Although the long-term safety of alendronate remains to be demonstrated, this drug provides an important alternative for the patient who cannot or will not take estrogen. Sodium fluoride is another nonhormonal approach to the prevention of and therapy for osteoporosis. When given in a slow-release formulation, with calcium, for more than four years, this drug induced a four to five percent increase a year in vertebral bone mass and a slightly lesser effect on the hip. The treatment was most effective in patients with minimal loss of bone density at initiation of therapy, almost eliminating new fractures in this group of patients. The discussion of the risks and benefits of hormone replacement therapy for osteoporosis has been overshadowed by emerging evidence that long-range estrogen therapy has a beneficial effect on the incidence of coronary artery disease.
Cardiovascular disease is the principal cause of death in postmenopausal women.
However, estrogen has other, direct, and probably more important effects. It has a vasodilatory action associated with increases in prostacyclin and nitric oxide and an atheroprotective effect probably related to inhibition of vascular proliferation. Thus, the decision to undertake estrogen replacement therapy should be taken with an awareness of its potential positive impact on cardiovascular disease. The benefits of estrogen on cardiovascular disease have thus far been seen in patients who are taking estrogen alone. Because most patients now take progestin as well as estrogen, it is important to anticipate the influence of combined treatment on lipid levels.