Hello and welcome to the Bone Health Series - Edition 6b - Medications and Hormone Therapy. To find previous editions simply scroll The Blog.
With 67% of the Australian population aged 50 years and older having osteoporosis or osteopenia (Healthy Bones Australia) bone health needs to be on our health radar. Why? Because poor bone health puts us at greater risk of a fragility fracture, a bone break from low force. It's estimated that 1 in 4 people who have a hip fracture die within the first 12 months and the likelihood of repeat fracturing, is very high. As humans, we all begin to lose bone mass from our 30's at about 1% a year. As women, we have a steep drop off, losing between 10-20% of our bone mass during our menopause transition with accelerated loss again after 70. So if you enter your menopause transition with sub-optimal bone health, it's much harder to maintain good bone strength in your future years.
Bone health is something we don't often focus on until we've had a fracture and the window of opportunity to pro-actively manage our bone health well, is almost closed. We also have a health system that doesn't make it a priority to measure our bone heath status until we are 70 years of age (unless we have had a low impact fracture after the age of 50 or if we have health condition that puts us at greater risk of sub-optimal bone health). That is way too late. It's setting us up for limited options to improve our bone health without taking medication.
There is so much we can do to optimise our bone heath before that tipping point. That's what this in-depth series is all about. To help you appreciate the many ways you can and have the power to help your bones...for future you.
Having said all that, some times medications are prescribed, when osteoporosis is at the point when the risk of fracture is high.
Medications & Hormone Therapy:
In this edition, the focus is on medications and hormone therapy that may help our bone health. It's NOT advice. Oh no. Let me make that very clear. I'm not a doctor or medical expert. What I am here to do is to flesh it out a little, so that you can have the conversation with your health team, armed with some information that you probably didn't have before.
It's another area of great confusion I think mostly because of the conflicting information and concerns around using them. Your health team members will have their views based on where they rely on getting their information from and their clinical experience.
As with many areas of women's health, more and more research is emerging. I believe it's important to have that on our radar too because it will take the health space years to catch up and incorporate it into available treatments. Bone health is no exception.
Medications for Bone Health:
These are used once poor bone health has been diagnosed - usually osteoporosis. I'm big on understanding why. Why is that form of medication recommended for my specific bone health needs? Listed below are the common medications that are prescribed and broadly how they work, how long they work for and the risks associated with them.
How they work is deeply connected to the bone remodeling process. Bone is active, living tissue with osteoblasts and osteoclasts doing much of the heavy lifting in that remodeling process. A process which is ongoing for most of our life.
I think of it this way. When you go to paint your walls, you prep them first. You may clean them and do a light sanding back so that when the fresh coat of paint is applied, it sticks well and holds. Bone remodeling is like that. Osteoclasts 'clean and sand back' the bone which prepares the surface and stimulates the formation of new bone to be laid down by osteoblasts, the bone builders.
Okay. With that in mind, let's dive into the specific medications.
Bone Medications
Bone medication falls in 2 main groups:
- Anti-Resorptive (bone break down where osteoclasts do most of the work) and
- Anabolic (stimulate bone formation where osteoblasts do much of the work).
Bisphosphonates:
Bisphosphonates are Anti-Resorptive meaning they slow down osteoclast activity.
Common Brand Names: Bisphosphonates are probably the most common form of bone medication used.
Tablets: Actonel ED, Fosamax
Injections/Infusion: Zoledronate
Benefit:
- Increase bone mineral density because osteoclast breakdown of bone is slowed down.
- Helps to reduce the risk of fracture.
"With respect to bone mineral density (BMD), alendronate, ibandronate, risedronate and zoledronic acid have been shown to increase BMD by 5-7% and 1.6-5% in the spine and femoral neck respectively after 3 years of treatment [3][4][5][6][7].
