MRI radiomics evaluation of liver-kidney tonifying formula combined with hormone replacement therapy for perimenopausal osteoporosis

Perimenopausal osteoporosis threatens the health of middle-aged and elderly women. Although hormone replacement therapy (HRT) is effective, it has side effects. This study aims to evaluate the clinical efficacy and mechanism of action of liver and kidney tonifying formula combined with HRT through magnetic resonance imaging (MRI) radiomics analysis. In this study, 126 patients were randomly divided into the control group (COG) (simple HRT) and the observation group (OBG) (HRT + liver and kidney tonifying formula), and were treated for 3 months. Dual-energy X-ray absorptiometry was employed to assess bone mineral density (BMD). Bone metabolism markers were analyzed via metabolomics, and bone microstructure changes were analyzed through MRI radiomics. The combination therapy demonstrated superior outcomes. The OBG showed a significantly higher overall treatment effective rate (93.65 % vs. 79.37 %, P = 0.024) and a markedly greater increase in BMD at all measured sites ( e.g., lumbar spine L2-L4: +0.16 g/cm 2 , 95 % CI: 0.12 to 0.20) compared to the COG. Bone resorption was more effectively inhibited, as evidenced by a greater reduction in Tartrate-resistant acid phosphatase 5b (TRACP-5b) (between-group difference: 4.5 U/L, 95 % CI: 5.8 to −3.2). Hormone profiles improved more favorably in the OBG, with a significant increase in E 2 (+5.1 pg/mL, 95 % CI: 3.2 to 7.0) and decrease in follicle-stimulating hormone (FSH) (−12.6 IU/L, 95 % CI: 14.5 to −10.7) compared to the COG. Crucially, MRI radiomics revealed enhanced trabecular microstructure in the OBG, indicated by a significant decrease in Gray Level Co-occurrence Matrix (GLCM) contrast (−6.5 %, 95 % CI: 8.1 % to −4.9 %) and increase in GLCM energy (+8.4 %, 95 % CI: 6.7 %–10.1 %). Metabolomics analysis identified 20 differential metabolites and activation of key pathways including arachidonic acid, amino acid, and vitamin D metabolism. The incidence of adverse events in the OBG was lower than that in the COG (20.63 % vs. 23.81 %), with no severe events reported in the OBG. The combination of liver and kidney tonifying formula and HRT significantly improves the bone metabolism and microstructure of patients. The radiomics features of MRI can objectively verify its therapeutic effect and reveal the dynamic repair process of bone microstructure that is difficult to capture by traditional methods.