It is hard to overestimate the importance of gonadal hormones – particularly oestrogen - to the skeleton. From pubertal bone accrual to growth plate closure to normal bone turnover to mechano-sensing, oestrogen is of key skeletal importance in both men and women. At menopause, oestrogen deficiency causes rapid bone loss - in the following decade women lose 9-10% of their total bone mass – and it continues to contribute to ongoing bone loss thereafter. It is not unsurprising, therefore, that randomised controlled trials demonstrated that oestrogen-alone and combined oestrogen-progestogen increase BMD and prevent vertebral and non-vertebral fractures in postmenopausal women. Perhaps what is surprising is how controversial menopausal hormone therapy (MHT) is in general, and for osteoporosis specifically. In large part, this is due to the premature closure and, arguably, sensational publications of the Women’s Health Initiative [WHI] trials. As a consequence, many endocrinologists are no longer familiar with prescribing MHT and indeed are uncomfortable continuing any form of gonadal hormone replacement in women aged over 50 years.
In recent years a closer analysis of the WHI and the risks vs. benefits of MHT have led to a re-evaluation and a question: in the widespread abandonment of MHT, have we lost a potentially valuable therapeutic option for prevention and/or treatment of osteoporosis? This talk will discuss the evidence for MHT specifically with respect to bone health, and provide a contextualised and nuanced approach to its use in 2019.