The transdermal route of administration is effective on cancellous and cortical bone, although fracture data are still lacking. Hormone replacement therapy is the treatment of choice to preserve skeletal health in women with premature ovarian insufficiency and early menopause. MHT can be considered in women aged < 60 years or within 10 years since menopause as, in this population, benefits outweigh possible risks, such as breast cancer and cardiovascular events. Despite the ensuing bone loss after MHT discontinuation, a residual antifracture effect persists. However, in women at risk of fracture, subsequent antiosteoporotic therapy may be needed, either with an antiosteoclastic or osteoanabolic agent. In any case, longitudinal data from randomized controlled trials comparing different estrogen doses and routes of administration, as well as designating the optimal treatment strategy after MHT discontinuation, are needed to elucidate these issues further.

Denosumab for cancer-related bone loss

INTRODUCTION

Prolonged use of anti-cancer treatments in breast and prostate tumors alters physiological bone turnover leading to adverse skeletal related events, such as osteoporosis, loss of bone mass, and increased risk of fractures. These complications known as cancer treatment-induced bone loss (CTIBL) should be managed with bone targeting agents such as the bisphosphonates and denosumab. The latter is a monoclonal antibody against the receptor activator of nuclear factor-kB ligand (RANKL) that suppresses osteoclasts function and survival increasing bone mass.

AREAS COVERED

This review will focus on the mechanisms associated with bone loss induced by cancer treatments and the most recent evidence about the use of denosumab as preventive and therapeutic strategy to protect bone health. Moreover, we will discuss several key aspects regarding the clinical practical use of denosumab to optimize the management of CTLIB in breast and prostate cancer.

EXPERT OPINION

Denosumab treatment strongly prevents cancer therapies-related skeletal issues in breast and prostate cancer with a good safety profile. Adjuvant six-monthly denosumab delays the time to first fracture onset in early stage breast cancer patients with normal or altered bone mineral density (BMD). Similarly, denosumab treatment is able to prevent fractures and BMD loss in nonmetastatic prostate cancer patients.

Association between age at menopause and fracture risk: a systematic review and meta-analysis

PURPOSE

Early menopause (EM, age at menopause < 45 years) and premature ovarian insufficiency (POI, age at menopause < 40 years) are associated with an increased risk of osteoporosis. However, their association with increased fracture risk has not been established, with studies yielding conflicting results. The primary aim of this systematic review and meta-analysis was to synthesize studies evaluating the association between age at menopause and fracture risk. The secondary aim was to evaluate this effect concerning the site of fractures.

METHODS

A comprehensive search was conducted in PubMed, CENTRAL and Scopus, up to 31 January 2018. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). The I² index was employed for quantifying heterogeneity.

RESULTS

Eighteen studies were included in the qualitative and quantitative analysis (462,393 postmenopausal women, 12,130 fractures). Compared with women with age at menopause > 45 years, women with EM demonstrated higher fracture risk (OR 1.36, 95% CI 1.11-1.66, p < 0.002, I² 81.5%). Women with POI did not display any difference in fracture risk compared either with women with age at menopause > 40 (OR 1.23, 95% CI 0.72-2.09, p = 0.436, I² 62.5%) or >45 years (OR 0.54, 95% CI 0.22-1.29, p = 0.17, I² 0%). No difference was evident when a separate analysis was performed for vertebral, non-vertebral and hip fractures.

CONCLUSIONS

This is the first meta-analysis showing that EM is associated with increased fracture risk compared with normal age at menopause, without any distinct effect on the site of the fracture.

Women's Mid-Life Night Sweats and 2-Year Bone Mineral Density Changes: A Prospective, Observational Population-Based Investigation from the Canadian Multicentre Osteoporosis Study (CaMos)

Women’s hot flushes and night sweats, collectively called vasomotor symptoms (VMS), are maximal (79%) in late perimenopause. The evidence describing whether VMS are associated with loss of areal bone mineral density (BMD) is mixed. We examined baseline and 2-year data for 1570 randomly selected women aged 43–63 in the Canadian Multicentre Osteoporosis Study (CaMos), a prospective Canada-wide study; we used linear regression to assess the relationship of night sweats (VMSn) with BMD and its changes. Clinically important VMSn occurred for 12.2%. Women with VMSn were slightly younger (54.5 vs. 55.3 years, p = 0.02) and less likely to use sex steroid therapies (39.8% vs. 51.4%, p < 0.05). BMD at the lumbar spine (L1-4), femoral neck (FN) and total hip (TH) were similar between those with/without VMSn. In adjusted models, we did not find a significant association between VMSn and 2-year change in L1-4, FN and TH BMD. Age, reproductive status, weight, sex steroid therapy and smoking status were associated with 2-year change in BMD. Incident fractures over 2 years also did not differ by VMSn. Our analyses were restricted to VMSn and may not truly capture the relationship between VMS and BMD. Additional research involving VMS, bone loss and fracture incidence is needed.

Estrogen therapy for osteoporosis in the modern era

Menopause predisposes women to osteoporosis due to declining estrogen levels. This results in a decrease in bone mineral density (BMD) and an increase in fractures. Osteoporotic fractures lead to substantial morbidity and mortality, and are considered one of the largest public health priorities by the World Health Organization (WHO). It is therefore essential for menopausal women to receive appropriate guidance for the prevention and management of osteoporosis. The Women's Health Initiative (WHI) randomized controlled trial first proved hormonal therapy (HT) reduces the incidence of all osteoporosis-related fractures in postmenopausal women. However, the study concluded that the adverse effects outweighed the potential benefits on bone, leading to a significant decrease in HT use for menopausal symptoms. Additionally, HT was not used as first-line therapy for osteoporosis and fractures. Subsequent studies have challenged these initial conclusions and have shown significant efficacy of HT in various doses, durations, regimens, and routes of administration. These studies support that HT improves BMD and reduces fracture risk in women with and without osteoporosis. Furthermore, the studies suggest that low-dose and transdermal HT are less likely associated with the adverse effects of breast cancer, endometrial hyperplasia, coronary artery disease (CAD), and venous thromboembolism (VTE) previously observed in standard-dose oral HT regimens. Given the need for estrogen in menopausal women and evidence supporting the cost effectiveness, safety, and efficacy of HT, we propose that HT should be considered for the primary prevention and treatment of osteoporosis in appropriate candidates. HT should be individualized and the once "lowest dose for shortest period of time" concept should no longer be used. This review will focus on the prior and current studies for various HT formulations used for the prevention and treatment of osteoporosis, exploring the safety profile of low-dose and transdermal HT that have been shown to be safer than oral standard-dose HT.

Patterns of menopausal hormone therapy use and hyperkyphosis in older women

OBJECTIVE

Hyperkyphosis, an exaggerated anterior curvature of the thoracic spine, is associated with poor physical function, falls, fractures, and earlier mortality. Low bone mineral density, bone loss, and vertebral fractures are strong risk factors for hyperkyphosis. Menopausal hormone therapy (HT) reverses bone loss, prevents vertebral fractures, and, therefore, we hypothesize, may reduce the risk for developing hyperkyphosis.

