Hormone replacement therapy is an effective method of preventing osteoporosis in women, ideally beginning at the time of the menopause and in some women in the pre-menopausal years. HRT needs to be given for 15 to 20 years to gain the maximal benefit. Women who have oestrogen therapy have about 10 percent more bone after three years treatment than those not on HRT. It is the greatest insurance policy a woman has against osteoporosis because it not only reduces the loss of minerals from the bone but slows down loss of collagen from the skeleton as well. Without HRT, 50 percent of women may be at risk of an eventual fracture by the age of 75 years. Replacement with oestrogen for fifteen years after the menopause extends the age of fracture to 90 years. HRT is also useful in women with established osteoporosis, improving vertebral bone mass and reducing the vertebral fracture rate.

Selective oestrogen receptor modulators, such as raloxifene (‘Evista’), are a new class of drug for the treatment of osteoporosis. Raloxifene selectively activates oestrogen receptor sites in bone and has been shown to increase bone density in the lumbar spine and hip. It does not relieve any menopausal symptoms and may in fact trigger hot flushes, so it is not suitable for peri-menopausal women. However, it can be an ideal alternative for slightly older women, especially if they are concerned about side effects of HRT. Raloxifene has no effect on vaginal bleeding, no risk of uterine cancers, no increase in breast discomfort/pain, and very importantly actually reduces the risk of breast cancer.

Alendronate is in a class of drugs called bisphosphonates. Alendronate reduces bone turnover. It has been shown to increase the bone mineral density and decrease the fracture rate of the hip and lumber spine. The main side effect associated with alendronate is indigestion and gastro-intestinal upset. It is taken as a daily tablet at least 30 minutes before the first food or drink of the day, and you must remain upright for at least 30 minutes after taking it. Etidronate is another type of bisphosphonate that can increase the strength of dematerialized bone and reduce the frequency of spinal fractures. If given continuously for prolonged periods it can actually lead to impaired bone formation, so it is administered cyclically for two weeks followed by a 13 week period of calcium treatment alone. It may also cause some gastro-intestinal side effects, though not as commonly as alendronate.  Bisphosphonate drugs can produce a terrible side effect known as osteonecrosis of the jaw.  This is where the jaw bone decays.

Calcitriol, which is the active form of natural vitamin D, has been shown to be effective in treating established post-menopausal osteoporosis, reducing the incidence of new fracures. It is also useful in the management of cortisone-induced osteoporosis. The drug is well tolerated but can be associated with excessive blood calcium levels. It is therefore important that patients on calcitriol therapy are monitored regularly with blood tests and should not take calcium supplements. Since the bisphosphonates and raloxifene have become available, there is less of a place for the use of calcitriol.

Anabolic steroids (male hormones), well known for their infamous role in competitive sports, have also been used in the past to help women with established osteoporosis. The rationale for their use is that menopausal women with high levels of testosterone have a slower loss of bone. The role that male hormones play is not clear, but they have been shown to help prevent bone loss and possibly produce some degree of bone gain in established osteoporosis. However, these injections may induce an increase in facial hair, greasy skin, pimples and voice deepening, so that some women refuse to continue with them. Bone loss may recur following cessation of treatment. Because other more effective treatments are now available for osteoporosis, there is really no place for the use of anabolic steroids any more. For men with low testosterone levels there is a clear decline in bone density, and replacement with testosterone (tablets or injections) may be recommended.

Overall, prevention of osteoporosis is the key, the aim being to maximize peak bone mass and minimize post-menopausal bone loss. As discussed above, this can be achieved by addressing your lifestyle, diet and nutritional programme, with or without the addition of HRT.