BMJ  2003;326:1398 (21 June), doi:10.1136/bmj.326.7403.1398-a

Letter

Making decisions about hormone replacement therapy

Bisphosphonates should not be recommended for women aged 50

EDITOR—Many people, including Rymer et al in their clinical review,¹ say that bisphosphonates can be used instead of oestrogen to prevent osteoporotic fractures. Clinical trials of bisphosphonates in perimenopausal women have shown a stabilisation of bone density but no difference in fracture rate compared with placebo.² A significant reduction in fractures with bisphosphonates has been shown in women who are older and already have osteoporosis.³ Lower fracture rates have been shown in women who used oestrogen for 10 to 20 years.⁴ These data do not exist for bisphosphonates. The long term (greater than 10 years) use of bisphosphonates might be beneficial, but they possibly could make the bone more brittle due to the profound suppression of bone formation rates.⁵

We should not recommend that women aged 50 take bisphosphonates to prevent fractures that are unlikely to occur before age 70 until we have data that these drugs are effective at preventing fractures 20 years in the future.

University of Washington, 98195 Washington, DC, USA smott{at}u.washington.edu

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Competing interests: None declared

References

1. Rymer J, Wilson R, Ballard K. Making decisions about hormone replacement therapy. BMJ 2003;326: 322-6. (8 February.)[Free Full Text]
2. Ravn P, Bidstrup M, Wasnich RD, Davis JW, McClung MR, Balske A, et al. Alendronate and estrogen-progestin in the long-term prevention of bone loss: four-year results from the early postmenopausal intervention cohort study. A randomized, controlled trial. Ann Intern Med 1999;131: 935-42.[Abstract/Free Full Text]
3. McClung MR, Geusens P, Miller PD, Zippel H, Bensen WG, Roux C, et al. Effect of risedronate on the risk of hip fracture in elderly women. Hip Intervention Program Study Group. N Engl J Med 2001;344: 333-40.[Abstract/Free Full Text]
4. Cauley JA, Zmuda JM, Ensrud KE, Bauer DC, Ettinger B. Timing of estrogen replacement therapy for optimal osteoporosis prevention. J Clin Endocrinol Metab 2001;86: 5700-5.[Abstract/Free Full Text]
5. Chavassieux PM, Arlot ME, Reda C, Wei L, Yates AJ, Meunier PJ. Histomorphometric assessment of the long-term effects of alendronate on bone quality and remodeling in patients with osteoporosis. J Clin Invest 1997;100: 1475-80.[ISI][Medline]

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Making decisions about hormone replacement therapy

Janice Rymer, Ruth Wilson, and Karen Ballard
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