METHODS

We evaluated the cross-sectional association between Cobb angle of kyphosis from lateral spine radiographs and pattern of self-reported HT use during the prior 15-year period in 1,063 women from the Study of Osteoporotic Fractures.

RESULTS

Participants had a mean age of 83.7 ± 3.3 years and a mean Cobb angle of 51.3 ± 14.6°. Forty-six per cent of women were characterized as never-users of HT, 24% as remote past users, 17% as intermittent users, and 12% as continuous users. In minimally adjusted models, the mean Cobb angle was 4.0° less in continuous HT users compared with never-users (P = 0.01); however, in fully adjusted models, this association was attenuated to 2.8° (P = 0.06). Remote past HT users had 3.0° less kyphosis compared with never-users in minimally adjusted models (P = 0.01), attenuated to 2.8° less in fully adjusted models (P = 0.02). Intermittent users did not differ from never-users in degree of kyphosis.

CONCLUSIONS

Women reporting continuous or remote past HT use had less pronounced kyphosis than never-users by their mid-eighties, suggesting a possible role for HT in the prevention of age-related hyperkyphosis.

Discontinuation of Denosumab therapy for osteoporosis: A systematic review and position statement by ECTS

INTRODUCTION

The optimal duration of osteoporosis treatment is controversial. As opposed to bisphosphonates, denosumab does not incorporate into bone matrix and bone turnover is not suppressed after its cessation. Recent reports imply that denosumab discontinuation may lead to an increased risk of multiple vertebral fractures.

METHODS

The European Calcified Tissue Society (ECTS) formed a working group to perform a systematic review of existing literature on the effects of stopping denosumab and provide advice on management.

RESULTS

Data from phase 2 and 3 clinical trials underscore a rapid decrease of bone mineral density (BMD) and a steep increase in bone turnover markers (BTMs) after discontinuation of denosumab. Clinical case series report multiple vertebral fractures after discontinuation of denosumab and a renewed analysis of FREEDOM and FREEDOM Extension Trial suggests, albeit does not prove, that the risk of multiple vertebral fractures may be increased when denosumab is stopped due to a rebound increase in bone resorption.

CONCLUSION

There appears to be an increased risk of multiple vertebral fractures after discontinuation of denosumab although strong evidence for such an effect and for measures to prevent the occurring bone loss is lacking. Clinicians and patients should be aware of this potential risk. Based on available data, a re-evaluation should be performed after 5years of denosumab treatment. Patients considered at high fracture risk should either continue denosumab therapy for up to 10years or be switched to an alternative treatment. For patients at low risk, a decision to discontinue denosumab could be made after 5years, but bisphosphonate therapy should be considered to reduce or prevent the rebound increase in bone turnover. However, since the optimal bisphosphonate regimen post-denosumab is currently unknown continuation of denosumab can also be considered until results from ongoing trials become available. Based on current data, denosumab should not be stopped without considering alternative treatment in order to prevent rapid BMD loss and a potential rebound in vertebral fracture risk.

Thai Osteoporosis Foundation (TOPF) position statements on management of osteoporosis

The adjusted incidence rate of hip fracture in Thailand has increased more than 31% from 1997 to 2006. Mortality and morbidity after hip fracture are also high. One year mortality after a hip fracture has increased from 18% in 1999 to 21% in 2007. The Thai Osteoporosis Foundation (TOPF) developed the first Clinical Practice Guideline (CPG) in 2002 and keeps updating the CPG since then. This latest version of the CPG is our attempt to provide comprehensive positional statement on the diagnosis, prevention and treatment of osteoporosis in Thailand. The study group who revised this position statement contains experts from the TOPF, Four Royal Colleges of Thailand, includes the Orthopaedic Surgeons, Gynecologists and Obstetricians, Physiatrists, Radiologists and 2 Associations of Endocrinologists and Rheumatologists which have involved in the management of patients with osteoporosis.

The role of hormones and aromatase inhibitors on breast tumor growth and general health in a postmenopausal mouse model

BACKGROUND

Breast cancer is the most frequently diagnosed cancer in women in the United States. Approximately 70% of breast cancers are diagnosed in postmenopausal women. Major clinical trials and experimental studies showed that aromatase inhibitors are effective against postmenopausal breast cancer. Despite their effectiveness in reducing tumor recurrence, aromatase inhibitors have adverse effects on the cardiovascular system and increase osteoporosis and bone fractures. Our study is aimed at investigating the role of natural steroid hormones on serum cardiovascular and bone resorption markers in an established mouse model mimicking postmenopausal breast cancer.

METHODS

Ovariectomized nude mice were transplanted with MCF-7 breast cancer cells constitutively expressing aromatase. The mice were treated with different combinations and doses of steroids, [estrogen (25 pg, 40 pg, 100 pg), progesterone (6 ng) and testosterone (50 ng)] along with dehydroepiandrostenedione (100 ug). Serum levels of HDL, LDL/VLDL, free and total cholesterol, total and bone specific alkaline phosphatase and triglycerides were analyzed after 5, 10 and 15 months.

RESULTS

Free cholesterol and LDL/VLDL levels in serum were reduced in groups mimicking estrous cycle and menstrual cycle hormones treatment. HDL cholesterol was increased in all the hormone treated groups except the estrous cycle-mimicking group. Bone specific alkaline phosphatase was decreased in menstrual cycle levels of estrogen and progesterone treatment.

CONCLUSIONS

All together our results show that use of natural hormones in appropriate combinations have beneficial effects on cardiac and bone toxicity, along with better tumor reduction than current treatments.

Associations between Body Composition, Hormonal and Lifestyle Factors, Bone Turnover, and BMD

BACKGROUND

The relative importance of body composition, lifestyle factors, bone turnover and hormonal factors in determining bone mineral density (BMD) is unknown. We studied younger postmenopausal women to determine whether modifiable or nonmodifiable risk factors for osteoporosis have stronger associations with BMD.

METHODS

In multivariable linear regression models, we tested associations between non-bone body composition measures, self-reported measures of physical activity and dietary intake, urinary N-telopeptide (NTx), sex hormone concentrations, and BMD in 109 postmenopausal women aged 50 to 64 years, adjusting for current hormone therapy use and clinical risk factors for low BMD. Lean mass, fat mass and areal BMD (aBMD) at the lumbar spine, femoral neck, total hip and distal radius were measured using dual energy X-ray absorptiometry.

RESULTS

Higher body weight and self-reported nonwhite race were independently associated with higher aBMD at the lumbar spine, femoral neck, total hip and distal radius. Lean and fat mass were not independently associated with aBMD. Older age and higher urinary NTx were independently associated with lower aBMD at the distal radius but not at weight-bearing sites. Sensitivity analyses demonstrated lack of an independent association between total daily protein or calorie intake and BMD.

CONCLUSIONS

BMD, weight and race were the most important determinants of aBMD at all sites. Older age and higher bone turnover were independently associated with lower aBMD at the distal radius. In a limited analysis, self-reported physical activity, dietary protein and calorie intake were not associated with aBMD after adjustment for the other variables.

