Hysteroscopic curettage of the endometrium is a wise step to take when bleeding is unexplained. Bisphosphonates are synthetic derivatives of pyrophosphate that inhibit osteoclast-mediated bone resorption and thus can theoretically restore the balance between bone formation and resorption at a higher bone density. The availability of alendronate represents a significant advance. A three-year study of women who received 10 mg of alendronate and 500 mg of calcium daily showed an almost nine percent increase in lumbar spine density and a 50 percent decrease in the rate of new spinal fractures. 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.