Treating Osteoporosis in Post-Menopausal Women: A Case Approach

A 79-year-old white woman presents with back pain. The patient is a widow and lives alone, spending most days watching television. Six months ago she fractured a rib after slipping on a throw rug on a hardwood floor. She has had hypertension for 5 years and depression for 1 year. She went through menopause at age 48 and was not treated with hormone replacement. She has a family history of osteoporosis. She does not smoke.

Medications. She takes a sedative for insomnia and an antihypertensive medication. She reports occasional dizziness, attributed to postural hypotension resulting from antihypertensive treatment.

Height: 156 cm (62 inches; 2 inches less than 10 years ago); weight 55 kg (121 lb).

Laboratory results:
• Serum calcium and thyroid function normal
• 25-hydroxycholecalciferol borderline low
• Parathyroid hormone level normal.

Spinal radiograph. Multiple compression fractures and multifocal vertebral degenerative changes.

A Major Public Health Problem
Osteoporosis and osteopenia affect almost 44 million people age 50 and older in the United States,(1) approximately 80% of whom are postmenopausal women. Both conditions increase susceptibility to fracture. (2-4)

Table 1
Risk Factors for Low Bone Mass

Nonmodifiable
White race
Female sex
Family history of osteoporosis
Previous atraumatic fracture
Advanced age

Potentially modifiable
Estrogen deficiency
Low calcium intake (lifelong)
Current cigarette smoking
Low body weight ( Excessive alcohol intake
Inadequate physical activity
Poor health
Frailty

Medications
Glucocorticoids
Anticonvulsants
Excess thyroid hormone
Heparin

Diseases
Rheumatoid arthritis
Hyperthyroidism
Hyperparathyroidism
Cushing disease
Lymphoma or leukemia
Myeloma
Sarcoidosis
Malabsorption, gastrectomy, or malnutrition

Approximately 700,000 osteoporosis-related vertebral fractures occur each year in the United States.1 Although fracture rates are highest in women with osteoporosis defined by bone density (T score -2.5 or below), the National Osteoporosis Risk Assessment (NORA) study5 found that most fractures (82%) occur in women with peripheral bone mineral density T scores greater than -2.5. Osteoporotic fractures are associated with increased morbidity and mortality, a compromised quality of life, (6-9) and an estimated $17 billion in direct medical expenditures annually. (10)

Too often, postmenopausal osteoporosis remains undiagnosed until a fragility fracture occurs. At this point, women are likely to sustain more fractures, and morbidity and mortality rates climb.

Cleveland Clinic Journal of Medicine
Volume 71, Number 10, October 2004

The author has indicated that he has received grant or research support from the Wyeth, Pfizer, Proctor and Gamble, Sanofi, NPS, and Alexis corporations and is on the speakers' bureaus of the Abbott, Merck, and Proctor and Gamble corporations. This paper discusses treatments that are experimental or are not approved by the US Food and Drug Administration for the use under discussion.