Milk consumption during teenage years and risk of hip fractures in older adults

IMPORTANCE

Milk consumption during adolescence is recommended to promote peak bone mass and thereby reduce fracture risk in later life. However, its role in hip fracture prevention is not established and high consumption may adversely influence risk by increasing height.

OBJECTIVES

To determine whether milk consumption during teenage years influences risk of hip fracture in older adults and to investigate the role of attained height in this association.

DESIGN, SETTING, AND PARTICIPANTS

Prospective cohort study over 22 years of follow-up in more than 96,000 white postmenopausal women from the Nurses' Health Study and men aged 50 years and older from the Health Professionals Follow-up Study in the United States.

EXPOSURES

Frequency of consumption of milk and other foods during ages 13 to 18 years and attained height were reported at baseline. Current diet, weight, smoking, physical activity, medication use, and other risk factors for hip fractures were reported on biennial questionnaires.

MAIN OUTCOMES AND MEASURES

Cox proportional hazards models were used to calculate relative risks (RRs) of first incidence of hip fracture from low-trauma events per glass (8 fl oz or 240 mL) of milk consumed per day during teenage years.

RESULTS

During follow-up, 1226 hip fractures were identified in women and 490 in men. After controlling for known risk factors and current milk consumption, each additional glass of milk per day during teenage years was associated with a significant 9% higher risk of hip fracture in men (RR = 1.09; 95% CI, 1.01-1.17). The association was attenuated when height was added to the model (RR = 1.06; 95% CI, 0.98-1.14). Teenage milk consumption was not associated with hip fractures in women (RR = 1.00 per glass per day; 95% CI, 0.95-1.05).

CONCLUSIONS AND RELEVANCE

Greater milk consumption during teenage years was not associated with a lower risk of hip fracture in older adults. The positive association observed in men was partially mediated through attained height.

Withaferin A: a proteasomal inhibitor promotes healing after injury and exerts anabolic effect on osteoporotic bone

Withania somnifera or Ashwagandha is a medicinal herb of Ayurveda. Though the extract and purified molecules, withanolides, from this plant have been shown to have different pharmacological activities, their effect on bone formation has not been studied. Here, we show that one of the withanolide, withaferin A (WFA) acts as a proteasomal inhibitor (PI) and binds to specific catalytic β subunit of the 20S proteasome. It exerts positive effect on osteoblast by increasing osteoblast proliferation and differentiation. WFA increased expression of osteoblast-specific transcription factor and mineralizing genes, promoted osteoblast survival and suppressed inflammatory cytokines. In osteoclast, WFA treatment decreased osteoclast number directly by decreasing expression of tartarate-resistant acid phosphatase and receptor activator of nuclear factor kappa-B (RANK) and indirectly by decreasing osteoprotegrin/RANK ligand ratio. Our data show that in vitro treatment of WFA to calvarial osteoblast cells decreased expression of E3 ubiquitin ligase, Smad ubiquitin regulatory factor 2 (Smurf2), preventing degradation of Runt-related transcription factor 2 (RunX2) and relevant Smad proteins, which are phosphorylated by bone morphogenetic protein 2. Increased Smurf2 expression due to exogenous treatment of tumor necrosis factor α (TNFα) to primary osteoblast cells was decreased by WFA treatment. This was corroborated by using small interfering RNA against Smurf2. Further, WFA also blocked nuclear factor kappa-B (NF-kB) signaling as assessed by tumor necrosis factor stimulated nuclear translocation of p65-subunit of NF-kB. Overall data show that in vitro proteasome inhibition by WFA simultaneously promoted osteoblastogenesis by stabilizing RunX2 and suppressed osteoclast differentiation, by inhibiting osteoclastogenesis. Oral administration of WFA to osteopenic ovariectomized mice increased osteoprogenitor cells in the bone marrow and increased expression of osteogenic genes. WFA supplementation improved trabecular micro-architecture of the long bones, increased biomechanical strength parameters of the vertebra and femur, decreased bone turnover markers (osteocalcin and TNFα) and expression of skeletal osteoclastogenic genes. It also increased new bone formation and expression of osteogenic genes in the femur bone as compared with vehicle groups (Sham) and ovariectomy (OVx), Bortezomib (known PI), injectible parathyroid hormone and alendronate (FDA approved drugs). WFA promoted the process of cortical bone regeneration at drill-holes site in the femur mid-diaphysis region and cortical gap was bridged with woven bone within 11 days of both estrogen sufficient and deficient (ovariectomized, Ovx) mice. Together our data suggest that WFA stimulates bone formation by abrogating proteasomal machinery and provides knowledge base for its clinical evaluation as a bone anabolic agent.

Discontinuation of denosumab and associated fracture incidence: analysis from the Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM) trial

Osteoporosis is a chronic disease and requires long-term treatment with pharmacologic therapy to ensure sustained antifracture benefit. Denosumab reduced the risk for new vertebral, nonvertebral, and hip fractures over 36 months in the Fracture Reduction Evaluation of Denosumab in Osteoporosis Every 6 Months (FREEDOM) trial. Whereas discontinuation of denosumab has been associated with transient increases in bone remodeling and declines in bone mineral density (BMD), the effect on fracture risk during treatment cessation is not as well characterized. To understand the fracture incidence between treatment groups after cessation of investigational product, we evaluated subjects in FREEDOM who discontinued treatment after receiving two to five doses of denosumab or placebo, and continued study participation for ≥7 months. The off-treatment observation period for each individual subject began 7 months after the last dose and lasted until the end of the study. This subgroup of 797 subjects (470 placebo, 327 denosumab), who were evaluable during the off-treatment period, showed similar baseline characteristics for age, prevalent fracture, and lumbar spine and total hip BMD T-scores. During treatment, more placebo-treated subjects as compared with denosumab-treated subjects sustained a fracture and had significant decreases in BMD. During the off-treatment period (median 0.8 years per subject), 42% versus 28% of placebo- and denosumab-treated subjects, respectively, initiated other therapy. Following discontinuation, similar percentages of subjects in both groups sustained a new fracture (9% placebo, 7% denosumab), resulting in a fracture rate per 100 subject-years of 13.5 for placebo and 9.7 for denosumab (hazard ratio [HR] 0.82; 95% confidence interval [CI], 0.49-1.38), adjusted for age and total hip BMD T-score at baseline. There was no apparent difference in fracture occurrence pattern between the groups during the off-treatment period. In summary, there does not appear to be an excess in fracture risk after treatment cessation with denosumab compared with placebo during the off-treatment period for up to 24 months.

