Clinical:Case Study: Osteopenia and Osteoporosis

Original materials created in February 2001 by Charlea Massion, M.D.

PART I Little Blood? Think Low Bone

Case 1: Tara

Tara was initially seen for primary care at age 39 in 1993. She had had moderate depression for years, currently on fluoxetine and trazodone. In 1992 she had taken a thyroid supplement. Her thyroid function tests (TFTs) were normal before, during, and after treatment. Nonsmoker.

Gyn History

GII, PII. Menarche age 14. Menses were regular until age 32, then bleeding was irregular. In 1993 she had some light bleeding. No menopausal symptoms.

Exam: Complete PE with Pap and pelvic normal.

1993 Lab: FSH menopausal range. All normal: Ca, CBC, TFTs, parathyroid hormone, prolactin, serum vitamin D, serum protein electrophoresis, 24- hour calcium. Endometrial biopsy: normal proliferative tissue.

1993 bone density: T-score hip -2.5, spine -2.3.

Case 2: Diana

Initial evaluation at age 41 in 1992. She was a massage therapist with bilateral carpal tunnel syndrome. Had noted intermittent insomnia for years. Nonsmoker.

GYN History: GI, P0, TABI. Menarche age 13. Menses regular until her early 30s when irregular cycles began. Since age 37 had had one day light spotting twice/year.

Exam: Complete PE with Pap and pelvic normal.

1992 Lab: FSH normal. TFTs normal. Declined bone density evaluation or any further tests.

In 1994 had normal GYN exam and requested further endocrine and bone density evaluation.

1994 Lab: Normal results for all tests (including nl FSH) listed for Case #1 plus serum estradiol 39 (low normal).

1994 Bone density: T-score hip -0.6, spine -1.4.

Case 3: Hera

Initial PE in 1991 at age 51. Her most recent visit to any physician had been at age 39 when her menses ceased. Reports her exam was normal. Does not recall any testing — records unavailable. No therapy advised. After menses stopped, had some mild nausea and hot flashes that resolved.

Gyn History: Menarche age 13. GIV, PIV. Had regular menses until her late 30s.

Exam: Complete exam included Pap and pelvic which were normal.

In 1995 her oldest son committed suicide, and treatment centered around her grief reaction and subsequent chronic depression, successfully treated with sertraline and psychotherapy.

1996 bone density: T-score hip -1.2, spine -2.5.

Discussion

Osteoporosis is defined as “a systemic skeletal disease characterized by low bone mass and microarchitectural deterioration of bone tissue with consequent increase in bone fragility and susceptibility to fracture.” In 1994 the World Health Organization established categories for osteoporosis that focus on fracture prevention. Using bone mineral density testing, these are:

• Normal: BMD within 1.0 standard deviation
  (SD) of young adult mean.
• Osteopenia: BMD 1.0-2.5 SD below gendermatched,
  young adult mean.
• Osteoporosis: BMD 2.5 SD or more below
  gender-matched, young adult mean.

By this definition, 28 million US women currently have osteopenia or osteoporosis. Four out of five people with osteoporosis are women. Women over 50 have a 40% lifetime risk for fractures. Up to 20% of women die within a year of fracture.

Many women are more concerned about cancer risk than risk for osteoporosis. However, the lifetime risk of fracture is equal to the combined risk of developing endometrial, uterine, and ovarian cancer.

The National Women’s Health Network (NWHN) believes that the WHO criteria have created a disease rather than defining osteoporosis as a risk factor. The NWHN believes “the relationship between osteoporosis and bone fracture should be viewed more like the relationship between high cholesterol and heart disease. High cholesterol is described as a risk factor for heart disease, not the disease itself.” In this brief discussion, the controversies about the age for bone density screening of women without additional risk factors for osteoporosis will not be reviewed. Some studies indicate that screening women at age 65 may be more beneficial. The three women described above are at a higher risk for osteoporosis because their estrogen levels were diminished before the average age of menopause.

Treatment of Osteopenia/Osteoporosis:

Primary and secondary prevention of osteoporosis is non-pharmacologic. With the massive marketing of pharmacologic treatment to both physicians and consumers, this perspective has been marginalized. Maximizing peak bone density requires development of healthy eating habits and active lifestyles beginning during childhood and adolescence. The astute clinician should emphasize this

Exercise and Nutrition:' Two types of exercise increase bone density significantly: weight bearing (walking, jogging) and resistive(weight training/ vigorous water exercises). Regular exercise can increase BMD about 5% in one year. Women who walk have a 50% lower fracture risk.

Calcium and Vitamin D Requirements for Girls and Women

Age Calcium Vitamin D

9-18 years 13 mg 200 I.U.

19-perimenopause 1000 mg 200 I.U.

50-65 1500 mg 400 I.U.

50-65 on hormone tx 1000 mg 400 I.U.

Over 65 1500 mg 600 I.U.

Caffeine:

Excessive caffeine decreases bone mineralization

and increases renal excretion of calcium. Decrease to less than 2-5 cups/day. Smoking Cessation: Smoking is associated with lower bone mass. Smokers have earlier menopause and increased metabolism of estrogen and progesterone. Alcohol:

An association between alcohol use and

low bone density has been found in some studies. Alcohol may cause osteoblasts dysfunction and impair bone formation and mineralization. Consistent consumption of 1-2 drinks/day can reduce bone density.

Vision Screening

Fracture risk increases

with poor vision - the most common causes of poor vision in elderly women are cataracts or needing glasses or better glasses.

Fall Prevention

Fall prevention is critical

for decreasing fracture risk. Elderly patients with gait instability should use a cane or walker when ambulating, even in their own homes. Medications, such as tranquilizers and antidepressants can be risk factors for dizziness and falls. Inappropriate foot wear is a risk factor. Rubber-soled shoes may provide better footing outdoors, but can increase the risk of falling on carpets. Other factors such as poor lighting, slippery rugs, and other environmental factors are also important to assess. Hip pads have been shown to decrease fractures as much as pharmacologic treatment of osteoporosis. Clinicians have also observed that small, nervous dogs and grandchildren’s toys with wheels are understudied risk factors for falling.

References

1. Smith M. and Shimp L. Chapter 20: Osteoporosis in 20 Common Problems: Women’s Health Care, McGraw Hill 2000
2. Taking Hormones and Women’s Health: Choices, Risks, and Benefit Published by the National Women’s Health Network. Order at: 202-377-1140 or website http://www.womenshealthnetwork.org
3. “Prevention and Treatment of Osteoporotic Fractures” Lecture by Steven Cummings, M.D. UCSF “Controversies in Women’s Health” December 2000
4. Special Issue: Calcium Alternative Therapies in Women’s Health, Vol. 2, No. 4 April 2000, pg. 25-32. Call 800-688-2421 or www.ahcpub.com/online.html

Part II March 2001: Review of Pharmacologic Treatment and follow up on Tara, Diana, and Hera