Was Mrs. W's back pain preventable?
Mrs. W, age 70, presented with chronic back pain that had been worsening over the past few months. The pain was now so severe that it was difficult for her to get out of bed. She thought the problem might be arthritis.
Mrs. W had a natural menopause at age 51 years and had never used HRT or a bisphosphonate. When asked during history-taking about height loss, the patient said she felt she might be shrinking, as her pants seemed too long for her legs. She noted increasing protuberance of her abdomen, which she felt also contributed to ill-fitting clothes. Her perception that she was getting shorter was objectively documented by a 3-inch height loss since her last exam four years ago.
Her family history was remarkable for maternal hip replacement at age 72 because of osteoporosis and intermittent, nearly lifelong glucocorticoid use for chronic asthma.
Bone scans—now and then
Mrs. W was sent home on pain medication while she awaited dual energy x-ray absorptiometry (DEXA) and back x-ray the following week. Compared with a DEXA scan from four years ago, the current results showed that she was osteoporotic, having had an 8% bone mineral density loss in her lumbar spine and a 10% loss in her pelvic bone. The back x-ray revealed a fracture at L-3.
When she returned for her follow-up visit, we told Mrs. W that her pain was caused by an osteoporotic vertebral fracture. However, we reassured her that it wasn't too late to stop the rapid bone loss and prescribed a monthly oral bisphosphonate. Unfortunately, Mrs. W stopped taking the medication after three months, when the pain had improved to only a dull ache.
A noncompliant patient
Two months after stopping the medication, Mrs. W got out of bed at an unusual strained angle. The twisting motion this caused triggered a severe pain that almost caused her to lose consciousness. Her husband brought her to the emergency department, where she was admitted for pain control. Lumbar x-ray revealed another fracture.
During rounds, the patient was asked why she had stopped her bisphosphonate. Her reasoning was that she had already suffered a fracture and height loss, and she felt there was nothing more that could be done for her osteoporosis. Moreover, since the medication caused occasional stomach upset, she was better off being shorter than having GI problems.
We also learned that Mrs. W thought she was getting enough calcium every day, since she consumed at least half a cup of milk with her cereal at breakfast and a one-serving container of yogurt with lunch. On further questioning, Mrs. W admitted that she never ventured out into sunlight for fear of developing skin cancer.
Mrs. W's bedside history prompted a consultation with a nutritionist, who determined that our patient's daily calcium intake was <750 mg and her vitamin D intake was <200 IU. These deficiencies along with her failure to continue the bisphosphonate contributed to her extensive bone loss. Putting her at even greater risk was a sedentary, relatively inactive lifestyle that involved quiet activities, such as watching television, playing cards, and reading.
An informed patient
Our patient was immediately put back on her bisphosphonate before hospital discharge, and the importance of taking the medication consistently and correctly without missing doses was stressed. In addition, she was told that the bisphosphonate couldn't build bone if it didn't have the proper building materials, and she was counseled on ways to increase her calcium and vitamin D intake. The nutritionist recommended a daily calcium intake of 1,200-1,500 mg and 800 IU of vitamin D.
For healthier living
Life after menopause is filled with new opportunities and new freedoms. Unfortunately, declining hormone levels also leave menopausal women open to some increased health risks. One of these is osteoporosis, which may cause painful fractures leading to a loss of mobility, independence, and self-esteem. With a little attention to diet and lifestyle, patients can slow or prevent this debilitating bone loss.
Calcium. The recommended daily amount of calcium in patients at risk for osteoporosis is 1,200-1,500 mg. If dietary calcium is inadequate, supplements should be taken in divided doses of 500 mg each. Single large doses, i.e., >500 mg, may not be absorbed from the stomach as efficiently as smaller doses. Calcium carbonate is inexpensive and easy to remember because it can be taken with meals. However, calcium citrate, while more costly than carbonate, does not require an acidic stomach for optimum absorption and can be absorbed even when taken with acid-suppressing drugs. Other calcium-delivery systems are also available (e.g., chewable, pills to swallow, liquid, and a candy form).
Vitamin D. It is recommended that perimenopausal women consume 800 IU of vitamin D daily to increase their calcium absorption. Vitamin D is available in eggs and in fortified products, such as milk and breakfast cereals. In addition, exposure to sunlight for 15 minutes a day will boost the body's own production of vitamin D. Patients who do not consume adequate amounts of vitamin D or get enough sun exposure should take supplements.
HRT. Hormone replacement is effective for providing short-term relief of menopausal symptoms; it can also increase estrogen levels. Estrogen improves calcium absorption and reduces the amount of calcium lost in the urine. Women may use low-dose estrogen therapy for bone-loss prevention. Physical activity. A sedentary lifestyle can contribute to osteoporosis risk. Experts recommend walking at least 10 minutes a day.
Health care. Regular monitoring of bone health is important. It includes annual follow-up visits with a clinician and biannual DEXA.
Mrs. W exemplifies the typical patient who does not understand the full implication of bone loss. Such patients are often noncompliant with their antiresorptive drug because they don't like the side effects and don't realize the importance of being persistent with taking the medication despite those effects. Moreover, many patients don't know that the 300 mg of dietary calcium provided by one cup of milk is far below the recommended daily adult requirement.
Many patients require a calcium supplement. It's vital, too, to remember the critical importance of vitamin D in the diet or as a supplement in populations with minimal exposure to the sun. This requirement is often forgotten in older populations. Last, some regular weight-bearing exercise is an important part of a bone-healthy and heart-healthy lifestyle. Armed with her newly acquired knowledge, Mrs. W could look forward to better bone health.