A 53-year-old woman of white ethnicity comes to the office to discuss the results of her bone density test. She feels well but is very concerned about osteoporotic fractures as her mother passed away at age 81 after sustaining a hip fracture. The patient had menopause at age 50 and currently has no hot flashes or vaginal dryness. She eats a healthy diet and exercises at least 5 days a week with a combination of strength training and aerobic conditioning exercises. Medical history is unremarkable and her only medication is a daily over-the-counter vitamin D3 supplement (800 IU). She has never been married and has no history of pregnancy. The patient drinks a glass of wine every night and does not use tobacco or illicit drugs. In addition to osteoporosis, family history is positive for breast cancer in a maternal aunt. Vital signs are normal. BMI is 25 kg/m². Physical examination is unremarkable. Fasting laboratory and bone mineral density results are as follows: The 10-year probability of fracture calculated using the fracture assessment tool (FRAX) is 12% and 0.6% for a major osteoporotic fracture and a hip fracture, respectively. Mammogram a year ago was normal. Which of the following is the most appropriate next step in management of this patient's low bone density?

Question

Quizplus · Accepted Answer

Explanation: 11ec2b69_bed5_1a9a_8f63_4167cee2fcaf_MD0005_00 Screening for osteoporosis by DXA is recommended for women age >65 and for postmenopausal women age <65 who have additional risk factors for osteoporosis (eg, low body weight, current smoking, family history of hip fracture, use of glucocorticoids). Postmenopausal women should also be counseled on preventive measures, including regular weight-bearing exercise and adequate intake of calcium and vitamin D. In addition to these general measures, bone-specific pharmacotherapy with bisphosphonates (eg, alendronate) is indicated for patients who have: Low bone mass with a history of fragility fracture Bone density criteria for osteoporosis (T-score <−2.5 on DXA) Osteopenia (T-score between −1 and −2.5) with a 10-year probability for major osteoporotic fracture >20% or hip fracture >3% based on the FRAX risk calculator This patient has osteopenia, but her fracture risk is much lower than the threshold to recommend bisphosphonate therapy (Choice C). However, most experts recommend periodic (eg, every 3-5 years) reassessment with DXA for postmenopausal women with osteopenia. (Choice B) Excessive alcohol intake (>3 drinks/day) is associated with increased fracture risk. However, this patient's moderate intake is not associated with an increased risk of fractures. (Choice D) Menopausal hormonal therapy (estrogen or combined estrogen/progestin therapy) is associated with a decreased risk of hip and vertebral fracture. However, it carries an increased risk for breast cancer, stroke, and venous thromboembolism and is generally advised only for women who have intolerable menopausal symptoms (eg, hot flashes). (Choice E) Selective estrogen receptor modulators (eg, raloxifene) can be considered as an alternate to bisphosphonates for treatment of osteoporosis in women who are at increased risk for breast cancer. However, this patient does not require additional therapy, and these medications are associated with an increased risk of venous thromboembolism. Educational objective: Bisphosphonate therapy is indicated for postmenopausal women with: Low bone mass with a history of fragility fracture Osteoporosis (T-score <−2.5 on DXA) Osteopenia (T-score between −1 and −2.5) and a 10-year probability for major osteoporotic fracture >20% or hip fracture >3% based on the fracture assessment tool (FRAX) risk calculator References: Evaluation and treatment of osteoporosis. (http://www.ncbi.nlm.nih.gov/pubmed/27235616) Clinical practice. Postmenopausal osteoporosis. (http://www.ncbi.nlm.nih.gov/pubmed/26789873)

A 53-Year-Old Woman of White Ethnicity Comes to the Office