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Osteoporosis is characterized by increased bone fragility and susceptibility to fracture resulting from low bone mass and microarchitectural deterioration of bone tissue. Although bone mineral density (BMD) is a major determinant of bone strength and fracture risk, one-half of fragility fractures occur in persons with BMD values in the osteopenic or normal range, suggesting that bone microarchitecture also affects bone strength.
Menopausal hormone therapy (MHT) has been shown to benefit BMD, but it has not previously been determined whether MHT may also improve bone microarchitecture, as reflected in trabecular bone score (TBS). The goal of this cross-sectional analysis by Papadakis and colleagues was to describe the effect of MHT on TBS and BMD before and after treatment withdrawal.
Hormone replacement therapy (HRT) can improve not only BMD but bone mass and structure, and the benefits of HRT on bone persist for at least 2 years after treatment is discontinued, a new cross-sectional analysis of a Swiss cohort indicates.
"We now know that almost half of all fragility fractures can occur in subjects who have either normal or osteopenic bone-mineral density," lead author Georgios Papadakis, MD, CHUV, Lausanne University Hospital, Lausanne, Switzerland, told Medscape Medical News.
"And bone microarchitecture has increasingly been recognized as an important factor in bone fragility, so used in the right context -- namely, in young postmenopausal women for whom the benefits outweigh the risks -- HRT is effective for both the prevention and treatment of osteoporosis," Dr Papadakis added.
The research was published online November 17 in the Journal of Clinical Endocrinology & Metabolism.[1]
Half of Women Were Current or Past Users of HRT
A total of 1279 women between 50 and 80 years old who were part of the larger OsteoLaus study[2] were available for the current analysis. They were divided into 3 groups: current HRT users, past HRT users, and women who had never taken HRT.
Current users had to have taken HRT for at least 6 months.
"Bone-mineral density was measured at the lumbar spine, femoral neck, and total hip with dual X-ray absorptiometry [DXA] while a trabecular bone score (TBS) of the spine was arrived at by evaluating pixel gray-level variations in the lumbar-spine DXA image," the investigators note.
As they point out, TBS provides an indirect index of trabecular bone microarchitecture and has been shown to predict fracture risk independently of BMD and the Fracture Risk Assessment tool.
Of the 1279 women included in the analysis, 282 (22%) were current users of HRT, 380 (30%) were past users, and 617 (48%) were nonusers.
It is important to note that past users were significantly older than the other 2 groups and had a higher prevalence of fractures. They also took calcium and vitamin D supplements more frequently than did current and never-users of HRT, although there were no between-group differences in body mass index (BMI) or dietary intake of calcium.
"Current-user group members had consistently higher values of TBS and BMD at all sites compared with never users and past users in both unadjusted and adjusted models," Dr Papadakis said.
Furthermore, after adjustment for age and BMI, past users had higher lumbar spine and total hip BMD than did never-users (P =.017 and P =.026, respectively), he added.
In addition, on multivariate analysis the investigators note that slopes for 10-year increments in TBS were significantly less steep in both current and past HRT users, "indicating that [HRT] slows down the age-associated loss of TBS," they observe.
In contrast, investigators found no differences in BMD based on duration of HRT use in either current or past users.
Table. Adjusted Mean BMD and TBS According to HRT Status
| Age and BMI-Adjusted BMD and TBS | Current HRT Users | Past HRT Users | Never HRT Users |
|---|---|---|---|
| BMD lumbar spine | 0.98 | 0.94 | 0.91 |
| TBS lumbar spine | 1.31 | 1.29 | 1.27 |
| BMD femoral neck | 0.76 | 0.73 | 0.72 |
| BMD total hip | 0.89 | 0.86 | 0.84 |
BMD, bone mineral density; BMI, body mass index; HRT, hormone replacement therapy; TBS, trabecular bone score.
Antiosteoporotic Drugs and Microarchitecture
As Dr Papadakis observed, drugs used to prevent fragility fractures in women with osteoporosis really should improve both BMD as well as bone microarchitecture.
However, so far current drugs used to treat osteoporosis actually have less of an effect on bone microarchitecture than they do on BMD, he pointed out.
He thus speculates that agents that more favorably influence bone microarchitecture, such as HRT, may well have advantages over those that do not, although this idea is still hypothetical.
"The idea is not to prescribe HRT to all women," he emphasized, "and I don't think HRT should be prescribed indefinitely, either," he added.
"But at least in young postmenopausal women at increased risk of osteoporosis, HRT can be a very effective first-line treatment, provided the woman has no contraindications and it can be continued for at least 5 and maybe even 10 years."
However, he emphasized that once HRT has been discontinued, any positive gains from HRT on either BMD or bone microarchitecture will likely be gone 2 years later.
Dr Papadakis has disclosed no relevant financial relationships. Disclosures for the coauthors are listed in the original study.
J Clin Endocrinol Metab. Published online November 17, 2016.
