Case studies (submitted by Felicia Cosman, M.D.).

Case 1

A 52-year-old woman, approximately nine months from her last menstrual period complains of hot flashes, night sweats and irritability. She asks for a bone density test because her mother had very stooped posture from a very young age. The BMD score in the spine is determined to be Ř2.2. This woman is clearly a very good candidate for estrogen or hormone replacement therapy. She has no specific contraindications for hormone replacement therapy and has substantial menopausal symptoms. This is a major indication for the use of estrogens. Her bone density is in the osteopenic, or low bone mass range, and she requires therapy for prevention of bone loss because of this as well as her family history of presumed osteoporosis. The ques-tion will be how long estrogen should be used in this woman. We can no longer routinely consider hormone replacement therapy as a treatment for the rest of a personís life.

Case 2

A 56-year-old woman recently developed back pain and acknowledged to her doctor that she had had approximately a one or perhaps slightly more than a one-inch height loss. Her x-ray did not show any clear abnormalities but there is a possibility of mild or mini-mum wedging of one vertebra. Her doctor suggested a bone density test. The BMD score in the spine was Ř2.3 and in the hip was Ř1.5. Her mother was recently diagnosed with breast cancer. This 56-year-old woman is a classic case of a woman with early osteo-porosis of the spine on x-ray. It is important that physicians review x- rays with radiolo-gists, because sometimes mild wedging on x-ray may not be reported in a typical x-ray report. However, this may be an early sign of vertebral osteoporosis. Her bone density T-score is also nearly in the osteoporotic range of -2.5 or below and with the x-ray evidence as well as the low bone density score, she is certainly a good candidate for treatment of osteo-porosis whether or not her back pain was really related to this wedging. Because her mother was recently diagnosed with breast cancer, she is probably not a good candidate for hormone replacement therapy. She is an excellent candidate for raloxifene, which not only reduces risk of vertebral fractures but may also reduce the risk of breast cancer in the future. OSTEOPOROSIS: THE ERA OF THE BISPHOSPHONAT E S - PART I We can no longer routinely consider hormone replacement therapy as a treatment for the rest of a person's life.

Case 3

A 62-year-old woman sees a new internist. She is well, but is going for a routine general physical exam and the new internist performs a comprehensive medical interview. She tells the doctor that she had a wrist fracture at age 54 after a fall when she slipped on a patch of ice on her driveway. The physician orders a bone density test which shows her T-score in the hip to be Ř2.3. The T-score in the spine is Ř2. However, there is an apparent artifact overlying at least one of the vertebrae. This is a classic case where the hip T-score should be used to determine the need for medical therapy in combination with the clinical history. This woman has a bone density nearly in the osteoporotic range and she also had an osteo-porosis- related fracture of the wrist. The T-score in the spine should not be used to dissuade therapy, since it probably involves artifact and because the hip BMD is probably the preferential test in women of her age group or perhaps in all postmenopausal women. Therapy, in addition to general nutrition and exercise should be considered here and the treatment of choice is probably a bisphosphonate. This woman is not having any menopausal symptoms, so starting estrogens at this point in time after menopause would therefore not be the treatment of choice. And because she already had a wrist fracture and a low bone density in the hip, she is showing that she is at risk for nonvertebral fractures. The only drugs that clearly reduce nonvertebral fractures are the bisphosphonates, so she was started on alendronate 70 mg once weekly because that is the easiest and most practical regimen currently available for osteoporosis treatment.