[What patients need to know about the risk of bone fracture and its prevention]

Post-menopausal osteoporosis is one of the classic complications of prolonged estrogen deficiency associated with menopause. It is defined as a state of the skeleton characterized by decreased bone strength with an increased risk of fracture. The natural history of osteoporosis and, in particular, the rapid increase in fracture recurrence after a first major fracture should justify a priori an approach for early detection of women at higher risk from the early postmenopausal phase. It is more of a chronic disease that requires support in the long term, in the absence of a truly curative treatment. Indeed, currently available therapies can at best reduce the incidence of fractures by about 50%, especially at the vertebral site, but do not cancel the disease. Moreover, duration of treatment is currently recommended for 5 to 10 years, which does not allow to consider that a single molecule could be taken "for the whole life". The fracture risk assessment based on the combination of densitometric measurement by DXA and the search for clinical risk factors is a prerequisite to any therapy. The first choice of treatment is especially important for a relatively young woman with high fracture risk. In early menopause (generally within the first decade of post-menopausal) and in the absence of contraindication, menopausal hormone therapy should remain the preferred option for first-line whenever possible. Raloxifene is an interesting alternative, due to its mechanisms of action and multiplicity of targets with, in particular, its preventive effect on the risk of estrogen receptor-positive breast cancer. It is only when there are contraindications to one or the other of these two molecules, that other osteoporosis treatments can be discussed. They should nevertheless be considered only in women whose 10-year-fracture risk is significantly increased. Indeed, it is mainly in this high risk of fracture, particularly because of an age greater than 65 years and a history of vertebral fracture, that their antifracture efficacy has been validated. In addition, it is mostly beyond this age that the question of the prevention of hip fracture has to be considered.

Postmenopausal osteoporosis treatment with antiresorptives: effects of discontinuation or long-term continuation on bone turnover and fracture risk--a perspective

Osteoporosis may be a lifelong condition. Robust data regarding the efficacy and safety of both long-term osteoporosis therapy and therapy discontinuation are therefore important. A paucity of clinical trial data regarding the long-term antifracture efficacy of osteoporosis therapies necessitates the use of surrogate endpoints in discussions surrounding long-term use and/or discontinuation. Long-term treatment (beyond 3-4 years) may produce further increases in bone mineral density (BMD) or BMD stability, depending on the specific treatment and the skeletal site. Bisphosphonates, when discontinued, are associated with a prolonged reduction in bone turnover markers (BTMs), with a very gradual increase to pretreatment levels within 3 to 60 months of treatment cessation, depending on the bisphosphonate used and the prior duration of therapy. In contrast, with nonbisphosphonate antiresorptive agents, such as estrogen and denosumab, BTMs rebound to above pretreatment values within months of discontinuation. The pattern of BTM change is generally mirrored by a more or less rapid decrease in BMD. Although the prolonged effect of some bisphosphonates on BTMs and BMD may contribute to residual benefit on bone strength, it may also raise safety concerns. Adequately powered postdiscontinuation fracture studies and conclusive evidence on maintenance or loss of fracture benefit is lacking for bisphosphonates. Similarly, the effects of rapid reversal of bone turnover upon discontinuation of denosumab on fracture risk remain unknown. Ideally, studies evaluating the effects of long-term treatment and treatment discontinuation should be designed to provide head-to-head "offset" data between bisphosphonates and nonbisphosphonate antiresorptive agents. In the absence of this, a clinical recommendation for physicians may be to periodically assess the benefits/risks of continuation versus discontinuation versus alternative management strategies.

Bone remodeling in postmenopausal women who discontinued denosumab treatment: off-treatment biopsy study

Denosumab is a fully human monoclonal antibody that neutralizes the activity of RANKL, leading to the inhibition of osteoclast maturation, bone-resorbing activity, and survival. Evaluation of trans-iliac crest bone biopsy specimens in the phase 3 pivotal fracture study with denosumab in postmenopausal women with osteoporosis showed evidence of reduced bone turnover at the tissue level in subjects receiving denosumab, and up to one-third of subjects did not have evidence of tetracycline labeling in trabecular or cortical bone. Discontinuation of denosumab therapy has demonstrated that the effects of denosumab are reversible, as assessed by biochemical markers of bone turnover (BTM) and BMD. The precise nature of changes that occur at the tissue level with denosumab discontinuation have not been explored. Fifteen subjects were enrolled in a cohort study to evaluate the effects of denosumab discontinuation at the tissue level. Subjects had discontinued osteoporosis treatment for a mean time of 25.1 months (range 21 to 29 months). Bone histomorphometry results were compared with results from placebo-treated women with osteoporosis in the denosumab phase 3 pivotal fracture bone biopsy substudy, and BTMs were compared with subjects' pretreatment values. The results of this study showed normal histology and bone remodeling similar to those observed in untreated postmenopausal women with osteoporosis. With treatment cessation, 100% of biopsy specimens had evidence of tetracycline labels. Biochemical markers were comparable to and highly correlated with pretreatment levels. These data confirm that the effects of denosumab on bone turnover at the tissue level are fully reversible.

Duration of treatment in postmenopausal osteoporosis: how long to treat and what are the consequences of cessation of treatment?

Although a variety of medications are effective for the treatment of postmenopausal osteoporosis, there is concern that long-term use may incur side effects. Consequently, some have proposed discontinuing or temporarily suspending treatment after a defined period of time. As the benefits of fracture risk reduction may recede during this "drug holiday", the clinician may be faced with deciding when to resume therapy (and with which agent) while avoiding the possible cumulative risk of side effects. This article summarizes data regarding length of treatment and the effects of cessation of treatment on bone density, bone turnover markers, and fracture risk.

Management of osteoporosis in postmenopausal women: 2010 position statement of The North American Menopause Society

OBJECTIVE

To update the evidence-based position statement published by The North American Menopause Society (NAMS) in 2006 regarding the management of osteoporosis in postmenopausal women.

METHODS

NAMS followed the general principles established for evidence-based guidelines to create this updated document. A panel of clinicians and researchers expert in the field of metabolic bone diseases and/or women's health was enlisted to review the 2006 NAMS position statement, compile supporting statements, and reach consensus on recommendations. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Osteoporosis, which is especially prevalent among older postmenopausal women, increases the risk of fractures. Hip and spine fractures are associated with particularly high morbidity and mortality in this population. Given the health implications of osteoporotic fractures, the primary goal of osteoporosis therapy is to prevent fractures, which is accomplished by slowing or stopping bone loss, maintaining bone strength, and minimizing or eliminating factors that may contribute to fractures. The evaluation of postmenopausal women for osteoporosis risk requires a medical history, physical examination, and diagnostic tests. Major risk factors for postmenopausal osteoporosis (as defined by bone mineral density) include advanced age, genetics, lifestyle factors (such as low calcium and vitamin D intake, smoking), thinness, and menopause status. The most common risk factors for osteoporotic fracture are advanced age, low bone mineral density, and previous fracture as an adult. Management focuses first on nonpharmacologic measures, such as a balanced diet, adequate calcium and vitamin D intake, adequate exercise, smoking cessation, avoidance of excessive alcohol intake, and fall prevention. If pharmacologic therapy is indicated, government-approved options are bisphosphonates, selective estrogen-receptor modulators, parathyroid hormone, estrogens, and calcitonin.

CONCLUSIONS

Management strategies for postmenopausal women involve identifying those at risk for fracture, followed by instituting measures that focus on reducing modifiable risk factors through dietary and lifestyle changes and, if indicated, pharmacologic therapy.