The same BPs (alendronate, risedronate, ibandronate and zoledronic acid) have been shown to reduce vertebral fracture risk by 60-70% within the first year of treatment. Reductions in non-vertebral fracture risk (20-30%) and hip fracture risk (40-50%) have also been demonstrated for alendronate, risedronate and zoledronic acid, but not for ibandronate[3][4][5][7]." (International Osteoporosis Foundation)
Risks & Concerns:
"Oral BPs can induce mild gastro-intestinal disturbances and intravenous bisphosphonates can induce a transient acute reaction with fever, bone and muscle pain. Concerns about atrial fibrillation with intravenous zoledronic acid and esophageal cancer with oral bisphosphonates have been raised but not confirmed [13]." (International Osteoporosis Foundation - IOF)
- Increase the chances of atypical femur fractures after 3-5 years of taking them. Atypical femur fractures are those that occur further down the femur (in the shaft) not in the neck of femur (NOF). They are harder to fix and take longer to heal than NOF fractures.
- Increase the chance of Osteonecrosis of the Jaw. Because of the frequent use of our jaw bones in eating and talking, bone turns over very frequently there. With this condition bone is infecting, dying and not being replaced. If you have dental work that exposes the jaw, like having teeth extracted or implants put in, it can mean that the jaw won't heal after these procedures. It's worthwhile not only speaking to your doctor about this risk but also you dentist who is likely to have seen more of this occurring. This condition is considered rare in most literature (like from those who make the medications and societies like Healthy Bones Australia) but there is also a school of thought that it's not widely reported on either so it could be understated. A must to chat you your health team about and perhaps get multiple opinions.
Read more about these conditions here on the International Osteoporosis Foundation website.
- Build Up of Bone is reduced. Because osteoclast activity is reduced, osteoblast activity is also reduced because that's what stimulates the laying down of new bone in the remodeling process. That's why they are effective in the 3-5 year period to increase density, but not so after that period.
- Bone Strength is not necessarily increased. Recall that bone has that hard outer shell but inside it has that network inside which gives it its strength - ability to bend before breaking. Just because bones are more dense (ie on the DEXA scan it shows increased density), doesn't mean bones are stronger.
You can also hear (and watch) Dr David Tognarini, the man who has brought REMS scanning to Australia talk about the importance of understanding your Fragility Score and appreciating how strong your bones are in this chat we had for my Midlife Unfiltered podcast. Let's get that language right. Density is not strength.
What happens when Usage is Stopped? Reviews typically occur at the 3 year mark for infusions and 5 years for oral tablet form. What happens then? That's a question for your health team.
Read Up: Find out more about these medications in the links below. They are easy to read.
: International Osteoporosis Foundation - Bisphosphonates
: Healthy Bones Australia - Types of Medication
: GP guidelines for osteoporosis management and fracture prevention in postmenopausal women and men over 50 years of age and here is the simpler framework form.
Denosumab
Denosumab is Anti-Resorptive and works similarly to Bisphosphonates, meaning it slows down osteoclast activity.
Common Brand Names: Prolia (6 monthly injection)
Benefit:
- Increase bone mineral density because osteoclast breakdown of bone is slowed down.
- Helps to reduce the risk of fracture.
"In the FREEDOM trial, subcutaneous injections of 60mg of denosumab every 6 months for 36 months decreased the risk of vertebral fracture by 70%, of non-spine fractures by 20% and of hip fracture by 40% in postmenopausal women with osteoporosis [3]. This effect on fracture risk is observed up to 10 years." (International Osteoporosis Foundation)
"In the absence of contraindications, denosumab is considered a second-line therapy (after bisphosphonates) in most countries for women with postmenopausal osteoporosis." (International Osteoporosis Foundation - IOF)
Risks & Concerns:
- Transient Rebound Effect - increase bone loss and increased fracture risk after coming off it. "Discontinuation of denosumab has been shown to be associated with a transient rebound effect: markers of bone turnover increase over baseline during the first year off therapy, BMD decreases to baseline values, and the rate of vertebral fracture increases to levels observed in non-treated patients [6][7]." (IOF)
- Increased Infections - because it can impact the immune system "adverse events like skin rashes, increased risk of infections such as cellulitis, hypocalcemia have been reported." (IOF)
- Atypical femoral fracture and Osteonecrosis of the Jaw as above for Bisphosphonates.
