Alternative strategies for prevention of postmenopausal osteoporosis

Osteoporosis is more readily prevented than treated, and early intervention with effective therapy would be expected to reduce significantly the impact of osteoporotic fractures among the aging population. For the postmenopausal female population, estrogen is the cornerstone of therapy, and multiple studies have demonstrated efficacy in reducing cortical and trabecular bone loss in the axial and peripheral skeleton. Alternative strategies for those who cannot, or will not, take estrogen and who can be documented to be at increased risk of osteoporosis, include calcium supplementation, progestogens, (particularly the 19-nortestosterone derivatives), calcitonin, diphosphonates, and anabolic steroids. All have been shown in some populations to reduce the rate of bone loss to a greater or lesser extent, although, overall, the data are as yet inconclusive. All regimes, with the exception of moderate calcium supplementation, have negative aspects to their use currently, and further research is required before a definitive alternative to estrogen for prevention of postmenopausal osteoporosis can be recommended. Only estrogens and calcitonin have Food and Drug Administration (FDA) approval for use in the treatment of osteoporosis. In the decision-making process for the woman at mid-life, risk factor assessment, although a poor quantitative tool for the individual patient, is the starting point for the evaluation of patients. Bone mass measurements play a crucial role in assisting the dubious patient (or physician) about the need for therapy. Estrogen use, however, is a more important issue for the postmenopausal female, with sequelae other than its effects on bone to be considered, including effects on cardiovascular disease, endometrial and breast cancer, which must be considered in the equation of risk-benefit. The greater the risks and costs of the intervention strategies available, the more important effective identification of the target population becomes. Estrogens, however, provide the most effective preventive treatment for osteoporosis. This review will deal primarily with the decision to introduce estrogen treatment, and the efficacy of estrogens, as well as alternative forms of prevention.