New thoughts about estrogen therapy from the Women's Health Initiative

Since the introduction of hormone replacement therapy (HRT) in 1942, the availability of scientific information regarding the physiologic action of estrogen alone and in combination with progesterone has grown substantially. The specific physiology of changes in endogenous estrogen as a causal factor in bone loss that occurs as the result of menopause is now better understood. Accumulating evidence regarding the benefit of estrogen in protecting against bone loss at the time of menopause made it the first choice for prevention and treatment of osteoporosis, until the findings of the Women's Health Initiative (WHI) were announced in 2002. Fortunately, the availability of multiple alternative agents for prevention and treatment of osteoporosis in menopausal women has provided clinicians with other options. There remain a small number of patients who cannot tolerate or afford these alternative therapies. Recent publications resulting from the WHI should be understood by practicing physicians who are faced with this dilemma and may need to consider HRT in treating patients with osteoporosis.

Interaction between playing golf and HRT on vertebral bone properties in post-menopausal women measured by QCT

We investigated the effect of playing regular golf and HRT on lumbar and thoracic vertebral bone parameters (measured by QCT) in 72 post-menopausal women. The main finding of this study was that there was positive interaction between golf and HRT on vertebral body CSA and BMC at the thoracic 12 and lumbar 2 vertebra but not the third and seventh thoracic vertebras.

INTRODUCTION

Identifying specific exercises that load the spine sufficiently to be osteogenic is an important component of primary osteoporosis prevention. The aim of this study was to determine if in postmenopausal women regular participation in golf resulted in greater paravertebral muscle mass and improved vertebral bone strength.

METHODS

Forty-seven postmenopausal women who played golf regularly were compared to 25 controls. Bone parameters at the mid-vertebral body were determined by QCT at spinal levels T3, T7, T12 and L2 (cross-sectional area (CSA), total volumetric BMD (vBMD), trabecular vBMD of the central 50% of total CSA, BMC and cortical rim thickness). At T7 and L2, CSA of trunk muscles was determined.

RESULTS

There was a positive interaction between golf and HRT for vertebral CSA and BMC at T12 and L2, but not at T3 or T7 (p ranging < 0.02 to 0.07). Current HRT use was associated with a 10-15% greater total and trabecular vBMD at all measured vertebral levels. Paravertebral muscle CSA did not differ between groups. Vertebral CSA was the bone parameter significantly related to muscle CSA.

CONCLUSION

These findings provide preliminary evidence that playing golf may improve lower spine bone strength in postmenopausal women who are using HRT.

Effectiveness of raloxifene on bone mineral density and serum lipid levels in post-menopausal women with low BMD after discontinuation of hormone replacement therapy

OBJECTIVE

To evaluate the effect of raloxifene on bone mineral density (BMD) and serum lipid levels in post-menopausal women who had discontinued hormone replacement therapy (HRT).

METHODS

Thirty-four post-menopausal women with low BMD who had taken 60 mg of raloxifene daily for 12 months after discontinuing HRT were evaluated retrospectively. Information about their demographics, fracture history, BMD, lipid profiles and adverse events were collected from medical records and intranet database. The outcome measures were changes in the spine (L2-L4) and femur BMD, serum lipid concentrations, fracture rate and tolerability.

RESULTS

The post-menopausal women had a significant increase in their spine (L2-L4) and femur BMD from their baseline BMD [spine, 2.9 +/- 4.6% (P < 0.001); femur, 3.0 +/- 6.6% (P = 0.01)]. Serum low-density lipoprotein (LDL) cholesterol was significantly reduced by 22.6% below baseline after 12 months (P = 0.007). No fractures were observed during therapy. Raloxifene was well tolerated. The most common adverse event was hot flash, which was generally mild.

CONCLUSIONS

Raloxifene increases BMD at important skeletal sites, and lowers LDL cholesterol with tolerable adverse events.

Skeletal consequences of hormone therapy discontinuance: a systematic review

Although hormone therapy protects against bone loss after menopause, currently it is not recommended once menopausal symptoms have subsided. We reviewed randomized clinical trials to quantify bone loss after stopping hormone therapy and summarize treatment options for women who discontinue hormone treatment. We conducted a search of MEDLINE and EMBASE for randomized, controlled trials measuring bone mineral density (BMD) after hormone therapy discontinuation. Other known published and unpublished data were also included. Eleven studies fulfilled the search criteria. In each, bone loss was rapid after stopping hormone therapy, with BMD declines ranging from 2.3% to 6.2% in the first year. Increases in bone turnover markers also occurred rapidly when hormone therapy was stopped. Limited data addressing treatment after hormone therapy is stopped exist; only 2 studies specifically evaluated therapy to protect bone after hormone discontinuation. Taken together, these 2 studies demonstrate that alendronate produced significant increases relative to placebo in spine, hip, and total body BMD in women with low bone density who had discontinued hormone therapy within the past 3 months, preventing the rapid bone loss seen on discontinuation of hormone therapy. Among treatment options for preventing bone loss on discontinuation of hormone therapy for which randomized clinical trial data are available, alendronate prevented bone loss or increased bone density in postmenopausal women with low bone density. Women who are discontinuing hormone therapy should be counseled about potential bone loss and effective treatment options.

TARGET AUDIENCE

Obstetricians & Gynecologists, Family Physicians.

LEARNING OBJECTIVES

After completion of this article, the reader should be able to state that discontinuation of replacement menopausal hormone therapy, which protects against bone loss, is not recommended after menopause symptoms have subsided; recall that it may accelerate bone loss; and explain that there is bone loss preventive treatment for women after discontinuation of hormone therapy.

Management of osteoporosis in postmenopausal women

OBJECTIVE

To update the evidence-based position statement published by The North American Menopause Society (NAMS) in 2002 regarding the management of osteoporosis in postmenopausal women.

DESIGN

NAMS followed the general principles established for evidence-based guidelines to create this updated document. A panel of clinicians and researchers expert in the field of metabolic bone diseases and/or women's health were enlisted to review the 2002 NAMS position statement, compile supporting statements, and reach consensus on recommendations. The panel's recommendations were reviewed and approved by the NAMS Board of Trustees.

RESULTS

Osteoporosis, whose prevalence is especially high among elderly postmenopausal women, increases the risk of fractures. Hip and spine fractures are associated with particularly high morbidity and mortality in this population. Given the health implications of osteoporotic fractures, the primary goal of osteoporosis therapy is to prevent fractures, which is accomplished by slowing or stopping bone loss, maintaining bone strength, and minimizing or eliminating factors that may contribute to fractures. The evaluation of postmenopausal women for osteoporosis risk requires a medical history, physical examination, and diagnostic tests. Major risk factors for postmenopausal osteoporosis (as defined by bone mineral density) include advanced age, genetics, lifestyle factors (such as low calcium and vitamin D intake, smoking), thinness, and menopause status. The most common risk factors for osteoporotic fracture are advanced age, low bone mineral density, and previous fracture as an adult. Management focuses first on nonpharmacologic measures, such as a balanced diet, adequate calcium and vitamin D intake, adequate exercise, smoking cessation, avoidance of excessive alcohol intake, and fall prevention. If pharmacologic therapy is indicated, government-approved options are bisphosphonates, a selective estrogen-receptor modulator, parathyroid hormone, estrogens, and calcitonin.

