I've reached menopause and my clinician wants to treat my hot flashes with estrogen because estrogen will also help prevent more bone loss. Is this true?

Estrogen therapy (ET) is the single most effective treatment for moderate vasomotor symptoms associated with menopause. Vasomotor symptoms[1], which include hot flashes and night sweats, are a direct result of low levels of estrogen that occur during perimenopause and postmenopause (see Question 9).

Vasomotor symptoms can start during perimenopause, the time period leading up to menopause, including the 12 months of no menses, when symptoms of hormonal changes occur. But if you only have an occasional hot flash or if you don't find daily hot flashes bothersome, then your symptoms probably don't require estrogen for treatment. If your symptoms are moderate to severe, then estrogen therapy might be a good option for both vasomotor symptom relief and bone protection. If you have a uterus, then you would need to take estrogen plus progestin therapy (EPT). The progestin protects the lining of the uterus from overgrowth, which can lead to endometrial cancer.

Estrogen is very effective in preventing and treating bone loss. Once you reach menopause, your bone loss becomes very rapid. You may lose as much as 5% of your bone density every year in the 4 to 8 years following menopause. Estrogen was FDA-approved for the management of osteoporosis back in 1972. More recently, the indication was changed to prevention of osteoporosis; however, it is not FDA-approved for treatment of osteoporosis. Studies of postmenopausal women taking estrogen for 1 year indicate that their bone density increases in their hip, spine, and forearm. Findings also indicate that the type of estrogen does not matter. All types of estrogen, including conjugated equine estrogen[2], bioidentical[3] estradiol, or synthetic estrogens, provide bone protection and help to increase bone mineral density.

While there was good evidence that bone density increased, it was not so clear whether estrogen actually reduced fracture rates until the Women's Health Initiative (WHI). The WHI was a very large study of thousands of postmenopausal women whose average age was about 63. The original intent of the study, which was started in 1991, was to research the cardiovascular effects of estrogen therapy or estrogen progestin therapy on postmenopausal women.

The clinicians and the women in the WHI were "blinded" in that they did not know whether a study participant was taking estrogen or a placebo. Older postmenopausal women without significant vasomotor symptoms were chosen because women in post-menopause who had hot flashes or night sweats would know that they were taking a drug instead of a placebo if the flashes or sweats went away.

The study results were also used to show the effect of estrogen on osteoporotic fractures. There was very good news for women's bones: Researchers found that fracture risk was reduced in both of the estrogen groups (also called "arms" of the study). In fact, spine and hip fractures were reduced by 33%. Although estrogen clearly demonstrated its positive effect on bone during the WHI, the estrogen progestin therapy arm of the study was stopped 3 years earlier than planned because of increased risk of breast cancer, heart disease, dementia, stroke, and clots. The estrogen-only arm was also stopped about 1 year early, not because it increased the risk of breast cancer but because estrogen alone also increased a woman's risk of stroke and clots (see Question 66).

The FDA now requires black-box warnings on all estrogen products for these effects, plus the risk of endometrial cancer. Endometrial cancer can be prevented with the use of progesterone in women who have their uterus (see Question 66). Also according to the black-box warning, menopause hormone therapy (MHT) is not to be used for preventing heart disease or dementia.

Don't forget that the WHI study participants were generally older. When the data were reanalyzed by looking at women in various age groups, the risks for heart disease were not increased in women immediately following menopause. The WHI data reanalysis supported findings from prior meta-analyses that showed using MHT immediately after menopause did not increase risks for heart disease (see Question 66).

So, yes, taking estrogen will not only help to prevent bone loss, it will also increase BMD and decrease your risk of fractures. Deciding whether to take MHT which customarily refers to either ET or EPT, is a very important decision for your overall health. If you do not have moderate-to-severe vasomotor symptoms, you should not take MHT solely to prevent osteoporosis. But if you need relief from your symptoms, you and your clinician should decide if the benefits of MHT outweigh the risks of taking it for you.

Faith's comment:

I started menopause in my 40s—-first the hot flashes and erratic periods, followed by mood swings. Because of my age and the fact that I had been on a medication for hypertension for a number of years, my gynecologist believed that menopause hormone therapy (MHT) was necessary to lessen the risk of heart disease and to keep my bones strong, since my mother has osteoporosis and I am small-boned. Although I was reluctant to begin MHT, the hot flashes, sleep deprivation, and incredible mood swings had worn me down. I wanted to be me again—fairly easy-going— not this person I no longer recognized. I took the MHT and experienced great relief. My bone test showed strong bones. All was great until the Women's Health Initiative study was released! Frightened, I stopped MHT.

Within 6 months my bone scan revealed osteopenia—worse in my spine, less severe in my hips. My gynecologist encouraged me to increase my calcium supplements, do weight-bearing exercises, and walk. I walked, lost weight, increased my calcium supplements to 1600 mg/day, and did free weights. I felt great. My bone scan the following year showed a slight improvement in my hips, but a worsening of my spine. Interestingly, I had also noticed that my posture seemed to be worsening . . . and that I seemed to constantly remind myself to stand up straight.

Looking back, I think my diet as a teenager and preadolescent was horrible—not much calcium (unless you count ice cream!) and meals that consisted of fries and Coke. I don't think I gave my bones much of a fighting chance.

My gynecologist recommended Fosamax, but I wanted a chance to try to improve my spine. However, a few months later when I had a physical by my nurse practitioner, she was adamant that I begin Fosamax immediately. She felt that my spine showed osteoporosis and that I was at risk of fractures. I began Fosamax. I'm curious to see what my next bone test looks like.

  • [1] Symptoms resulting from irregular functioning of the part of the brain that controls body heat, usually experienced as hot flashes and sweats that may or may not be followed by feeling cold or chilled.
  • [2] The most common form of estrogen used in hormone therapy (HT), extracted from the urine of pregnant mares.
  • [3] Refers to hormones manufactured in a laboratory, usually from wild yam or soy, that have the exact same chemical makeup as the hormones made in the body; also termed "natural" hormones.
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