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Case Study 1
A 57-year-old woman at risk
for osteoporosis
Patient profile
Ellen G. is a married, retired elementary
school teacher, aged 57 years. She is 5' 2"
in height and her weight is 124 lbs. She
has had two pregnancies with normal outcomes.
Her history includes a diagnosis of
Hashimoto's thyroiditis at age 40, for which
she currently takes levothyroxine sodium.
She was also diagnosed with multiple sclerosis
at age 40 and currently takes metaxalone
for musculoskeletal pain. At age 46,
she had bilateral breast biopsies; focal mild
atypia were found. She also has several small
uterine fibroids.
Ellen has been on continuous, combined hormone
replacement therapy (estradiol 1mg
plus medroxyprogesterone acetate 2.5mgqd)
since menopause at age 48. She also takes
calcium supplements and vitamin D. Like
many postmenopausal women taking HRT,
she reacted to the news of the Women's
Health Initiative results with concern. She
called her physician to discuss the discontinuation
of her HRT, as well as potential
alternatives to prevent bone loss. After discussion,
it was agreed that she should be
tapered off HRT. Her physician also recommended
a bone mineral density (BMD) test;
the results are shown in Table 1.
Discussion
Bone density measurements differ among
the various measurement technologies
used and, for that reason, actual bone mineral
density is not used for diagnosis.
Instead, standardized scores (T-scores or Zscores)
compare the patient's BMD with that
of a reference population of adults. The
result is expressed in standard deviations
(SD) above or below the mean BMD for that
population. According to World Health
Organization guidelines, osteoporosis is
defined as having a BMD > 2.5 SDs below
the mean for young adults. ABMD between
1 and 2.5 SDs below the mean is defined as
osteopenia, or low bone mass. Treatment
is currently recommended for women with
BMD T-scores < -2 if no additional risk factors
are present and < -1.5 if one or more
additional risk factors (especially prior
fractures) are present. Women with osteopenia
who do not meet these criteria may
also be candidates for treatment if they have
several risk factors. Ellen meets the criteria
for osteopenia at several skeletal points
and was clearly a candidate for treatment,
which was initiated with a once-weekly
bisphsophonate. She was not considered to
be a good candidate for raloxifene because
she continued to experience moderate-tosevere
vasomotor symptoms after HRT was
withdrawn. The therapy is well tolerated
and she continues to take supplemental
calcium and vitamin D.
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