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Hormone replacement therapy (HRT) has fallen out of favor as a long-term treatment for osteoporosis. However, estrogen replacement for women and testosterone for men often are an effective, short-term treatment for the disease.

There is no doubt that hormone replacement therapy (HRT) is effective in most cases of primary osteoporosis. When osteoporosis is not secondary, a complication of another condition or a result of medication, estrogen replacement therapy for women and testosterone replacement therapy for men increase bone mineral density and prevent fractures. There are downsides to HRT, however, that limit its use in treating osteoporosis.

Estrogen replacement therapy (ERT) for women

There was a time when ERT was the only FDA-approved treatment for women who have osteoporosis. It is beginning to be replaced by selective estrogen receptor modulators (SERMs) and other biological treatments because of serious complications of long-term estrogen replacement therapy such as increased risk of breast and uterine cancer, blood clots, stroke, heart attack, and mental health issues.

ERT is not given to any woman who has a history of breast or uterine cancer, or a recent history of blood clots. It is not administered to women who are still menstruating, and it is not given to men.  Most ot the time ERT is accompanied by progesterone therapy 14 days out of every 28. Adding progesterone to ERT greatly reduces the risk of uterine cancer. Women who have had a hysterectomy have no further risk of uterine cancer, and are usually not given progesterone.

The best time for a woman to start ERT to prevent future fractures is the beginning of menopause. However, many endocrinologists report good results giving women estrogen as much as 10 years after menopause. 

Estrogen can be given as a patch or as a pill. If you use an estrogen patch, you will probably replace it either once or twice a week. Pill are taken daily. Women who have an intact uterus are usually also given progesterone therapy 14 days out of every 28. Adding progesterone to ERT greatly reduces the risk of uterine cancer. Women who have had a hysterectomy have no further risk of uterine cancer, and are usually not given progesterone.

Testosterone replacement therapy for men

Osteoporosis in men does not have a single cause, but testosterone is known to stimulate bone mineralization in men. When testosterone levels drop, bone mineralization decreases and fractures become more frequent. Testosterone replacement therapy in men helps to prevent fractures.

Many men get testosterone replacement therapy without a proper lab workup and careful screening. Ideally, every man who gets supplemental testosterone would have consistently low testosterone values found in blood samples drawn in the early morning. There would be no history of prostate enlargement or prostate cancer, and the man would be warned about the possibility of rebound hypogonadism, shrinking of the penis and testicles when the treatment is completed.

The (American) Endocrine Society recommends that all white men aged 50 to 69 and all African-American men aged 40 to 69 get a "finger exam" for enlargement of the prostate before being put on testosterone replacement therapy. Then testosterone levels need to be checked after three to six months to make sure they are increasing, and bone mineral density needs to be checked in one to two years to make sure the treatment is increasing bone mineral density.

About 20 percent of men who get testosterone replacement therapy for osteoporosis got their condition by taking opioid pain medications over a long time period. 

Although testosterone replacement therapy is not given to men who already have prostate cancer, it does not increase the risk of developing prostate cancer. In fact, men who take testosterone are less likely to develop prostate cancer than men who do not, and if they develop prostate cancer, they tend to get less aggressive forms of the disease.

Alternatives to HRT for men and women

HRT is a short-term treatment for osteoporosis in both men and women, although men tend to stay on their HRT longer than women for a a variety of reasons. When HRT is completed, there are other options to continue to promote good bone health.

  • Calcium supplementation of up to 1,000 mg per day for women and up to 1,300 mg per day for men, in doses of up to 500 mg, is always indicated when there is a history of bone fracture. Calcium should be accompanied by vitamin D (which is included in the formula for some bisphosphonate drugs), vitamin K2, and magnesium, and the diet should provide adequate but not excessive protein.
  • Once-a-year infusions of zoledronic acid (Reclast) are often prescribed for men and women. This potent bisphosphonate drug usually increases bone mineral density in both the hip and spine. The downside of Reclast is that it can cause bone pain and a variety of flu-like symptoms that take up to 14 days to resolve.
  • Many other medications, such as selective estrogen receptor modulators (SERMs) for women and selective androgen receptor modulators (SARMs) for men exist to slow the progress of osteoporosis. Your endocrinologist is sure to recommend them after you complete HRT.

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  • Photo courtesy of SteadyHealth

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