What happens when Usage is Stopped:
"Some patients discontinuing denosumab experience multiple and severe vertebral fractures [6]. In these cases transition to bisphosphonate treatment should be considered [8]."(IOF). Certainly something to talk to your health team about.
Read Up: please head to the links above under Bisphosphonates.
Anabolic Medications
Anabolic medications work differently to those listed above. Rather than reducing osteoclast activity, they build bone, by promoting osteoblast activity without compromising osteoclasts. They are usually prescribed for severe osteoporosis. "These types of medicine are typically reserved for people who have very low bone density, who have had fractures or whose osteoporosis is caused by steroids. They also may be used when other medicines are not tolerated, or bone density worsens despite other medications. They are not usually used in combination or along with the other medicines." (Mayo Clinic)
Common Brand Names: See 'Read Up' below for links to more specific information.
Teriparatide - Forteo (injection)
Abaloparatide - Eladynos (injection) also known at Tymlos
Romosozumab - Evenity
Benefits:
- Increase bone mineral density
- Improve bone strength
- Helps to reduce the risk of fracture.
Risks & Concerns:
- Side effects of Evenity include joint pain and headache.
- Side effects of Forteo include joint pain, headache, dizziness, digestive problems, kidney stones worsening.
- Side effects of Eladynos include mild hypercalcemia, headache, fatigue, nausea, vomiting, constipation.
What happens when Usage is Stopped:
"The bone forming effects of anabolic therapy appear to be self-limited, making it imperative that it be followed by anti-resorptive therapy to enhance or consolidate the beneficial effects achieved." (Anabolic therapy for osteoporosis: update on efficacy and safety) The Anti-Resorptives are above. Something to talk you your health team about.
Read Up:
: International Osteoporosis Foundation - Anabolics
: Healthdirect - Teriparatides, Abaloparatide, Romosozumab
SERM'S
Selective oestrogen receptor modulators (SERM)
This medication is taken daily and acts on bones in a similar way to that of the hormone oestrogen, slowing bone loss and reducing the risk of spinal fractures in women who have been through menopause. (Healthy Bones Australia).
"It may also be used to lower the risk of breast cancer in people with osteoporosis or who are at high risk of breast cancer after menopause. It works by blocking the hormone estrogen in breast tissue, which prevents breast cancer cells from spreading or growing." (Cleveland Clinic).
Common Brand Names:
Raloxifene (brand name Evista).
Benefits:
- slows or stops the bone breaking down.
- bone mineral density increases (2-3% in spine but not in hip - Dr Doug Lucas) and
- the risk of fracture is reduced. (Arthritis Australia)
Risks & Concerns:
- Similar to that of oral oestrogen
- Hot flushes, flu-like symptoms, insomnia, vomiting
- Blood clots.
Risks are explained in more detail here.
What happens when Usage is Stopped:
After 1 year, benefits of bone protection are potentially lost. "Our results show that 5 years of treatment with either Ral or CEE did not protect against bone loss after 1 year of withdrawal of therapy, and that the rate of bone loss was not significantly different from that of placebo-treated women." (Effect of 1 year of discontinuation of raloxifene or estrogen therapy on bone mineral density after 5 years of treatment in healthy postmenopausal women - PubMed)
Talk to your health team about what happens next. Can it be continued?
Read Up:
Raloxifene - Royal Osteoporosis Society
Hormone Therapy For Bone Health
Hormone therapy has been getting a LOT of airplay recently which is bloody brilliant! I hope you are starting to firm up your views on it. Conflicting and confusing information comes with that too so finding credible sources is really important.