CONCLUSIONS

Management strategies for postmenopausal women involve identifying those at risk of low bone density and fracture, followed by instituting measures that focus on reducing modifiable risk factors through lifestyle changes and, if indicated, pharmacologic therapy.

What is the role of DXA, QUS and bone markers in fracture prediction, treatment allocation and monitoring?

There is evidence that treatment can decrease the risk of fractures in osteoporotic patients, and screening of these patients is therefore relevant. Diagnosis of osteoporosis is based on the T-score calculated from bone mineral density (BMD) measurements. BMD measurements have been widely used for the management of osteoporosis, and a low BMD is a strong risk factor for fractures. But BMD measurement has several limitations in both diagnosis, prediction of fracture risk, and treatment follow-up. Quantitative ultrasound (QUS) parameters, an alternative to BMD in the assessment of bone, are independent risk factors for osteoporotic fracture. However, the use of QUS cannot be recommended for both allocation and monitoring of treatment. Biochemical markers of bone remodelling can be useful for both prediction of fracture risk and monitoring of treatment if sources of variability are controlled.

How to manage osteoporosis after the menopause

Many women seek advice about bone health at the time of the menopause. Although fracture probability is low in the majority, treatment may be cost-effective if targeted at those at highest risk. Optimal selection of individuals for intervention is based on a case-finding approach, fracture probability being estimated using a combination of bone mineral density and clinical risk factors. A variety of therapeutic interventions is available for the prevention of osteoporotic fractures in postmenopausal women. Hormone replacement therapy (HRT) is a second-line option in most, although it has a place in the management of perimenopausal women with menopausal symptoms who are at risk from fracture and in other postmenopausal women who express a preference for HRT over other options, after being fully informed about known risks and benefits.

Tapered progesterone withdrawal enhances behavioral and molecular recovery after traumatic brain injury

Systemic injections of the neurosteroid progesterone improve cognitive recovery after traumatic brain injury (TBI) and stroke, and decrease molecular indicators of neuronal damage. Suddenly withdrawing progesterone after repeated dosing (PW) exacerbates ischemia and causes increased anxiety, seizure susceptibility, and excitotoxicity. Adult male Sprague-Dawley rats received either bilateral medial frontal cortex contusions or sham surgery. Injections were administered at 1 and 6 h post-injury, then every 24 h for 7 days. Vehicle-treated rats received 2-hydroxypropyl-beta-cyclodextrin (HBC). Acute PW (AW) rats received a full 16 mg/ml of progesterone for 7 days, and tapered PW (TW) rats received 5 days at full dosage, then 2 days with progressively halved dosages. Anxiety behaviors were observed pre- and post-surgery, and compared to levels at the peak of withdrawal. AW rats with lesions exhibited significantly more anxiety than any other treatment group, while both lesion- and sham-operated TW rats were indistinguishable from vehicle-treated intact animals. After behavioral tests were complete, the brains were extracted and prepared for Western blotting. TNFalpha, cFos, Caspase-3, and NFkappaB, among others, were investigated. While all progesterone treatments resulted in improved molecular recovery, TW animals had significantly fewer active markers for apoptosis and inflammation than AW animals. In conclusion, although progesterone treatment decreases inflammation and apoptosis, acute withdrawal increases activity in some apoptotic and inflammatory pathways and increases anxiety behavior during the acute healing phase. A tapered withdrawal of the hormone further enhances short-term recovery after TBI.

Does osteopenia warrant treatment?

The progressive loss of bone mass that leads to osteoporosis in postmenopausal women is known to result in substantial morbidity and mortality. Underdiagnosed and undertreated, osteoporosis jeopardizes the health of an estimated 8 million American women 50 years of age or older who are at high risk for hip, vertebral, and other fractures. Because osteopenia is generally a subclinical condition that results in a lower fracture rate than osteoporosis, its potential impact is more difficult to recognize, although it is nearly three times more prevalent than osteoporosis. The question arises as to whether osteopenia should be diagnosed and treated before it transitions into osteoporosis. Because the number of postmenopausal women is projected to increase substantially in the near future and the number of postmenopausal women who will or who have discontinued their use of hormone therapy has increased sharply, the consequences of failing to identify and treat women at increased fracture risk are considerable. Moreover, the rate of bone loss in the first year after discontinuation of hormone therapy is especially rapid and similar to the rate that occurs early after menopause. Accordingly, fracture risk is substantially increased at this time in relation to the magnitude of bone loss. The goal of nonpharmacologic and pharmacologic therapy is to prevent the first fracture in any woman at risk for fracture. Initiation of antiresorptive therapy known to provide rapid efficacy can be particularly important in achieving the treatment goal in appropriate osteopenic women.

Skeletal effects of raloxifene after 8 years: results from the continuing outcomes relevant to Evista (CORE) study

In the CORE breast cancer trial of 4011 women continuing from MORE, the incidence of nonvertebral fractures at 8 years was similar between placebo and raloxifene 60 mg/day. CORE had limitations for assessing fracture risk. In a subset of 386 women, 7 years of raloxifene treatment significantly increased lumbar spine and femoral neck BMD compared from the baseline of MORE.

INTRODUCTION

The multicenter, double-blind Continuing Outcomes Relevant to Evista (CORE) trial assessed the effects of raloxifene on breast cancer for 4 additional years beyond the 4-year Multiple Outcomes of Raloxifene Evaluation (MORE) osteoporosis treatment trial.

MATERIALS AND METHODS

In CORE, placebo-treated women from MORE continued with placebo (n = 1286), whereas those previously given raloxifene (60 or 120 mg/day) received raloxifene 60 mg/day (n = 2725). As a secondary endpoint, new nonvertebral fractures were analyzed as time-to-first event in 4011 postmenopausal women at 8 years. A substudy assessed lumbar spine and femoral neck BMD at 7 years, with the primary analysis based on 386 women (127 placebo, 259 raloxifene) who did not take other bone-active agents from the fourth year of MORE and who were > or =80% compliant with study medication in CORE.

RESULTS

The risk of at least one new nonvertebral fracture was similar in the placebo (22.9%) and raloxifene (22.8%) groups (hazard ratio [HR], 1.00; Bonferroni-adjusted CI, 0.82, 1.21). The incidence of at least one new nonvertebral fracture at six major sites (clavicle, humerus, wrist, pelvis, hip, lower leg) was 17.5% in both groups. Posthoc Poisson analyses, which account for multiple events, showed no overall effect on nonvertebral fracture risk, and a decreased risk at six major nonvertebral sites in women with prevalent vertebral fractures (HR, 0.78; 95% CI, 0.63, 0.96). At 7 years after MORE randomization, the differences in mean lumbar spine and femoral neck BMD with raloxifene were 1.7% (p = 0.30) and 2.4% (p = 0.045), respectively, from placebo. Compared with MORE baseline, after 7 years, raloxifene treatment significantly increased lumbar spine (4.3% from baseline, 2.2% from placebo) and femoral neck BMD (1.9% from baseline, 3.0% from placebo). BMDs were significantly increased from MORE baseline at all time-points at both sites with raloxifene.

