Estrogen Therapy: Question Six
Your answer is incorrect. The correct answer is D.
What is the safest and most reasonable option now for this patient
- Option A Discontinue HT and recheck BMD in 2 years
- Option B Discontinue HT and start an oral bisphosphonate
- Option C Discontinue HT and start nasal calcitonin
- Option D Reduce HT dose by 50% and have her f/u in one month
How do you discontinue HT and is there any evidence that lower doses of estrogen can increase bone mass or reduce fracture rate?
Most women will be able to stop HT abruptly. However, for a woman who is symptomatic after missing doses, it is best to taper the estrogen. The tapering schedule will depend entirely on how symptomatic a woman is and how much she can tolerate. A reasonable approach is to lower the estrogen dose to 0.3 mg a day to see how symptomatic the patient becomes and the dose can be adjusted as warranted. An attempt to taper the estrogen should be done every 6 to 12 months to see if menopausal symptoms have abated. Once the HT has been discontinued and the patient is not at high risk for fractures, DXA study should be repeated in about 2 years.
There are no studies that assess fracture rates on low doses of estrogen (<6.25 mg c. estrogen). However, there are several studies that have shown that BMD increases in both early postmenopausal women >65 on low doses of estrogen compared to women on placebo (1-4).
The Women's HOPE (Health, Osteoporosis, Progestin, Estrogen trial) study was a large RCT that studied the effects of 0.3 mg, 0.45 mg and 0.625 mg of conjugated estrogen (with or without medroxyprogesterone) on BMD in postmenopausal women ages 40-64 (within 4 years of last menstrual period) (1). All doses of estrogen (with or without medroxyproegesterone) significantly increased BMD in the spine and hip from baseline over two years. All placebo treated patients had significant losses of BMD in the spine. There was a dose response effect in the estrogen treated group. The low dose estrogen-progestin regimens also demonstrated beneficial effects on vasomotor symptoms, vaginal atrophy, and lipid profiles.
- Lindsay R, Gallagher JC, Kleerekoper M, Pickar JH. Effect of lower doses of conjugated equine estrogens with and without medroxyprogesterone acetate on bone in early postmenopausal women. JAMA 2002; 287: 2668-2676.
- Genant HK, Lucas J, Weiss S, et al. Low dose esterified estrogen therapy: effects on bone plasma estradiol concentrations, endometrium, and lipid levels. Arch Intern Med 1997; 157: 2609-2615.
- Recker RR, Davies KM, Dowd RM, Heaney RP. The effect of low-dose continuous estrogen and progesterone therapy with calcium and vitamin D on bone in elderly women: a randomized, controlled trial. Ann Intern Med 1999; 130: 897-904.
- Prestwood KM, Kenny AM, Kleppinger A, Kulldorff M. Ultralow-dose micronized 17beta-estradiol and bone density and bone metabolism in older women: a randomized controlled trial. JAMA 2003; 290: 1042-8.