Osteoporosis International

, Volume 29, Issue 5, pp 1049–1055 | Cite as

Estrogen therapy for osteoporosis in the modern era

  • V. A. Levin
  • X. Jiang
  • R. Kagan
Concise Clinical Review


Menopause predisposes women to osteoporosis due to declining estrogen levels. This results in a decrease in bone mineral density (BMD) and an increase in fractures. Osteoporotic fractures lead to substantial morbidity and mortality, and are considered one of the largest public health priorities by the World Health Organization (WHO). It is therefore essential for menopausal women to receive appropriate guidance for the prevention and management of osteoporosis. The Women’s Health Initiative (WHI) randomized controlled trial first proved hormonal therapy (HT) reduces the incidence of all osteoporosis-related fractures in postmenopausal women. However, the study concluded that the adverse effects outweighed the potential benefits on bone, leading to a significant decrease in HT use for menopausal symptoms. Additionally, HT was not used as first-line therapy for osteoporosis and fractures. Subsequent studies have challenged these initial conclusions and have shown significant efficacy of HT in various doses, durations, regimens, and routes of administration. These studies support that HT improves BMD and reduces fracture risk in women with and without osteoporosis. Furthermore, the studies suggest that low-dose and transdermal HT are less likely associated with the adverse effects of breast cancer, endometrial hyperplasia, coronary artery disease (CAD), and venous thromboembolism (VTE) previously observed in standard-dose oral HT regimens. Given the need for estrogen in menopausal women and evidence supporting the cost effectiveness, safety, and efficacy of HT, we propose that HT should be considered for the primary prevention and treatment of osteoporosis in appropriate candidates. HT should be individualized and the once “lowest dose for shortest period of time” concept should no longer be used. This review will focus on the prior and current studies for various HT formulations used for the prevention and treatment of osteoporosis, exploring the safety profile of low-dose and transdermal HT that have been shown to be safer than oral standard-dose HT.


Bone mineral density (BMD) Hormone therapy (HT) Menopause Osteoporosis 


Compliance with ethical standards

Conflict of interest

None for VL and XJ, R Kagan has received research grants and support from Therapeutics MD (paid to Sutter Health), and has served as a consultant to Amgen, Merck, and Pfizer.


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Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2018

Authors and Affiliations

  1. 1.Department of ObGynThe Reading Hospital of Tower HealthReadingUSA
  2. 2.Department of ObGynSidney Kimmel Medical College of Thomas Jefferson UniversityPhiladelphiaUSA
  3. 3.Department of Obstetrics, Gynecology and Reproductive SciencesUCSFSan FranciscoUSA
  4. 4.Sutter East Bay Medical FoundationBerkeleyUSA

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