Table Of ContentSince 1973 the Royal College of
Obstetricians and Gynaecologists has
regularly convened Study Groups to
address important growth areas within
obstetrics and gynaecology. An
international group of eminent scientists
and clinicians from various disciplines is
invited to present the results of recent
research and take part in in-depth
discussion. The resulting volume
containing the papers presented and also
edited transcripts of the discussions is
published within a few months of the
meeting and provides a summary of the
subject that is both authoritative and up
to date.
Previous Study Group publications
available from Springer-Verlag:
Early Pregnancy Loss
Edited by R. W. Beard and F. Sharp
AIDS in Obstetrics and Gynaecology
Edited by C. N. Hudson and F. Sharp
Fetal Growth
Edited by F. Sharp, R. B. Fraser and
R. D. G. Milner
Micturition
Edited by J. O. Drife, P. Hilton and
S. L. Stanton
The Royal College of Obstetricians and
Gynaecologists gratefully acknowledges
the sponsorship of the Study Group by
Ciba-Geigy Pharmaceuticals; The
Department of Health; Duphar
Laboratories Limited; The National
Dairy Council; Organon Laboratories
Limited; Roussel Laboratories Limited;
Schering Health Care Limited; Syntex
Pharmaceuticals Limited; Wyeth
Laboratories
HRT and
Osteoporosis
Edited by
J. O. Drife and J. W. W. Studd
With 65 Figures
Springer-Verlag
London Berlin Heidelberg New York
Paris Tokyo Hong Kong
James O. Drife, MD, FRCSEd, FRCOG
Professor of Obstetrics and Gynaecology, Clarendon Wing, Leeds
General Infirmary, Leeds LSI 3EX
John W. W. Studd, MD, BS, FRCOG
Consultant Obstetrician and Gynaecologist, King's College Hospital,
London SE5 9RS and Director, The Menopause Clinic, Dulwich
Hospital, East Dulwich Grove, London SE22 8PT
British Library Cataloguing in Publication Data
HRT and osteoporosis.
1. Women. Bones. Osteoporosis. Drug therapy. Oestrogens
I. Drife, James O. (James Owen) 1947- II. Studd, John W.W. 616.71
ISBN-I 3: 978-I -447 I -I 80 I -5 e-ISBN-I 3: 978-I -447 I -1799-5
DOl: 1O.l007/978-1-4471-1799-5
Library of Congress Cataloging-in-Publication Data
HRT and osteoporosis/ edited by James O. Drife and John W. W. Studd.
p. cm. Based on the 22nd Study Group of the Royal College of Obstetricians and
Gynaecologists held in January 1990: sponsored by Ciba-Geigy Pharmaceuticals and
others. Includes index.
1. Osteoporosis-Hormone therapy-Congresses. 2. Osteoporosis-Hormone
therapy-Complications and sequelae-Congrcsses. 3. Aged women-Diseases
Congresses. I. Drife, James 0.,1947- II. Studd, John. III. Geigy Pharmaceuticals.
IV. Royal College of Obstetricians and Gynaecologists (Great Britain). Study Group
(22nd: 1990)
[DNLM: 1. Estrogen Replacement Therapy--<:ongresses. 2. Menopause--<:ongresses.
4. Osteoporosis-etiology-eongrcsses. 5. Osteoporosis-prevention & control
congresses. WE 250 H873 1990) RC931.073H77 1990 616.7'I6-dc20
DNLMIDLC
for Library of Congress 90---10029
CIP
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Preface
For many years the fact that older women are susceptible to fractures
was dismissed as a natural consequence of ageing. Now, both doctors
and the general public are becoming increasingly aware that ovarian
failure is an important cause of osteoporosis and that much of the
bone loss after the menopause can be prevented by oestrogen
treatment. This has raised important questions about the safety and
acceptability of long-term treatment with sex hormones, about the
economic costs and benefits of such treatment, and about the role of
specialists and general practitioners in promoting and monitoring
hormone replacement therapy (HRT).
These questions have far-reaching implications involving many
medical disciplines and they have revealed serious gaps in our
knowledge. Nevertheless, practical guidance is urgently needed by
women and their doctors and by those responsible for public health
policies. The Royal College of Obstetricians and Gynaecologists
made osteoporosis the subject of its 22nd Study Group, held in
January 1990. An international panel of leading researchers was
invited to participate in a three-day workshop, allowing time for in
depth discussion as well as the presentation of papers.