You no doubt have heard about the Women's Health Initiative (WHI) study which is often spoken about in this area of hormones for women's health because of the way in which the research was misinterpreted. Other studies of large numbers of women have been done but the WHI is referenced the most. Findings from the WHI is now being put into today's context and re-explained. Women are beginning to have more conversations about hormones and health but, the gap is still wide. The knowledge gap our health providers still have and the confidence they have in prescribing it for us. That's not a slight on them. There is a choice here. A choice to get up to speed and practice it if its a priority, or not.
I recently changed endocrinologists (a specialist in hormones) because of that very gap which I felt, resulted in a gap in my treatment. A gap I now appreciate could have been helped with hormones. More on that next week.
That's not to say it's the solution for you. Not at all. But I mention it because it was through my reading that I came to learn about the fact that the WHI confirmed some 30+ years ago, that hormones where protective for bone health (and other systems). That our falling oestrogen and progesterone levels that accelerated bone health decline during the menopause transition, could be reduced with hormone therapy.
What you put them back with matters.
The risks highlighted in the WHI (mainly around breast cancer) are now believed to be minimised through the use of topical oestrogen creams/gels/patches where oestrogen is absorbed through our skin (and in doing so, bypasses the liver). That and the fact that in the WHI study, not only were women given oral oestrogen, it was a form that was synthesised from horse's urine. Topcial and many oral oestrogen's today are not.
The form of progesterone used in the WHI is also thought to be a contributor to elevated risk. Back then the form used was oral synthesised progestins. Today many are micronised progesterone. That's difference in terminology though confusing, matters. Body-identical progesterone (micronised progesterone) is superior to the synthetic progestins manufactured.
This PDF from the Australian Menopause Society is an easy to read one-pager about Hormone Therapy, the risks and the WHI as well as the different forms of oestrogen and progesterone available here. Worth a 2 minute read right now.
The Role Oestrogen Plays In Bone Health
Going back to our bone remodeling diagram below, let's look at the impacts oestrogen has on our bones.
It seems that Oestrogen has a greater influence on BMD - bone mineral density.
"The role of estrogen in bone physiology and pathophysiology is complex and results of its direct activity on osteoblasts, osteoclasts, and osteocytes. Estrogens increase osteoblast differentiation and activity and limit both osteoblast and osteocyte apoptosis (cell death).
In addition, estrogens have a suppressive action on bone resorption by promoting osteoclastic apoptosis and reducing osteoclast function. Estrogen reduction during the menopausal transition results in increased bone remodeling, with a greater augmentation of bone resorption than formation, leading to a loss of BMD and increased fracture risk." (From: Estrogen hormone therapy and postmenopausal osteoporosis: does it really take two to tango?).
In other words, reducing oestrogen in our menopause transition, results in more bone being lost than made which leads to a loss of bone mineral density and increased fracture risk. Because of the way in which oestrogen interacts with osteoclasts and osteoblasts - our bone cells in the remodeling process.
The Role Progesterone Plays In Bone Health
Progesterone on the other hand seems to influence our Bone Quality more which is largely determined by the inside trabecular bone matrix. Quality gives bone its ability to bend and flex and contributes greatly to its strength and risk of fracture. Progesterone also plays a significant role in building bone.
"Progesterone sits on specific osteoblast receptors and stimulates new osteoblasts to be made from mesenchymal stem cells (instead of into adipocytes) and also stimulates osteoblasts to create more bone matrix. It is women's bone formation-stimulating hormone." (Progesterone for the prevention and treatment of osteoporosis in women).
The same research review indicates that progesterone aids oestrogen in the improvement of bone mineral density.
But...there are not a larger number of studies done on the influence of progesterone on bone health so again, it's one for the health radar girls. And certainly one to talk to your health team about.
Q: Does it makes sense then that if losing oestrogen and progesterone degrades our bone health, if we add them back in, it may help to improve it? But at what risk? For how long? And what are the right amounts?
