Physiological versus standard sex steroid replacement in young women with premature ovarian failure: effects on bone mass acquisition and turnover.

Background The aim of this exploratory study was to establish whether we could improve skeletal health with a physiological regimen of SSR in young women with premature ovarian failure (POF). Patients and Methods In an open-label randomized controlled crossover trial, 34 women with POF were randomized to 4-week cycles of pSSR (transdermal oestradiol, 100 mu g daily for week 1, 150 mu g for weeks 2-4; vaginal progesterone, 200 mg twice daily for weeks 3-4) or standard hormone replacement treatment (sHRT) (oral ethinyloestradiol 30 mu g and 1 center dot 5 mg norethisterone daily for weeks 1-3, week 4 'pill-free') for 12 months. Bone mineral density (BMD) was measured by DEXA at study entry and after each 12-month treatment period. Blood samples for hormones and markers of bone formation (bone alkaline phosphatase, BALP and type I collagen N-terminal propeptide, PINP) and bone resorption (CrossLaps) were collected pre-/postwashout and after 3, 6 and 12 months of each treatment. Results Eighteen women, mean 27 (range 19-39) years, completed the study. Both regimens caused similar suppression of LH and FSH. Mean baseline lumbar spine BMD z-score was -0 center dot 89 (95% CI -1 center dot 27 to -0 center dot 51) and increased by +0 center dot 17 (CI +0 center dot 07 to +0 center dot 27) in response to pSSR (P = 0 center dot 003), compared with +0 center dot 07 (CI -0 center dot 03 to +0 center dot 18) during standard HRT (P = 0 center dot 2). During pSSR, the increment in lumbar spine BMD z-score was related positively to oestradiol (r = +0 center dot 49, P = 0 center dot 04) and inversely to FSH (r = -0 center dot 65, P = 0 center dot 004). Bone formation markers, BALP and P1NP increased in the pSSR arm (anovaP < 0 center dot 001) but decreased in the sHRT arm (P < 0 center dot 01). Both treatments suppressed the bone resorption marker, CrossLaps (P < 0 center dot 001). Conclusion We conclude that pSSR over 12 months has a beneficial affect on bone mass acquisition on the lumbar spine in women with POF, mediated by increased bone formation and decreased bone resorption.