PAD Refills

Do guidelines recommend initiating menopause hormone therapy (MHT) for the prevention or treatment of osteoporosis?

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Conclusion: Current guidelines do not recommend MHT for the prevention or treatment of osteoporosis in the absence of menopause symptoms. They do support MHT as an option in postmenopausal patients who are under the age of 60 or within 10 years of menopause onset for managing co-occurring menopause symptoms and osteoporosis, in the absence of contraindications to MHT.

The BC Provincial Academic Detailing (PAD) service’s topic Medications for menopause-associated vasomotor and genitourinary symptoms delivers evidence and practical drug information for the most commonly prescribed estrogen and progestogen products (oral, transdermal, vaginal).¹ Visit www.bcpad.ca to book a session with an academic detailing pharmacist in your area.

MHT refers to the combined use of estrogen plus a progestogen, or estrogen alone in people with a hysterectomy. Several oral and transdermal estrogen products have a Health Canada indication for the prevention of postmenopausal osteoporosis.² Health Canada’s labelling of these products advise that non-estrogen medications (e.g., bisphosphonates, denosumab, anabolics) should be considered in patients with significant fracture risk. No MHT product has a treatment of osteoporosis indication. In guidelines, MHT is not recommended for osteoporosis in the absence of managing menopause symptoms known to be responsive to estrogen therapy (e.g., hot flashes).^3-5 However, improvements in bone mineral density and reductions in fracture risk are recognized as secondary benefits while someone is taking MHT for menopause symptoms. The table below summarizes current guideline recommendations regarding the role of MHT for osteoporosis.

Table: Menopause hormone therapy for osteoporosis clinical practice guideline recommendations
Osteoporosis Canada 20233		For postmenopausal females aged less than 60 years or within 10 years of menopause initiating pharmacotherapy for osteoporosis who prioritize alleviation of substantial menopausal symptoms, we suggest menopausal hormone therapy as an alternative option to bisphosphonate therapy.
North American Menopause Society 20224		In the absence of contraindications, in women aged younger than 60 years or within 10 years of menopause onset, systemic hormone therapy is an appropriate therapy to protect against bone loss. Decisions regarding initiation and discontinuation of hormone therapy should be made primarily on the basis of extraskeletal benefits (i.e., reduction of vasomotor symptoms) and risks.
Society of Obstetricians and Gynecologists of Canada 20215		Menopausal hormone therapy may be given to postmenopausal women experiencing menopausal symptoms at low, intermediate, or high fracture risk if they are under the age of 60 years, with no history of breast cancer or thromboembolic disease and at a low risk of cerebrovascular or cardiovascular disease.

The Women’s Health Initiative (WHI) Trial which enrolled healthy, postmenopausal women contributes the most weight to meta-analyses evaluating the effect of MHT on fractures. ^6,7 The trial demonstrated a small reduction in hip fractures with concurrent small increases in other serious adverse events. For example, in the subgroup of participants aged 50-59 randomized to estrogen (Premarin) and a progestogen for endometrial protection (Provera), there were 3 fewer hip fractures, 5 more coronary heart disease events and 6 more invasive breast cancers per 10,000 person years. A publicly accessible 2013 WHI publication shows the results across age subgroups (50-59, 60-69, 70-79).⁷  

In the 2023 podcast Hormone replacement therapy and the Women’s Health Initiative with host Peter Attia MD, one of the WHI’s principal investigators, JoAnn Manson MD, provides a contemporary review of the WHI including a focused discussion weighing the beneficial effects of MHT on fractures with the increase in other adverse health outcomes.⁸

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¹BC PAD Service Medications for Menopause-Associated Vasomotor and Genitourinary Symptoms (May 2025); ²Health Canada Drug Product Database; ³Osteoporosis Canada 2023 (PMID:37816527); ⁴North American Menopause Society (PMID:35797481); ⁵Society of Obstetricians and Gynecologists of Canada 2021 (PMID:35577424); ⁶US Preventive Task Force 2022 (PMID:36318128); ⁷Manson J WHI JAMA 2013 (PMID:24084921); ⁸The Peter Attia Drive Podcast Episode 253 with JoAnn Manson MD