CONCLUSION

Raloxifene therapy had no effect on nonvertebral fracture risk after 8 years, although CORE had limitations for fracture risk assessment. BMD increases were maintained after 7 years of raloxifene.

Benefits and risks of sex hormone replacement in postmenopausal women

Because cardiovascular disease (CVD), which is far less common in young women than in men, but increases in prevalence in the postmenopausal years to that of men, estrogen repletion therapy (ERT) or combined hormone replacement therapy (HRT), has been widely used to protect against development of both CVD and osteoporosis, and possibly to delay or prevent cognitive loss or Alzheimer's disease (AD). To test the validity of favorable findings in many small-scale studies, and in clinical practice, a large-scale trial: the Women's Health Initiative (WHI) was undertaken by the National Institutes of Health (NIH), a trial that was prematurely ended because of increased CVD complications, despite some lessening of hip fractures. This paper suggests that the customary high intake of calcium (Ca)-advised to protect against osteoporosis, and the marginal magnesium (Mg) intake in the USA, might well be contributory to the adverse CV effects, that were all thromboembolic in nature. The procoagulant effect of estrogen is intensified by Ca; Mg-which counteracts many steps in the coagulation cascade and inhibits platelet aggregation and adhesion-is commonly consumed in sub-optimal amounts. The high American dietary Ca/Mg ratio might also be contributory to the WHI failure to confirm ERT's favorable mental effects. Discussed are mechanisms by which Mg enhances estrogen's central nervous system protective effects. Mg's improvement of cerebral blood flow, which improves brain metabolism, can also enhance removal of the beta amyloid peptide, accumulation of which is implicated in AD.

The effects of calcitriol therapy on serum interleukin-1, interleukin-6 and tumour necrosis factor-alpha concentrations in post-menopausal patients with osteoporosis

Seventy post-menopausal women with osteoporosis were randomized into two groups: 40 patients received calcitriol (0.5 microg/day) and calcium (1000 mg/day); and 30 control patients received calcium (1000 mg/day) alone. Thirty healthy women formed the healthy control group. Bone mineral density (BMD) and serum interleukin (IL)-1, IL-6 and tumour necrosis factor-alpha (TNF-alpha) concentrations were measured at baseline and after 6 months of treatment. Calcitriol treatment for 6 months significantly increased BMD and reduced serum IL-1 and TNF-alpha concentrations compared with no significant changes in patients treated with calcium alone. Both treatments increased serum calcium and decreased parathyroid hormone concentrations. The healthy control group had a significantly lower IL-6 concentration than the post-menopausal women with osteoporosis. We have shown that calcitriol was an effective treatment for osteoporosis. Significant reductions in serum IL-1 and TNF-alpha concentrations suggest that, in addition to increasing the absorption of calcium, calcitriol may directly affect bone metabolism via cytokines.

Changes in bone density and turnover after alendronate or estrogen withdrawal

OBJECTIVE

To compare bone mineral density (BMD) and bone turnover changes after therapy withdrawal in postmenopausal women treated with alendronate or estrogen-progestin.

DESIGN

In this randomized, blinded, multinational, placebo-controlled trial, 1,609 healthy postmenopausal women ages 45 to 59 years were assigned to receive alendronate, placebo, or open-label estrogen-progestin (conjugated equine estrogens plus medroxyprogesterone acetate or a cyclic regimen of 17 beta-estradiol, norethisterone acetate and estradiol). Of the original women, one third after year 2 and one third after year 4 were switched from alendronate to placebo, while remaining blinded to treatment assignment. The women taking estrogen-progestin in years 1 to 4 were followed off therapy in years 5 and 6. BMD at the lumbar spine and hip and biochemical markers of bone turnover were measured.

RESULTS

The treatment groups described in the current report represent 860 women at baseline; 481 women entered year 5, and 430 completed 6 years. BMD steadily decreased in the placebo group during all 6 years. In contrast, spine and hip BMD increased during the first 4 years in the groups receiving daily continuous alendronate 5 mg and estrogen-progestin. During years 5 and 6, BMD decreased at the lumbar spine -2.42% (95% CI = -4.10, -0.74) and total hip -1.09% (-2.60, 0.41) in the group previously treated with alendronate 5 mg for 4 years. In comparison, large BMD decreases were observed at the spine [-7.69% (-8.96, -6.41)] and total hip [-5.16% (-6.30, -4.01)] among women who had received estrogen-progestin for 4 years.

CONCLUSION

Alendronate produces greater residual skeletal effects than estrogen-progestin after therapy discontinuation.

Ostéoporose et traitement hormonal substitutif

Hormone replacement therapy prevents bone loss and the increase in bone resorption due to the hormone deficiency in oestrogen in postmenopausal women. The WHI (Women's Health Initiative) randomised, double-blind study against placebo, demonstrated that which all the epidemiological trials had already suggested: replacement therapy can reducing by around 30% the risk of fractures in postmenopausal women. Administration of hormone replacement therapy requires account being taken of (in view of the uncertainties regarding the anti-fracture effect of low dose therapy): the duration (in view of the absence of remnant effect of the product on bone loss and on the risk of fracture) and the benefit/risk ration (in view of the benefits demonstrated on climacteric disorders, but the increase in risk of breast cancer). The menopause is the occasion to assess individual risks, notably vascular and of fractures, taking into account the clinical risk factors and measurement of bone density.

Alendronate Therapy May Be Effective in the Prevention of Bone Loss Around Titanium Implants Inserted in Estrogen-Deficient Rats

BACKGROUND

This study evaluated whether alendronate (ALD) influences bone healing around titanium implants inserted in ovariectomized rats and whether it provides a residual effect after its withdrawal.

METHODS

Bilateral ovariectomies were performed in 87 Wistar rats and one screw-shaped titanium implant was placed in the tibiae. The animals were divided into the following groups: group SHAM (N = 15): sham surgeries; group OVX (N = 15): ovariectomy; group AT (N = 15): OVX plus alendronate administration for 80 days; group AW (N = 14): OVX plus alendronate administration for 40 days; group ET (N = 14): OVX plus 17beta estradiol administration for 80 days; or group EW (N = 14): OVX plus 17beta estradiol administration for 40 days. Bone-to-implant contact (BIC), bone area (BA) within the limits of implant threads, and bone density in a 500 microm-wide zone lateral to the implant (BD) were obtained and measured for the cortical (zone A) and cancellous (zone B) regions.

RESULTS

In zone A, data analysis showed no significant differences among the groups regarding BIC and BD (P >0.05), and a slight beneficial effect of estradiol on BA when compared with the OVX, EW, and AW groups (P <0.05). In zone B, OVX negatively impacted bone healing around the implants, resulting in reduced BA and BD (P<0.05). ALD (continuous/interrupted) and estradiol (only continuous) positively affected BIC, BA, and BD, resulting in values at the same level as the control group (SHAM).

