Alternatives to HRT in prevention and treatment.

Oestrogen hormone replacement therapy remains the first choice for the treatment and prevention of osteoporosis in postmenopausal women, but for patients who are unsuitable for this therapy, which of course includes men, other satisfactory treatments are available. Several placebo-controlled studies have demonstrated that bisphosphonates and calcitonin prevent bone loss or perhaps increase bone density over 2-3-year periods, and reduce the rate of fracture. It is not known whether these treatments will increase bone density over longer periods of time. Cyclical etidronate has recently become licensed in the UK for use in the treatment of osteoporosis, and it is hoped that other bisphosphonates and intranasal calcitonin will soon be added to the available treatments. Fluoride appears to increase bone density but, at doses above a very narrow therapeutic window, it increases the fracture rate, either because of bone redistribution, formation of poor quality bone or a toxic effect on osteoblasts. At present, fluoride remains a treatment to be used only under expert supervision or within the context of controlled clinical trials. Anabolic steroids may be of value in selected elderly patients with osteoporosis. The patient may be able to contribute to the prevention of osteoporotic fracture by exercising, which will improve dexterity and may have a small effect to increase bone density, and by avoiding the factors that predispose to falls, such as icy paths and excess alcohol. Changes in the diet are unlikely to play a major role in the maintenance of bone density in women living in the Western world.