Letters To The Editor

Glucocorticoid-induced osteoporosis

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To the Editor: I have to say I am disappointed, but not surprised, at Dr. Dore’s article, “How to prevent glucocorticoid-induced osteoporosis” in your August issue.1 The section “Estrogen is being used more selectively” was shorter and had older and out of date references compared with the section “A role for testosterone?” and it was actually blatantly sexist: the comment in the estrogen section is that “…the consensus…that hormone replacement therapy should be restricted to women with menopausal symptoms or to older women who cannot tolerate other therapies or who express a strong preference for hormone replacement therapy despite being informed about potential adverse events” [my italics],1 while the comment in the testosterone section is that males who “… are hypogonadal, and have no contraindications to androgen replacement therapy (eg, prostate cancer) be offered testosterone therapy to preserve lean body mass and bone mineral density” [my italics].1

While I am not arguing that menopausal hormone therapy should be used first-line for the prevention or treatment of glucocorticoid-induced osteoporosis, I would like to note the following:

First, the referenced 2002 Women’s Health Initiative study2 was a prevention trial, not a therapeutic menopausal trial, and to reference it as a position statement on the use of hormone therapy is ridiculous and perpetuates misinformation about the role of menopausal hormone therapy.

Next, there has been updated information from the Women’s Health Initiative, as well as updated position statements on the use of hormone therapy—the 2010 position statement on the use of estrogen and progestogen in menopausal women3 as well as the 2008 American Association of Clinical Endocrinologists position statement4 noting that the benefits of hormone therapy outweigh the risks for most women under age 60. So Dr. Dore’s reference citation from 20045 is hopelessly outdated.

And lastly, females, unlike males, routinely become hypogonadal at midlife. When faced with a medical condition that requires glucocorticoids that further intensifies the hypogonadal state by suppressing adrenal adrenogens, females may face a “triple whammy” on the bone.

The Women’s Health Initiative actually showed fracture reduction in postmenopausal women who did not even carry the diagnosis of osteoporosis, while the referenced studies in Dr. Dore’s article related to males admittedly “cannot be considered conclusive in view of their small size and the lack of fracture data…”1

So what is bad (actually potentially good) for the goose is apparently just fine for the gander.

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