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Am Fam Physician. 2005;72(5):926-928

Postmenopausal osteoporosis is a serious health concern worldwide. Available treatment options include hormone therapy, calcitonin, bisphosphonates, vitamin K, and vitamin D. These therapies can reduce bone loss and incidence of fractures in postmenopausal women. However, no studies have compared the effectiveness of these treatments in randomized trials. Ishida and Kawai evaluated the effectiveness of hormone therapy, the bisphosphonate etidronate (Didronel), calcitonin (Calcimar), active vitamin D (alfacalcidol), and vitamin K (menatetrenone) in osteoporosis prevention.

The randomized study included 50- to 75-year-old women who were at least five years postmenopause (natural or surgically induced). The participants also met at least one criteria of osteoporosis. The participants were randomized into six treatment groups: hormone therapy, 0.625 mg conjugated estrogen daily plus 2.5 mg medroxyprogesterone (Depo-Provera) daily; etidronate, 200 mg daily for two weeks followed by 10 weeks of no treatment; eel calcitonin, 20 IU weekly; active vitamin D, 1 mcg daily; vitamin K, 45 mg daily; and placebo. The primary outcome was change in bone density after two years. Bone mineral density was measured with dual-energy absorptiometry (interpreters were blinded to what treatment the patients were undergoing). The secondary outcome was the incidence of vertebral fractures, which were assessed using lateral thoracic and lumbar spine radiographs at baseline and every three months. Biochemical markers for bone turnover also were measured at baseline and every three months.

The final analysis included 372 women. Bone mineral density increased by 2 percent in the hormone therapy group and by 1.6 percent in the calcitonin group. Bone mineral density decreased by 0.5 percent in the etidronate group, by 3.6 percent in the active vitamin D group, by 1.9 percent in the vitamin K group, and by 3.3 percent in the placebo group. Twenty-six percent of placebo patients developed new vertebral fractures. The relative risk for vertebral fractures, compared with placebo, were 0.35 for hormone therapy, 0.40 for etidronate, 0.41 for calcitonin, 0.56 for active vitamin D, and 0.44 for vitamin K. Women in the hormone therapy, etidronate, active vitamin D, and calcitonin groups without new vertebral fractures had a significant increase in bone mineral density compared with those who did develop vertebral fractures.

The authors concluded that hormone therapy, etidronate, and calcitonin significantly reduced the incidence of vertebral fractures in postmenopausal women. They also note that women who received hormone therapy or calcitonin had significant improvement in bone mineral density. The authors believe these results can assist physicians in deciding how to manage postmenopausal osteoporosis.

editor’s note: In Ishida and Kawai’s study,1 hormone therapy was one of the more beneficial treatment options in increasing bone mineral density and reducing vertebral fractures in postmenopausal women. However, physicians must balance these benefits with the risks of hormone therapy. The potential risks of combination hormone therapy are clarified in the Women’s Health Initiative.2 The authors of this study concluded that the overall health risks of treating postmenopausal women with estrogen and progesterone exceeded the benefits. They suggested that physicians should weigh the risks and benefits for each patient before deciding on hormone therapy for osteoporosis prevention.—k.e.m.

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Copyright © 2005 by the American Academy of Family Physicians.

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