Highlight
- Women discontinuing menopausal hormone replacement therapy (HRT) experience a transient increase in fracture risk, followed by a significant long-term reduction compared to women never exposed to HRT.
- The study utilized a large, real-world UK cohort, assessing up to 25 years post-HRT discontinuation, and found benefits even among women with short-term HRT use.
- Findings suggest the bone-protective effects of HRT may persist well beyond the treatment window, revising long-held clinical assumptions.
- Results contrast with previous landmark studies, such as the Women’s Health Initiative, prompting reconsideration of bone health management post-HRT.
Background
Osteoporotic fractures represent a significant clinical and public health burden in postmenopausal women, leading to increased morbidity, mortality, and healthcare costs. Estrogen deficiency after menopause accelerates bone loss, raising fracture risk. Hormone replacement therapy (HRT), which includes estrogen and often progestogen, has been shown to reduce bone turnover and fracture risk. However, concerns about HRT’s risks—particularly breast cancer and cardiovascular events—have limited its long-term use. Traditional understanding holds that the skeletal benefits of HRT dissipate rapidly after discontinuation, yet robust long-term, real-world data have been lacking, leaving uncertainty about optimal bone health strategies after stopping HRT.
Study Overview and Methodological Design
The recent study by Vinogradova et al., published in The Lancet Healthy Longevity, addresses this evidence gap with a comprehensive nested case-control design. Investigators analyzed health records from the UK Clinical Practice Research Datalink, including 648,747 women aged 40 years or older who experienced a first recorded fracture between 1998 and 2023. Each case was matched to up to five controls (totaling over 2.3 million) by age and general practice location, with no prior fracture history. Exposure to any HRT containing estrogen and progestogen was evaluated, and fracture risk was assessed using conditional logistic regression, adjusting for age, demographics, family history, menopausal symptoms, comorbidities, and concurrent medications. Crucially, the study tracked fracture risk up to 25 years post-HRT discontinuation, providing unprecedented longitudinal insight.
Key Findings
The analysis revealed a biphasic fracture risk trajectory among women discontinuing HRT:
- Initial Period Post-Discontinuation: There was a sharp, short-term increase in fracture risk immediately after stopping HRT.
- Long-Term Follow-Up: Over subsequent years, fracture risk not only normalized but ultimately became significantly lower than that of women who had never received HRT. This risk reduction persisted for up to 25 years after cessation.
- Short-Term HRT Use: Importantly, even women who had taken HRT for relatively brief durations (for example, those who discontinued due to concerns about breast cancer) experienced long-term skeletal protection.
These findings contrast with the Women’s Health Initiative post-trial study, which found no persistent fracture benefit after stopping HRT. The large sample size, extended follow-up, and adjustment for confounders in the Vinogradova study provide robust evidence for a sustained protective effect.
Mechanistic Insights and Pathophysiological Context
Estrogen plays a central role in regulating bone remodeling by inhibiting bone resorption and promoting osteoblastic activity. During the menopausal transition, declining estrogen levels cause rapid bone loss. HRT reverses this by restoring estrogenic effects. The persistent reduction in fracture risk observed long after discontinuation suggests that HRT may induce durable changes in bone microarchitecture or peak bone mass, possibly via prolonged suppression of bone turnover or epigenetic mechanisms. These hypotheses require further mechanistic exploration, but the clinical data support a durable legacy effect.
Clinical Implications
This study’s findings have immediate clinical relevance:
- Women and clinicians may be reassured that even short-term HRT use confers long-term skeletal benefits, potentially shifting risk-benefit discussions for those with heightened fracture risk.
- For patients who must discontinue HRT due to emerging contraindications (e.g., breast cancer risk), the persistent fracture protection may inform follow-up care and monitoring strategies.
- Guidelines may require revision to reflect these new data, especially regarding HRT duration and post-discontinuation bone health management.
- Screening and preventive strategies for osteoporosis might be tailored according to prior HRT exposure and duration.
Limitations and Controversies
While the study boasts considerable strengths—large, representative sample size and long-term follow-up—limitations exist. Registry-based designs are subject to coding errors and residual confounding. Medication adherence, HRT formulation, and dosing were not granularly assessed. Selection bias may persist if fracture risk influenced HRT discontinuation. Additionally, the results diverge from previous randomized controlled trials (notably the Women’s Health Initiative), possibly due to differences in population, HRT type, or follow-up duration. As always, translating population-level findings to individual patients requires nuanced clinical judgment.
Expert Commentary or Guideline Positioning
Current guidelines from bodies such as the North American Menopause Society and NICE (UK) recognize HRT as a first-line option for vasomotor symptoms and for osteoporosis prevention in selected women but recommend individualized assessment of risks and benefits. Dr. Vinogradova and colleagues propose that the durable legacy benefit for fracture prevention should be considered in shared decision-making. Dr. Kwolek, a bone health expert, notes that the new data may prompt re-evaluation of the timing and duration of HRT in relation to bone health, especially as the window of risk benefit appears broader than previously assumed.
Conclusion
The Vinogradova study provides compelling evidence that menopausal HRT confers long-lasting protection against fractures, persisting for decades after discontinuation—even among women with brief exposure. While an initial transient increase in fracture risk exists post-cessation, the long-term reduction is clinically meaningful. These findings challenge previous paradigms, support more nuanced discussions around HRT discontinuation, and highlight the need for further mechanistic research. Integration of these insights into clinical practice and guidelines will optimize bone health outcomes for postmenopausal women.
References
- Vinogradova Y, Iyen B, Masud T, Taylor L, Kai J. Discontinuation of menopausal hormone therapy and risk of fracture: nested case-control studies using routinely collected primary care data. Lancet Healthy Longev. 2025 Jul 21:100729. doi: 10.1016/j.lanhl.2025.100729 IF: 14.6 Q1 . Epub ahead of print. PMID: 40713950 IF: 14.6 Q1 .
- Rossouw JE, Prentice RL, Manson JE, et al. Postmenopausal hormone therapy and risk of cardiovascular disease by age and years since menopause. JAMA. 2007;297(13):1465-1477.
- North American Menopause Society. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause. 2022;29(7):767-794.
- NICE guideline [NG23]: Menopause: diagnosis and management. National Institute for Health and Care Excellence. 2015 (updated 2019).
