Morten Karsdal

Recommendations on the management of fragility fracture risk in women younger than 70 years

The risk for fragility fracture represents a problem of enormous magnitude. It is estimated that only a small fraction of women with this risk take the benefit of preventive measures. The relationship between estrogen and bone mass is well known as they are the other factors related to the risk for fracture. There are precise diagnostic methods, including a tool to diagnose the risk for fracture. Yet there continues to be an under-diagnosis, with the unrecoverable delay in instituting preventive measures. Women under the age of 70 years, being much more numerous than those older, and having risk factors, are a group in which it is essential to avoid that first fragility fracture. Today it is usual not to differentiate between the treatment and the prevention of osteoporosis since the common aim is to prevent fragility fractures. Included in this are women with osteoporosis or with low bone mass and increased risk for fracture, for whom risk factors play a primary role. There is clearly controversy over the type of treatment and its duration, especially given the possible adverse effects of long-term use. This justifies the concept of sequential treatment, even more so in women under the age of 70, since they presumably will need treatment for many years. Bone metabolism is age-dependent. In postmenopausal women under 70 years of age, the increase in bone resorption is clearly predominant, related to a sharp drop in estrogens. Thus a logical treatment is the prevention of fragility fractures by hormone replacement therapy (HRT) and, in asymptomatic women, selective estradiol receptor modulators (SERMs). Afterwards, there is a period of greater resorption, albeit less intense but continuous, when one could utilise anti-resorptive treatments such as bisphosphonates or denosumab or a dual agent like strontium ranelate. Bone formation treatment, such as parathyroid hormone (PTH), in women under 70 years will be uncommon. That is because it should be used in cases where the formation is greatly diminished and there is a high risk for fracture, something found in much older women.

Potentials of Estrogens in the Prevention of Osteoarthritis: What Do We Know and What Questions are Still Pending?

Publisher Summary Currently hormone therapy is not recommended for primary prevention of Osteoarthritis (OA). The decision is based on findings of the Womens Health Initiative study, which found risks exceeding benefits when the therapy was given as an estrogen plus progestin combination, and a balanced risk-benefit profile when the therapy was given as estrogen only. Hormone users in observational studies are women who initiate hormone therapy due to a need to control symptoms of estrogen deficiency arising in the early phase of the menopause. This period might actually open a therapeutic window for maximizing the multiple benefits of the therapy for effective long-term prevention of menopause-related diseases. When applied in this critical period, even 2 to 3 years of hormone replacement therapy (HRT) can bring lasting benefits for postmenopausal women after treatment withdrawal, in terms of prevention of osteoporotic fractures and cognitive decline. This chapter illustrates that diversity of methods and selected end points have a considerable impact on the overall impression as to whether HRT carries chondroprotective effects. Therefore, there is an unmet need for standardizing and enhancing the accuracy and precision of methodology and thereby the reliability of methodologic approaches to the quantification of changes in articular cartilage. However, it is important to point out that the potential benefits of estrogen replacement for the prevention of OA have not been considered in the equation of the global index of risk and benefits. Current research on estrogen and OA appears to be conflicting, yet there is enough experimental and clinical evidence to support further investigation into the therapeutic effects.