Does Stopping Hormone Therapy Increase Fracture Risk?
Yes. This large observational cohort study followed 80,955 postmenopausal women who were taking hormone therapy as of July 2002, and found that women who discontinued it had a 55% greater risk of hip fracture than women who kept taking it (hazard ratio 1.55; 95% CI 1.36 to 1.77) over 6.5 years of follow-up. The risk was already elevated as early as 2 years after stopping (hazard ratio 1.52; 95% CI 1.26 to 1.84), which makes transition planning important for women who need to come off treatment.
Dr. Kumar’s Take
This study addresses one of the most overlooked aspects of hormone therapy: what happens after you stop. Many women are told to discontinue at arbitrary ages without any consideration of what that does to bone. The authors’ conclusion is blunt, that the protective association of hormone therapy with hip fracture disappeared within 2 years of cessation. That timeline is short enough that I think stopping deserves as much clinical attention as starting, including bone density assessment and a plan for what replaces the protection. I would also note the design honestly: this is an observational cohort, not a randomized trial, so it shows association rather than proving cause.
What the Research Shows
The study drew on 80,955 postmenopausal women aged 60 or older enrolled at Kaiser Permanente Southern California, all of whom had filled hormone therapy prescriptions at least once between January and June 2002. They were followed through December 2008 using the electronic medical record and pharmacy system across 11 medical centers, and every hip fracture was verified by chart review performed blinded to hormone therapy status. Fractures from tumors, periprosthetic fractures, and high-energy trauma were excluded.
The comparison here is not users versus never-users. It is women who discontinued hormone therapy versus women who continued it. After 6.5 years of follow-up, age- and race-adjusted models showed a 55% greater hip fracture risk in those who discontinued (hazard ratio 1.55; 95% CI 1.36 to 1.77). Risk was raised as early as 2 years after cessation (hazard ratio 1.52; 95% CI 1.26 to 1.84) and rose incrementally with longer time off therapy (P for trend < 0.0001).
Bone mineral density was measured by DXA scan in 54,209 of these women during the study period, recorded as the lower T score of the hip and lumbar regions. Longer duration of cessation was linearly correlated with lower bone mineral density, at a beta estimate of -0.13 T-score SD units per year off hormone therapy (SE 0.003; P < 0.0001).
How This Works (Biological Rationale)
Protection from bone loss and fracture is one of the established benefits of hormone therapy. This cohort shows both halves of that relationship coming apart after cessation: bone density falls in proportion to how long a woman has been off treatment, and hip fracture risk climbs with the same pattern, incrementally with duration of cessation. The density signal and the fracture signal point in the same direction, which is what you would expect if the loss of estrogen exposure is driving the bone change rather than some incidental difference between the groups.
Hip fracture is not a minor endpoint. The authors note a 25% case-fatality rate associated with it, which is why they frame a population-wide wave of discontinuation after the initial Women’s Health Initiative publication as a public health concern rather than an individual inconvenience.
Practical Takeaways
- Understand that the bone protection from hormone therapy fades fast, with hip fracture risk elevated as early as 2 years after stopping
- Plan bone health monitoring before discontinuing, not after
- Consider bone density testing when you come off hormone therapy, since density in this cohort tracked with time since cessation
- Discuss antiosteoporotic alternatives such as bisphosphonates with your physician if you need to stop hormone therapy
- Don’t stop without a plan for maintaining bone health
- Recognize that the decision to stop should account for your individual fracture risk, not an arbitrary age cutoff
What This Means for Perimenopause and Menopause Care
Millions of women in the United States and elsewhere abruptly stopped hormone therapy after the first Women’s Health Initiative publication in June 2002, and very little research has looked at what happened to them afterward. This study is one attempt to answer that in a general population. It suggests hormone therapy decisions should be individualized and that stopping requires as much planning as starting. The speed at which the protective association disappears, within 2 years by the authors’ own conclusion, argues against automatically discontinuing at a set age without weighing individual bone risk.
Related Studies and Research
- The Mortality Toll of Estrogen Avoidance
- Effects of menopause on temperature regulation
- The Effects of Menopause Hormone Therapy on Lipid Profile in Postmenopausal Women
- Sleep disturbance associated with the menopause
- Episode 27: Perimenopause, Menopause, and HRT - What Every Woman Should Know
FAQs
How quickly do I lose bone protection after stopping hormone therapy?
In this cohort, hip fracture risk was already elevated as early as 2 years after cessation (hazard ratio 1.52; 95% CI 1.26 to 1.84), and the authors concluded the protective association disappeared within 2 years of stopping. Risk continued to rise the longer women stayed off therapy.
Should I have a bone density test before stopping hormone therapy?
I think so. Bone density in this study fell in proportion to time since cessation, so knowing where you start gives you a baseline to track against and helps guide whether you need an alternative bone protection strategy.
Are there alternatives to hormone therapy for bone protection?
The study tracked antiosteoporotic medication use, specifically bisphosphonates, alongside hormone therapy. Options should be discussed with your physician before you stop, not after a fracture.
Bottom Line
Women who discontinued postmenopausal hormone therapy had a 55% greater risk of hip fracture than women who continued (hazard ratio 1.55; 95% CI 1.36 to 1.77) over 6.5 years of follow-up, with risk elevated as early as 2 years after stopping and bone density lower the longer they had been off treatment. Women coming off hormone therapy need proactive bone health monitoring and a plan for alternative protection.