The participants included epidemiologists, endocrinologists and a
geriatrician as well as gynaecologists, scientists and physicians
specialising in bone disease. The meeting began with discussions on
benefits and risks of oestrogen treatment before focusing on the
problems of screening for osteoporosis and the place of HRT in the
community. The interaction between leading authorities from dif
ferent disciplines was intensely stimulating and the meeting provided
a rare opportunity for comprehensive discussion. It was not possible
to refer all material back to the authors or discussants; it is hoped that
the proceedings have been reported fairly and accurately.
The Editors are very grateful to Miss Sally Barber, Postgraduate
Secretary of the RCOG, for her pleasant efficiency in supervising the
production schedule for this book. They also wish to thank the
participants who gave so much of their time and expertise to the
meeting, and whose constructive co-operation produced a series of
practical conclusions and recommendations. We hope these will
make a helpful contribution to the development of this important
aspect of preventive medicine.
London 1990 James Drife
John Studd
Contents
Preface ........................................................................ v
Participants .................................................................. xi
SECTION I: PATHOPHYSIOLOGY OF THE MENOPAUSE
1 Biology of the Menopause
D. T. Baird .................................................................. 3
2 The Biology of Bone
D. C. Anderson ............................................................ 11
Discussion ................................................................... 19
3 Symptoms and Metabolic Sequelae of the Menopause
J. W. W. Studd, N. R. Watson and A. Henderson ................. 23
4 Psychological Effects of the Menopause
D. Gath and S. lies ........................................................ 35
Discussion ................................................................... 42
5 Oestrogen Deficiency and Connective Tissues
M. Brincat, C. Moniz, M. Savvas and J. W. W. Studd 47
6 Oestrogen Deficiency and the Bladder
L. D. Cardozo .............................................................. 57
Discussion ................................................................... 68
SECTION II: PATHOPHYSIOLOGY OF OSTEOPOROSIS
7 Epidemiology of Osteoporosis
R. Lindsay and F. Cosman .............................................. 75
viii Contents
8 Implications of Osteoporotic Fractures in the Elderly
R. M. Francis and A. Sutcliffe ............................ .............. 87
Discussion ................................................................... 93
9 Structure of Osteoporotic Bone
A. Boyde ..................................................................... 101
Discussion ................................................................... 102
10 Endocrinology and Osteoporosis
P. L. Selby................................................................... 105
Discussion .......................... .............. ........................... 114
11 The Measurement of Bone Density
I. Fogelman and A. Rodin ............................................... 119
12 Screening Techniques in the Evaluation of Osteoporosis
J. A. Kanis, E. V. McCloskey, K. S. Eyres, D. V. O'Doherty
and J. Aaron ................................................................ 135
13 The Patient's View of Osteoporosis
L. Edwards .................................................................. 149
Discussion ................................................................... 154
SECTION III: RISKS AND BENEFITS OF HRT
14 Hormone Replacement Therapy and the Risk of Cancer in
the Breast and Reproductive Organs: A Review of
Epidemiological Data
l. Persson, H. O. Adami and L Bergkvist ........................... 165
15 Oestrogens and Cancer
M. P. Cust, K. F. Gangar and M. l. Whitehead .................... 177
Discussion ................................................................... 187
16 Progestogens: Symptomatic and Metabolic Side Effects
J. C. Montgomery and D. Crook....................................... 197
17 Oestrogen Replacement Therapy and Cardiovascular
Disease
R. K. Ross, M. C. Pike, T. M. Mack and B. E. Henderson..... 209
18 Oestrogens and Thrombosis
T. W. Meade ................................................................ 223
Discussion ................................................................... 233
Contents ix
SECTION IV: THERAPEUTIC POTENTIAL
19 Population Screening and the Prevention of Osteoporosis
D. W. Purdie and A. Horsman ......................................... 251
20 Long-term Follow-up of Women on HRT
D. M. Hart .................................................................. 265
Discussion ................................................................... 273
21 Effects of Oral, Percutaneous and Transdermal Oestrogens
on Postmenopausal Bone
M. I. Whitehead ............................................................ 279
22 Reversal of Bone Loss with Percutaneous Oestrogens
T. Garnett, M. Savvas and J. W. W. Studd .......................... 295
Discussion ................................................................... 307
23 Prevention and Treatment of Osteoporosis
J. C. Stevenson, T. C. Hillard and M. Ellerington ................. 315
24 Lifestyle, Exercise and Osteoporosis
M. Notelovitz .......... ,..................................................... 323
Discussion ................................................................... 342
SECTION V: HRT AND THE COMMUNITY
2S Premenopausal Hormone Therapy
J. O. Drife ................................................................... 351
Discussion ................................................................... 358