How Effective Is Hormone Therapy?
Depending on the studies you read, will answer that for you. They are varied and numerous. AND it's a very personal thing.
Each of us has a unique body and how we metabolise hormones (and medications for that matter) will be unique to us. So the research-based information below is a guide.
When we are talking about bone health, the ultimate aim is to preserve it so that our risk of fracture is decreased. Because once we fracture, we are inclined to fracture again and that means reduced quality of life - reduced healthspan. None of us want that.
"...a meta-analysis* of 28 studies including 33,426 participants showed that menopausal hormone therapy (MHT) reduces the risk of hip, vertebral, and all fractures by 28 percent, 37 percent, and 26 percent, respectively (Zhu et al. Citation2016). Furthermore, although studies have shown an increase in the risk of osteoporotic fractures following the cessation of MHT, the benefit of MHT on BMD may persist for at least 2 years after treatment discontinuation." (From: Estrogen hormone therapy and postmenopausal osteoporosis: does it really take two to tango?
- (a Meta Analysis is where they group together the findings of many studies on the topic, filter those that are not aligned with the criteria they are searching for and look at the combined results. This way the numbers (ie people) included in the findings are of a larger volume so in theory, should lead to a more accurate result).
Combining HT and Exercise - Research Findings
I found this research article helpful. You might too. It's another meta analysis.
This research review looked at the effects of HT (MHT) and Exercise on Bone Health in Post Menopausal women. It's from 2025 so is very recent. "Impact of menopause hormone therapy, exercise, and their combination on bone mineral density and mental wellbeing in menopausal women: a scoping review."
The reason why I like this study is because it brings together hormone therapy and exercise. Protecting and maximising bone health is a multi-pronged approach. Drugs (including hormone therapy) alone are not going to maximise outcomes for you. They have a role to play but are not the only players. Exercise (the right form of exercise done correctly) and diet also play their part. As too does regular monitoring to know how you're doing.
"This review highlights that a combination of MHT and structured exercise offers the most effective approach for increasing BMD in menopausal women. For those with a uterus, combined estrogen and progestogen MHT has shown the greatest benefit in preserving bone health. However, due to ongoing debate surrounding the long-term safety of MHT for BMD preservation, exercise remains a critical and universally applicable strategy in the prevention and management of postmenopausal osteoporosis. Specifically, combined RT performed two to three times per week at an intensity of 70%–85% of 1RM, along with impact-loading activities such as jogging, jumping, or hopping at least three times per week, has been shown to be optimal for improving BMD in postmenopausal women. These interventions should be maintained for a minimum of 6 months and progress gradually in intensity and complexity to sustain their effectiveness."
How Long and How Much HT is Used May Matter Too:
It's important to consider the 'what happens when I come off this' in discussions with your health team as well as the doseage that's right for you.
Duration:
From the review above its suggested that , "Evidence supports the use of MHT in the prevention of osteoporosis. A 25-year cohort study, involving 3,222 women, identified a negative correlation between MHT duration and BMD loss, with greater bone loss in PMW on MHT for 3.75 years compared to 7.66 years (30).
Dosage:
Similarly, a 10-year study of 279 PMW examined the effect of continuous combined MHT [Estradiol valerate (E2 V) and MPA] at a low (1 mg E2 V þ 2.5 mg MPA (1 þ 2.5)], medium [1 mg E2 V þ 5 mg MPA (1 þ 5)], and high dose [2 mg E2Vþ5 mg MPA (2 þ 5)] on BMD, and the effect 1-year post-discontinuation after 9 years (31). Long-term low-dose MHT maintained FN BMD for 5–6 years and LS BMD for at least 9 years (31), with high dosages accelerating bone loss after discontinuation.
That's why it's important to keep measuring your bone health and monitor the effects of whatever treatment you have. Talk about this with your health team too. The frequency of monitoring and how to do that effectively for your treatment.
