Bone fracture risk for women discontinuing menopausal hormone replacement therapy (HRT) initially spikes but eventually shows a reduced long-term fracture risk compared to women who never underwent hormone therapy. This is according to new findings published in The Lancet.
“It’s reassuring that long term, you didn’t seem to be worse off if you had taken hormones in the past,” said Dr. Deborah Kwolek, a certified menopause specialist, in an interview with Medscape Medical News. “And it reconfirms that when you first go off the hormones, you’re going to lose some benefit, which can translate into higher fracture risk and that needs attention.” Dr. Kwolek is an assistant professor at Harvard Medical School and the founding lead of the Mass General Women’s Health and Sex and Gender Medicine Program.
Comprehensive Study Involving Millions of Women
The study, led by Dr. Yana Vinogradova from the Centre for Academic Primary Care at the University of Nottingham, analyzed the health records of 648,747 women aged 40 and older. These women, registered with primary care practices between 1998 and 2023, had their first recorded fracture during this period. They were matched with up to five control women (totaling 2,357,125) with no fracture history but similar age and registration at the same practices.
Researchers used conditional logistic regression to assess HRT-related fracture risks, adjusting for demographics, family history, menopausal symptoms, comorbidities, and other medications. The study was designed to evaluate all HRT prescriptions containing estrogen and progestogen listed in the British National Formulary, assessing risk estimates up to 25 years post-therapy.
Long-Term Benefits and Comparison with Previous Studies
“Our study suggests that, even after stopping menopausal hormone therapy, women could benefit from notably reduced fracture risk in older age,” the authors noted. This finding is particularly significant for women who may have used HRT for shorter durations due to concerns like breast cancer.
The results contrast with some previous large-scale studies, such as the Women’s Health Initiative post-trial study, which followed over 15,000 women for five years and found no increased fracture risk after stopping hormone therapy. Dr. Kwolek explained that estrogen’s role in bone health is well-documented, particularly during the perimenopausal to menopausal transition, where it helps prevent bone loss associated with menopause.
“We had been saying more recently that when women go off estrogen, there should be a plan for how their bone health may be addressed, potentially with medication and close monitoring,” Dr. Kwolek added.
Individualized Approach to Bone Health
Dr. Kwolek emphasized the importance of considering a patient’s baseline fracture risk. For a young, healthy woman without osteoporosis, a slight increase in risk after stopping HRT may not be significant. However, “for a woman who’s 70 and she comes off her hormones and already has osteoporosis, the effects may be more significant,” she noted. In such cases, starting another medication to strengthen bones might be advisable.
She warned against viewing the temporary increase in fracture risk after stopping HRT as a deterrent to starting therapy. The study’s strengths include its large dataset and long follow-up period, highlighting an often-overlooked area of women’s healthcare.
“Whether in primary care or gynecologic appointments, people aren’t paying as much attention to these transitions as I think they should,” Dr. Kwolek said.
Both the study authors and Dr. Kwolek reported no relevant financial relationships, underscoring the impartiality of the findings.
Implications and Future Directions
The findings of this study could influence future guidelines on managing bone health in post-menopausal women. As healthcare providers become more aware of the long-term benefits of HRT, there may be a shift towards more personalized treatment plans that consider individual risks and benefits.
Looking forward, further research could explore the mechanisms behind the sustained benefits of HRT on bone health and develop strategies to mitigate the initial spike in fracture risk post-therapy. As awareness grows, women can be better informed about their options, leading to improved outcomes in managing menopausal transitions.
