Hormone replacement therapy is recommended as second-line treatment for prevention of fractures for women with menopausal symptoms and there are no contraindications for hormone replacement therapy.
The recommendation is strong because there is evidence of effect on fracture prevention, and because of large effect size on hot flushes and night sweats that may deteriorate sleep and working ability and strongly decrease quality of life.
A Cochrane review [Abstract] 3 assessing long-term use of hormone replacement therapy (HRT) included 22 studies with a total of 43 637 subjects. Women taking HRT had a significantly decreased incidence of hip fracture with long-term use (table T1).
| Outcomes | Relative effect(95% CI) | Assumed risk- Placebo | Corresponding risk - HRT (95% CI) | No. of participants(studies)Quality of the evidence |
|---|---|---|---|---|
| All clinical fracturesOestrogen-only hormone therapy: follow-up: mean 7.1 years | RR 0.73(0.65 to 0.80) | 141 per 1000 | 103 per 1000(92 to 113) | 10 739(1) Moderate |
| All clinical fracturesCombined continuous hormone therapy: follow-up: mean 5.6 years | RR 0.78(0.71 to 0.86) | 111 per 1000 | 87 per 1000(79 to 96) | 16 608(1) Moderate |
A meta-analysis 1 included 28 studies with a total of 33426 participants and 2516 fractures cases. The overall relative risk with hormone replacement therapy (HRT) compared to placebo was 0.74 (95% CI, 0.69 to 0.80) for total fractures, 0.72 (95% CI 0.53 to 0.98) for hip fractures, and 0.63 (95% CI 0.44 to 0.91) for vertebral fractures. Estradiol led to greater decrease in the risk of total fractures compared with conjugated equine estrogens (P = .01). There was greater reduction in total fracture risk in trials of follow-up less than 36 months than that of follow-up more than 36 months (P = 0.003). No increase in the incidence of total cancer events but an increase in the incidence of thrombus was found to be associated with HRT.
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