Hormone Therapy Vs Medications
Medications and hormone therapy are rather different. Not only in the way they work potentially, but when they are used.
The medications mentioned above are usually prescribed once you have been diagnosed as having osteoporosis. Not as a preventative for it.
Hormone Therapy on the other hand, may be suggested as a protective preventative treatment for many reasons, including bone health. It is also used as a treatment once you have been diagnosed with osteoporosis.
I think that is an important difference. To take a minute and let it sink in.
Prof Susan Davis is a prominent researcher based at Monash University in Melbourne. She has participated in writing the revised guidelines for hormone therapy for medical practitioners here in Australia - Practitioner's Toolkit for Managing Menopause was released in 2023.
In an interview she did with the ABC specifically about bone health this is what she said:
"A lot of GPs go straight for the bone drugs and we are basically saying, 'Do you really need to go to the big guns or can you take a step back and consider hormone therapy for a few years?You want to stop someone who has low bone density from progressing to osteoporosis, and you will do that with hormone therapy, in most cases."
The new menopause toolkit recommends GPs consider it for women under age 65 with a T-score of -1.8 or less.
Dr Eden is also referenced in that ABC article. Talking about medications for osteoporosis vs hormone therapy. Again, something to consider when you're having your discussions with your health team.
"While Professor Davis says some might find the toolkit's recommendation "controversial", gynaecologist and endocrinologist John Eden says it's backed by decades of research.
There's tens of thousands of women around age 55 who have low bone density aren't being treated with anything. They should be given hormone replacement therapy.
Importantly, Dr Eden says after someone stops the hormone therapy, bone deterioration returns to its slower, pre-menopausal rate.
He says this a huge advantage over denosumab (marketed as Prolia), the most common drug used to treat osteoporosis in women after menopause.
If someone stops taking this drug, they tend to experience immediate and profound bone loss so they have to take it for the rest of their life, Dr Eden says."
Final Thoughts
Okay. How are you feeling? It's another BIG topic but a really important one when it comes to managing your bone health. Medications (following a diagnosis of osteoporosis) and HT for prevention and/or treatment after a diagnosis of osteopenia and/or osteoporosis are another piece in your bone health puzzle; together with exercise, nutrition (diet and supplementation) and measuring to monitor your bone health progress.
Each of them are pieces in our deep dive into Bone Health series.
It is really important that you understand that whilst we have looked at each of these pieces in this series individually so far, your bone health and the treatment options you seek are, particular to YOUR unique situation.
Gather your information. Read up. Print this edition out and keep it handy for when you have the conversations with your health team about how to best manage your bone health. Read and learn before you decide the right solution for you. Weigh up the risks vs benefits in the short and long term.
Your health team members should be able to tell you what they are basing their recommendations on and the source. Take the time and learn from those resources and others. Arm yourself with evidence based, unbiased information and have the conversations.
Get A Bone Scan!
If you don't currently have a diagnosis of osteoporosis, do you know what your bone health status is? If not, please find out asap. The earlier you know, the earlier you can start managing it pro-actively with the right exercise and diet. Get your team in place. Book in for your bone scan now. Make an appointment to visit your GP for a DEXA scan referral and book at a radiology practice you can return to again and again that has a DEXA machine. Alternatively book in for a REMS bone scan. You don't need a referral for that.
To strengthen your bones for future you - your independence. Living longer, well.
Because bone health is an indicator of health span. Keep it on your radar. Make it a priority.
Remember the contents of this post are meant for education purposes only. This newsletter is here to spark thoughts and conversations not to give advice. Conversation not consultation. I'm not a doctor or a qualified health professional offering advice. That's on you to glean from your health team and determine what's best for you.
Take care, and be kind to you. Because girl...you are just getting started.
Anita xx
p.s. Scroll to look out for other blog posts in my Bone Health Series. They're near by so it won't take long to find them :)
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