Osteoporosis prevention should start in childhood, and there are a number of things that can be done to build stronger bones. These include encouraging children (boys as well as girls) to eat foods rich in calcium such as milk, cheese, yoghurt and fish with bones, and to take regular exercise. Sadly, many older women now suffering from osteoporosis were brought up at a time when there was little emphasis on a well-balanced diet and regular weight-bearing exercise. Many took as gospel the misguided words of the Duchess of Windsor, ‘You can never be too thin or too rich’.

More than 50 per cent of Australian women (and 30 per cent of Australian men) consume less than the recommended dietary intake of calcium. For teenagers it’s no better, with nearly a third of fifteen-year-old girls getting less than half the calcium they need, according to a national dietary survey of Australian schoolchildren aged from ten to fifteen years.

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The idea of prescribing HRT for women solely to keep them receptive to their partners’ advances is outrageous, as Germaine Greer has argued. Unfortunately this seems to have happened in the 1970s. ‘Because they desire the preservation of cosmetic youth and the unflagging libido of patients, physicians have championed estrogen [oestrogen] replacement therapy in the hope of attaining a maximal quality of life for their patients,’ the US medical researchers Dr Harry Ziel and Dr William Finkle said in 1976. Equally objectionable were the pharmaceutical advertisements of this era that promoted HRT ‘for the menopausal problems that bother him the most [our emphasis]‘.

Yet there are many middle-aged and older women wanting to have genital sex with partners who feel the same. If the way their vaginas feel prevents this, they should consider the use of substances including oestrogen, either as a cream, tablet or pessary applied directly to the vagina, as pills to be swallowed, or in some other form. The crucial difference is that they understand and accept the therapy, with all its pros and cons, and use it to meet their own needs rather than the needs of others.

If you are wondering whether the direct application of oestrogen to the vagina has identical effects to that of oestrogen by pill, patch or implant, the answer is a conditional yes. Oestrogen-containing vaginal creams have the disadvantage of being messy, but they do increase lubrication and vaginal tone, and they may improve libido and feelings of wellbeing. They also impinge minimally on other body tissues when used as directed, thus reducing the chances of unwanted effects.

Testosterone implants to increase energy and sexual appetite are an appropriate option for some women. These can be used on their own or in addition to oestrogen.

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To make a significant impact on the risk of osteoporosis, you will require HRT for at least ten years, ideally starting therapy within about two years of the last menstrual period. It does appear that the longer a woman remains on HRT, the stronger her bones. Another factor to consider, if you are a smoker taking oestrogen to avoid osteoporosis, is the importance of quitting because smoking reduces oestrogen’s protective effect on bone.

Various studies show a 50 to 75 per cent reduction in the risk of fracture from osteoporosis after extended HRT. An adequate hormone dose is vital. The minimum daily oral dose of oestrogen required for prevention of bone loss is 0.625 mg of Premarin, 1.25 to 2.5 mg of Ogen, 2 to 4 mg of Progy-nova, or 0.02 mg of Estigyn. Some women prescribed HRT primarily for symptom control have more than an adequate dose to maintain their bone strength. In other cases, the prescribed dose is insufficient to prevent bone loss: some women have a low tolerance of hormones and are on the minimum, others smoke or have dietary imbalances that interfere with oestrogen uptake, and others again have such a fast rate of bone loss that even maximum hormone doses cannot keep pace.

For example, Premarin protects bones in most women at a dose of 0.625 mg daily, but studies tracking women’s bone density over a number of years indicate that 15 per cent need twice this amount to gain protection. Yet other studies show that half this amount, as little as 0.3 mg of Premarin a day, is effective if combined with a daily intake of 1500 mg of calcium. Women whose menopause occurred many years previously may need to start at a lower hormone dose to minimise possible unwanted effects like breast tenderness. Dosage levels may then be increased gradually if prevention of bone weakness is a major reason for taking HRT.

Oestrogens can be used in pill, implant or skin patch form. If you still have your uterus you will need to take a progestogen as well to protect its lining from an increased risk of cancer. The chances of this cancer developing are about one in 25 000 for women before menopause, and one in 1100 for women not on oestrogen after menopause or women with a uterus receiving both oestrogen and progestogen. The risk of endometrial cancer for women with a uterus who use oestrogen alone in pill, patch or implant form for five years or more after menopause increases to approximately one in 200. However, with an adequate dose and duration of progestogen, the risk falls again to one in 1100 or less.

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During the fertile years progesterone is produced within the ovaries as a result of ovulation. It dampens down oestrogen’s effect on the growth and thickening of the endometrium, the lining of the uterus. When the levels of oestrogen and progesterone decline towards the end of the menstrual cycle, the endometrium is shed as a menstrual bleed. The term progestogen is used to describe any manufactured substance that has similar chemical effects on the body to those of progesterone.

PROGESTOGENS USED IN HRT Although all the progestogens used in HRT have properties similar to those of progesterone, the body breaks them down in rather different ways. They are all more powerful than progesterone too, having more pronounced effects when given at doses comparable to the levels of progesterone found in the body. (For a detailed description of the varieties of progestogen used in HRT see page 176.) The main reason for including progestogen in HRT is to protect the endometrium, the lining of the uterus. If the endometrium is exposed to constant oestrogen without progestogen, the endometrium may become

too thick. This condition is known as hyperplasia, which occasionally develops into cancer.

It follows that, if you have had a hysterectomy, endometrial hyperplasia is not something for you to be concerned about. The way is clear for you to use an oestrogen-only form of HRT. This seems to be an option with few side effects or risks, but you must be carefully monitored.

Some women cannot tolerate the progestogen component of HRT as it can produce unwanted results such as breast tenderness, increased blood pressure, mood swings, depression, acne, backache, bloating and abdominal cramps. These symptoms resemble those of premenstrual syndrome. ‘I hate progestogen,’ said thirty-year-old Mardi, whose diseased ovaries were removed two years ago. She has since tried various combinations of oestrogen and progestogen, partly because of her mood changes. ‘The progestogen makes me snappy and irrational and I get fed up with it. Some months I’m a bit naughty: I don’t take the progestogen at all.’

At those times when Mardi has both progestogen and oestrogen she has regular withdrawal bleeds, that is, bleeding for a few days at a predictable time of the month. Withdrawal bleeds are usually indistinguishable from short menstrual bleeds (they tend to be two to four days long) but, of course, they come about in different ways, being induced by hormone therapy. If you are taking progestogen you may also experience unpredictable bleeding, which is known as breakthrough bleeding. Understandably, such withdrawal bleeds and breakthrough bleeds deter some women from embarking on HRT or persevering with it, since an advantage of menopause for many women is an end to the bother of tampons and pads. A number of women appear to be happy to continue having withdrawal bleeds. The particular combination and timing of oestrogen and progestogen in HRT have a major influence on whether and when women experience bleeding.

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