The impact of estrogen replacement therapy and raloxifene on osteoporosis,cardiovascular disease, and gynecologic cancers

OBJECTIVE: To compare the clinical utility of estrogen replacement therapy (ERT) and raloxifene in osteoporosis and cardiovascular disease in postmeno pausal women and to evaluate the contrasting adverse effects of these thera pies. DATA SOURCES: A MEDLINE search was performed for January 1980 through Septe mber 1998 using the key terms raloxifene, estrogen, CVD, lipoproteins, and osteoporosis. STUDY SELECTION AND DATA EXTRACTION: All; clinical studies assessing ERT an d raloxifene in cardiovascular disease or osteoporosis were evaluated. DATA SYNTHESIS: ERT remains the standard for prevention and treatment of os teoporosis in women. Its use increases total bone mineral density (BMD) up to 12.1% and reduces hip fracture risk by 66-73%. It reduces low-density li poprotein (LDL) cholesterol by 15-19% and increases high-density lipoprotei n (HDL) cholesterol by 6-18%. Raloxifene, an alternative to ERT in the prev ention of osteoporosis, increases total BMD by 2.2%. It reduces LDL by 6.2- 14.1% and increases HDL by 1.5-5.7%. Preliminary data suggest that raloxife ne has contrasting effects on gynecologic cancers compared with the increas ed risk posed by ERT. CONCLUSIONS: Clinical trials have illustrated greater effects on BMD with E RT than with raloxifene. Studies of significant duration assessing raloxife ne and its fracture risk effects are lacking. ERT appears to have greater b eneficial cardiovascular risk factor effects than raloxifene. Prospective, primary prevention studies evaluating overall cardiovascular risk reduction do not exist for either intervention. Raloxifene, while more costly, is an alternative that may have a lower associated risk of breast cancer compare d with ERT.