26 Hormone Replacement Therapy in the Menopause: Risks,
Benefits and Costs
M. Roche and M. Vessey ................................................. 363
27 Should HRT be Recommended in the Community?
D. H. Barlow............................................................... 373
Discussion ................................................................... 381
Conclusions and Recommendations .................................... 387
Subject Index ................................................................ 389
Participants
Professor D. C. Anderson
Professor of Endocrinology, University of Manchester, Department
of Medicine, Hope Hospital, Salford M6 8HD, UK
Professor D. T. Baird
MRC Clinical Research Professor of Reproductive Endocrinology,
Department of Obstetrics and Gynaecology, University of Edinburgh,
Centre for Reproductive Biology, 37 Chalmers Street, Edinburgh EH3
9EW, UK
Dr D. H. Barlow
Clinical Reader, Nuffield Department of Obstetrics and Gynaecology,
University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU,
UK
Professor A. Boyde
Department of Anatomy and Developmental Biology, University
College London, Gower Street, London WCIE 6BT, UK
Dr M. Brincat
Consultant, Department of Obstetrics and Gynaecology, St Luke's
Hospital Medical School, G'mangia, Malta
Miss L. D. Cardozo
Consultant Obstetrician and Gynaecologist, King's College Hospital,
Denmark Hill, London SES 9RS, UK
DrM. P. Cust
Lecturer in Obstetrics and Gynaecology, Department of Obstetrics
and Gynaecology, University Hospital, Nottingham NG7 2UH, UK
xii Participants
Dr J. O. Drife
Convener of Study Groups, RCOG and Honorary Consultant,
Professor of Obstetrics and Gynaecology, Clarendon Wing, Leeds
General Infirmary, Leeds LSI 3EX, UK
Mrs L. K. Edwards
The Director, National Osteoporosis Society, Barton Meade House,
PO Box 10, Radstock, Bath BA3 3YB, UK
Dr I. Fogelman
Consultant Physician, Director of Nuclear Medicine, Department of
Nuclear Medicine, Guy's Hospital, London SEI 9RT, UK
Dr R. M. Francis
Senior Lecturer in Medicine (Geriatrics), Department of Medicine
(Geriatrics), University of Newcastle upon Tyne, Newcastle General
Hospital, Newcastle upon Tyne NE4 6BE, UK
Dr T. J. Garnett
Research Assistant, The Menopause Clinic, Dulwich Hospital, East
Dulwich Grove, London SE22 8PT, UK
DrD. H. Gath
Clinical Reader in Psychiatry, University Department of Psychiatry,
Warneford Hospital, Oxford OX3 7JX, UK
Dr N. P. Halliday
Senior Principal Medical Officer, Department of Health, Eileen
House, 80-94 Newington Causeway, London SEI 6YX, UK
Dr D. McK. Hart
Consultant Gynaecologist and Honorary Clinical Lecturer, Stobhill
Hospital, Glasgow G21 3UW and Western Infirmary, Glasgow
Gl16NT, UK
Dr J. A. Kanis
Reader and Consultant Physician, Department of Human Metabolism
and Clinical Biochemistry, Medical School, Beech Hill Road, Sheffield
S102RX, UK
Dr R. Lindsay
Professor of Clinical Medicine and Chief of Internal Medicine, Helen
Hayes Hospital, Route 9W, West Haverstaw, New York 10993, USA
Dr T. W. Meade
Director, MRC Epidemiology and Medical Care Unit, Northwick
Park Hospital, Harrow HAl 3UJ, UK
