Aktuelle Rheumatologie 2001; 26(5): 187-194
DOI: 10.1055/s-2001-18143
THERAPIE

© Georg Thieme Verlag Stuttgart · New York

Hormonersatztherapie und selektive Östrogenrezeptor-Modulatoren

Prevention of Osteoporosis - Role of Hormonal Replacement Therapy and Selective Oestrogen Receptor ModulatorsMartina Dören
  • Freie Universität Berlin, Universitätsklinikum Benjamin Franklin, Klinisches Forschungszentrum Frauengesundheit (Univ.-Prof. Dr. med. M. Dören) Berlin
Further Information

Publication History

Publication Date:
31 October 2001 (online)

Zusammenfassung

Eine Hormonsubstitution mit Östrogenen in der Postmenopause - optimale Dosen sind 2 mg Östradiol, 0,625 mg konjugierte equine Östrogene, 1,25 mg Östron, 50 µg Östradiol transdermal - vermag die densitometrisch an frakturrelevanten Regionen quantifizierbare Knochendichte zu erhalten. Die knochenspezifischen Vorteile einer Östrogensubstitution sind unabhängig vom (postmenopausalen) Alter. Die Anwendung eines Gestagens vermindert zumindest nicht diese Effekte. Tibolon, ein Gestagen mit androgenen und östrogenen Partialwirkungen vermag ebenfalls die Knochendichte zu erhalten. Observationsstudien legen nahe, dass eine Östrogensubstitution das Risiko einer Schenkelhalsfraktur um mindestens 25 % reduziert, wenn ein Vergleich zwischen Frauen, die jemals Hormone anwendeten, und denen ohne jegliche gegenwärtige und ehemalige Substitution zugrunde gelegt wird. Die Beendigung einer Substitution zieht nach wenigen Jahren den Wiederanstieg des Frakturrisikos nach sich, die beabsichtigte Osteoprotektion besteht nicht mehr. Es bestehen zur Zeit deutliche Defizite in der Datenlage im Hinblick auf formale Frakturstudien zur Beurteilung der Effektivität einer Substitution, die zur Primärprävention - Verhinderung einer Osteoporose - oder zur Sekundärprävention - Verhinderung weiterer Frakturen - durchgeführt wird. Raloxifen, ein selektiver Östrogenrezeptormodulator, erhält die Knochendichte im Sinn der Primärprävention und vermag die Häufigkeit vertebraler Frakturen bei Frauen mit manifester Osteoporose annähernd zu halbieren. Jede Nutzen-Risiken-Evaluation sollte die erhöhte (erniedrigte) Diagnosewahrscheinlichkeit von Brustkrebs (Kolonkarzinom) bei Langzeitsubstitution mit Östrogenen beinhalten.

Prevention of Osteoporosis - Role of Hormonal Replacement Therapy and Selective Oestrogen Receptor Modulators

Oestrogen replacement therapy (ERT) is generally regarded as first choice for prevention of osteoporosis in women apart from life style modifications. Natural and synthetic oestrogens at least preserve bone mineral density (BMD) dose-dependently irrespective of postmenopausal age and mode of administration. Maximum effects can be achieved by daily use of 2 mg oestradiol, 0.625 mg conjugated equine oestrogens, 1.25 mg oestrone, and 50 µg transdermal patch oestradiol. Progestogens neither attenuate nor augment the effect of oestrogens. Tibolone 2.5 mg daily, a synthetic steroid related to norethisterone acetate, also preserves BMD. Observational studies suggest a hip fracture risk reduction by at least 25 % in permanent non-contraceptive oestrogen users. There are no designated fracture trials available for any oestrogen. A selective oestrogen receptor modulator such as raloxifene reduces vertebral fractures in postmenopausal women with low BMD and incident vertebral fractures, respectively. The recommendation to use oestrogen as first-line pharmacological prevention for postmenopausal osteoporosis is not well supported due to lack of direct evidence by fracture trials and the rare use of oestrogen in (late) postmenopausal women. Fracture trials of women including the advanced should be conducted to overcome the current lack of evidence for ERT compared with other drugs approved for the prophylaxis of postmenopausal osteoporosis. An individual assessment of risks and benefits of long-term HRT including an increased (decreased) likelihood for breast (colon) cancer diagnosis should be taken into account in counselling.

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Univ.-Prof. Dr. med. Martina Dören

Freie Universität Berlin
Universitätsklinikum Benjamin Franklin
Klinisches Forschungszentrum Frauengesundheit

Klingsorstraße 109 a
12203 Berlin

Email: E-mail: doeren@cipmail.ukbf.fu-berlin.de

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