Atypical Presentation: Case Study
A 56-year-old White woman presents for her annual screenings. She is in excellent health and does not take any medications (weight, 59.9 kg; BMI 20; menses cessation, age 52). She reports engaging in regular daily exercise, plays golf, and sees a trainer to guide a weight lifting regimen. She requests a dual-energy x-ray absorptiometry densitometry (DXA) scan. She has requested this screening in previous years but was told she was either too young or not at high risk. The patient denies smoking, alcohol use, a history of autoimmune disease, a family history of osteoporosis, glucocorticoid use, or previous fragility fracture (a fracture of the wrist, arm, pelvis or femur sustained while standing). The patient reports that her menarche was late (age 16) and that she only developed regular menses after the birth of her first child at age 26. As an 18-year-old, she dieted and lost 33 pounds from her 5’8” frame, reaching 108 pounds. In her early 20s, she regained some weight, reaching approximately 125 pounds. Her laboratory findings from her late 40s, although always normal in other areas, demonstrate very high follicle-stimulating hormone levels and menopausal levels of estrogen while she was still menstruating. The DXA scan is performed and yields a T-score of –4.2 for the lumbar spine and –2.6 for the left femoral neck. She is given the diagnosis of severe osteoporosis. Vertebral radiographs show the patient has no vertebral compression fractures, indicating that with prompt medical therapy she likely will be able to avoid future fragility fractures.
Treatment of Osteoporosis
The cornerstone of osteoporosis prevention and treatment remains patient education and long-lasting lifestyle habits. Early intervention and healthy lifestyle education should occur well before the menopausal transition. Women of all ages need to be informed about the importance of daily exercise, moderate sun exposure, adequate calcium and Vitamin D intake, as well as limited alcohol and soft drink consumption to promote healthy bones later in life.5,6 All postmenopausal women should be getting 1200 mg/d of calcium, primarily from food sources, and 800 to 1000 IU/d of vitamin D.11
Encouraging patients of all ages to engage in weight-bearing exercise and balance, strength, and endurance training is vital to reduce the risk for falls and associated fractures. Regular walking as exercise has been shown to reduce hip fracture by 30%.16 Regular weight-bearing exercises such as Pilates and Tai Chi have been associated with a decrease in falls due to bone loss as well as improvement in BMD, flexibility, balance, posture, and overall health.17
A healthy diet, high in fruits and vegetables, whole grains, poultry, fish, nuts and legumes, and low-fat dairy products, has been shown to be associated with improved bone health and reduced fracture rates.18
When to Prescribe Medications
For women with osteopenia, practitioners must decide whether to prescribe bisphosphonate treatment, balancing the benefits and harms. Women with osteopenia who are younger than 65 years and those who are older than 65 years and have mild osteopenia.
(T-scores between –1.0 and –1.5) will benefit less from medical therapy than older women with osteopenia (T-scores < –2.0).14 Only 10% of women with mild osteopenia develop osteoporosis within 15 years, and 10% of women with advanced osteopenia (T-score –2.0 to –2.49) develop osteoporosis within 1 year.14 The decision to treat osteopenia should consider a patient’s DXA scores, age, family history, and whether or not they have sustained a fragility fracture. Calculating a FRAX score for all postmenopausal women older than 50 years of age is the first step in determining risk stratification, possible DXA scanning, and the need for medical therapy (Table 4).11
Treatment should be patient centered, with practitioners and patients setting reasonable mutual goals. All medications should be given only after a thorough workup to identify any secondary causes of bone loss. Secondary causes of osteoporosis are numerous and include hypogonadal states, genetic, endocrine, hematologic, rheumatologic, and autoimmune diseases, and musculoskeletal risk factors.11
Bisphosphonates remain the first-line treatment for most men and women who are at high risk for hip and vertebral fractures.19 There are a number of commercially available bisphosphonates on the market: alendronate, alendronate/cholecalciferol, ibandronate, risedronate, zolendronic acid. They are available as oral medications (effervescent tablets, tablets, or solution) or injections.19 The antiresorptive effects of a bisphosphonate are maintained in the bone for years after a patient stops taking the drug.20 After 3 to 5 years of therapy, a drug holiday should be considered, with close follow up of BMD.