Authors' objectives:

To systematically review and evaluate studies of the use of estrogen and selective estrogen receptor modulators (SERMs) to prevent bone loss and fractures in healthy postmenopausal women.

Authors' results and conclusions: For bone density outcomes, randomized controlled trials consistently indicated improved bone density with estrogen use. These findings were similar between prevention and treatment trials, opposed and unopposed regimens, oral and transdermal forms of estrogen, and types of progestins. For fracture outcomes, 5 randomized controlled trials of estrogen were identified and none met criteria to be ranked as a good-quality study. A primary prevention trial indicated a significant decrease in risk of nonvertebral fractures in 1 of 2 estrogen arms. None of the other trials indicated a significant risk reduction with estrogen, but all had important methodologic limitations. A recent meta-analysis of 22 trials of estrogen, many with unpublished data, reported an overall 27% reduction in nonvertebral fractures (relative risk [RR], 0.73; confidence interval [CI], 0.56-0.94). Six good-quality cohort studies were identified, and 3 of 4 studies reported 20% to 35% reductions in adjusted relative risks for hip fractures among ever users. In randomized controlled trials, raloxifene increased bone density at lumbar spine, hip, and wrist sites, and tamoxifen modestly increased bone density at the hip and spine, although results were inconsistent between studies. The largest trial of raloxifene reported a protective effect for vertebral fractures (RR, 0.59; 95% CI, 0.05-0.70), but not for nonvertebral fractures. A large trial of tamoxifen indicated no statistically significant fracture benefit.

Authors' recommendations: The results of these studies support a benefit for estrogen in improving bone density and protecting against fractures, although the evidence for fractures is based on one arm of one randomized controlled trial and good-quality cohort studies. Trials indicate that raloxifene increases bone density and protects against vertebral fractures.

Authors' methods: Systematic review

Project Status: Completed

URL for project: http://www.ahrq.gov/clinic/uspstf/uspspmho.htm

Year Published: 2002

English language abstract: An English language summary is available

Publication Type: Not Assigned

Country: United States

Organisation Name: Agency for Healthcare Research and Quality

Contact Address: Center for Outcomes and Evidence Technology Assessment Program, 540 Gaither Road, Rockville, MD 20850, USA. Tel: +1 301 427 1610; Fax: +1 301 427 1639;

Contact Name: martin.erlichman@ahrq.hhs.gov

Contact Email: martin.erlichman@ahrq.hhs.gov

Copyright: Agency for Healthcare Research and Quality (AHRQ)