A 65-year-old woman comes to the office to discuss the results of a screening DXA test. She has been healthy all her life, has no chronic medical conditions, and takes no medications. The patient experienced menopause at age 52; she was treated with combined estrogen/progestin menopausal hormone therapy due to hot flashes but discontinued the treatment after a few months due to concerns regarding adverse effects. She has experienced a 1 cm (0.4 in) loss of height since that time. The patient quit smoking 30 years ago and drinks wine only on social occasions. She lives alone and has no children. Her mother died of breast cancer at age 56 and her father died at age 82 from a stroke.
BMI is 22 kg/m². Physical examination is unremarkable.
DXA reveals a T score of −2.1 and −2.6 at femoral neck and lumbar spine, respectively. Complete blood count, comprehensive metabolic panel, and serum phosphorus are normal.
Which of the following additional investigations should be performed for this patient at this time?

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11ec193a_97d0_2225_853d_b7040720391c_MD0002_00 Osteoporosis is a common disorder in postmenopausal women. It has a long asymptomatic phase, and treatment can reduce the risk of fracture in patients with osteoporosis. It is therefore an ideal subject for a routine screening program. Screening for osteoporosis by DXA is recommended for women age ≥65, and for younger women with significant risk factors (eg, prior low-trauma fracture, long-term glucocorticoid use, low body weight). Screening DXA is typically performed at the lumbar spine and hips; a T score ≤−2.5 at any location is consistent with osteoporosis. Osteoporosis is most commonly due to age-related bone loss, which accelerates following menopause in most women. However, patients with a new diagnosis of osteoporosis warrant a basic laboratory evaluation for reversible secondary causes. Typical studies include serum chemistries (eg, calcium, phosphorus, albumin, total protein, and renal and hepatic function markers) and complete blood count. In addition, vitamin D stores should be assessed with a 25-hydroxyvitamin D level. Intake of adequate amounts of vitamin D and calcium helps reduce bone loss. (Choice A) Many experts advise measurement of 24-hour urine calcium excretion, especially in women who are likely to have inadequate intestinal absorption of calcium (eg, malabsorptive syndromes) or signs of excess calcium excretion (eg, kidney stones). However, this should be performed only after correction of vitamin D deficiency, and patients should have adequate intake of calcium (1,000-1,200 mg/day) for 2 weeks prior to the test. (Choice C) Spinal imaging (eg, lateral spine x-ray) is indicated for patients with low bone density who are most likely to have vertebral fracture, including women age ≥70 (men age ≥80), loss of height >4 cm, self-reported vertebral fracture, and systemic glucocorticoid therapy >3 months. This patient's minimal loss of height does not require imaging. (Choice D) Patients with a new diagnosis of osteoporosis warrant a basic laboratory evaluation for reversible secondary causes. (Choice E) Serum protein electrophoresis is indicated in patients with evidence of a possible plasma cell dyscrasia (eg, multiple myeloma), such as anemia, renal insufficiency, hypercalcemia, or proteinuria. Educational objective: Patients with osteoporosis warrant laboratory testing for reversible secondary causes. The evaluation should include serum chemistries (eg, calcium, phosphorus, albumin, total protein, and renal and hepatic function markers) and complete blood count. In addition, vitamin D stores should be assessed with a 25-hydroxyvitamin D level. __________ References: Clinician's guide to prevention and treatment of osteoporosis (http://www.ncbi.nlm.nih.gov/pubmed/25182228) American Association of Clinical Endocrinologists and American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis. 2016 executive summary. (http://www.ncbi.nlm.nih.gov/pubmed/27643923)

A 65-Year-Old Woman Comes to the Office to Discuss the Results