CONCLUSIONS

ALD may prevent the negative influence of estrogen deficiency on bone healing around titanium implants inserted in OVX rats. This positive effect, in contrast to estradiol, is sustained following its withdrawal.

Bone loss and the evolving role of bisphosphonate therapy in prostate cancer

Androgen deprivation therapy (ADT) can result in significant loss of bone mineral density (BMD) but to date, there are no prospective studies that document the true severity of bone loss and resulting fracture rates. In the general population, however, the incidence of low BMD is increasing in elderly men. Men suffer more morbidity and mortality from fractures associated with low BMD than women. Problems of underdiagnosis and undertreatment in men can be addressed with enhanced awareness of the risk factors for bone loss in men and the available treatment options. Guidelines for diagnosis of low BMD in women can probably be applied to men. Treatment options have not been studied as extensively in men. For men treated with ADT for prostate cancer, however, use of intravenous zoledronic acid at the initiation of ADT has been shown to prevent and even reverse bone loss. Although the routine use of bisphosphonates to prevent bone loss is not yet recommended, zoledronic acid is a logical choice of therapy in men who have low BMD at baseline or who develop bone loss during the course of therapy. In addition to its effects on BMD, zoledronic acid has also been shown to decrease skeletal morbidity in men with metastatic hormone-refractory prostate cancer. Whether zoledronic acid or other bisphosphonates might actually prevent or delay the development of bone metastases remains to be studied in randomized clinical trials.

Two to three years of hormone replacement treatment in healthy women have long-term preventive effects on bone mass and osteoporotic fractures: the PERF study

Hormone replacement therapy (HRT) is often prescribed for a few years to suppress menopausal symptoms. Although its long-term use of HRT for the primary prevention of osteoporosis is not currently recommended, the long-term skeletal benefits of the limited therapy are of great interest. To determine whether administration of HRT for 2-3 years in the early postmenopausal years provides long-term benefits, such as prevention of bone loss and osteoporotic fractures, we studied a group of 347 healthy postmenopausal women with normal bone mass who had earlier completed one of four placebo-controlled HRT trials and who were reexamined 5, 11, or 15 years after stopping HRT. Of these women, 263 received either HRT or placebo for 2-3 years with no further bone-sparing treatment until follow-up, and the remaining 84 women reported either prolonged or current use of HRT at reexamination. Bone mineral density (BMD) at the spine (L1-L4) and bone mineral content (BMC) in the forearm were measured at baseline, the end of the trials, and follow-up. At follow-up, we assessed the radiological presence of vertebral fracture and collected information on the new incidence of nonvertebral fractures. Compared with that of the placebo-treated women, the BMD and BMC of HRT-treated women continued to show significantly higher values (>5%) even many years after stopping HRT. After stopping treatment, the rate of bone loss returned to normal postmenopausal rates. The preservation of bone mass in the HRT group was accompanied by a significantly reduced risk of all osteoporotic fractures as compared with the placebo group [OR = 0.48 (95% CI, 0.26-0.88)]. 'Fast losers' on placebo had more than a 4-fold higher risk of fractures than had the women on limited HRT with a normal rate of bone loss after withdrawal. In conclusion, limited HRT administered in the early postmenopausal years offers long-lasting benefits for the prevention of postmenopausal bone loss and osteoporotic fracture.

Recency and duration of postmenopausal hormone therapy: effects on bone mineral density and fracture risk in the National Osteoporosis Risk Assessment (NORA) study

OBJECTIVES

Results from the Women's Health Initiative showed that postmenopausal hormone replacement therapy (HRT) prevents fractures but has an overall unfavorable risk:benefit ratio, leading to the recommendation that HRT be used only for women with troublesome menopause symptoms, and for as short a time as possible. This recommendation has important implications for the timing and duration of HRT and the prevention of osteoporosis. The large number of women participating in the National Osteoporosis Risk Assessment (NORA) program provided the opportunity to evaluate bone mineral density (BMD) and 1-year fracture risk in analyses stratified by duration and recency of HRT.

DESIGN

Participants were 170,852 postmenopausal women aged 50 to 104, without known osteoporosis, who were recruited from primary physicians offices across the US. BMD was measured at one of four peripheral sites, and the 1-year risk of osteoporotic fracture was assessed by questionnaire.

RESULTS

At baseline, current HRT users had the highest T-scores at every age. Among current hormone users, women who had used HRT longest had the highest BMD levels. Women who had stopped HRT more than 5 years previously, regardless of duration of use, had T-scores similar to never-users. Current but not past hormone use at baseline was associated with a 25% to 29% lower risk of osteoporotic fracture (P < 0.0001) in 1 year, compared with nonusers. These findings were independent of age, ethnicity, body mass index, lifestyle, years postmenopausal, and site of BMD measurement.

CONCLUSIONS

We conclude that postmenopausal BMD and fracture are closely associated with current, but not prior, HRT use. Use of HRT for 5 years or less, as proposed for treatment of symptomatic women during menopause transition, is unlikely to preserve bone or significantly reduce fracture risk in later years.

A simulation model at trabecular level to predict effects of antiresorptive treatment after menopause

Antiresorptive drugs are widely used to prevent osteoporotic fractures in men and women. Large clinical trials have shown vertebral fracture risk reductions up to 50%, resulting from relatively small increases of 3-8% in bone mineral density (BMD). We developed a computer model that mimics bone turnover in human vertebral cancellous bone during menopause and antiresorptive treatment. This model links cell activity in trabeculae to changes in bone volume and mechanical properties. We asked whether treatment started shortly after menopause is better than treatment started late after menopause. In order to answer this question we used the model to simulate menopause and 5 years of anti-resorptive treatment with two different agents: one incorporated in the tissue, one not incorporated. We found that late treatment can result in almost the same bone mass as early treatment, but early treatment is much better in conserving the strength and stiffness of the cancellous bone. The effect of the incorporation of drugs in the tissue (giving the drugs a long half-life) was small. After discontinuation of treatment, bone was lost slower, but after 20 years the difference between the incorporated and the not incorporated drug in stiffness and bone volume was below 3%. This kind of simulation model may be used to preclinically test new pharmaceuticals and treatment protocols and to predict long-term effects of treatment before patient data become available.

Disorders associated with acute rapid and severe bone loss

We describe a constellation of bone diseases characterized by the common feature of acute, rapid, and severe bone loss accompanied by dramatic fracture rates. These disorders are poorly recognized, resulting mainly from systemic diseases, frailty, immobilization, and immunosuppressive drugs, such as glucocorticoids and the calcineurin inhibitors. The opportunity to prevent or treat fractures is commonly missed because they are often not detected. Ideally, patients need to be identified early and preventative therapy initiated promptly to avoid the rapid bone loss and fractures. The most effective therapy at present seems to be the bisphosphonates, particularly when bone resorption is predominant. However, more severe forms of bone loss that result from an osteoblastic defect and reduced bone formation may benefit potentially more from newer anabolic agents, such as recombinant human parathyroid hormone (rhPTH).