A 53-year-old woman comes to the physician for her annual health care visit. Her last menstrual period was 1 year ago. She initially had hot flashes which have gradually subsided. Her past medical history is unremarkable. The patient takes no medications, vitamins, or herbal supplements. She does not smoke or drink alcohol. Her father has premature coronary artery disease. There is no history of cancer or osteoporosis in her family. She jogs and does weight-training exercises for up to 1 hour daily. Her mammogram and pelvic exam were normal last year. The patient's vital signs are normal and her physical examination is unremarkable. Which of the following is the best next step in management of this patient?

Question

A 53-year-old woman comes to the physician for her annual health care visit.  Her last menstrual period was >1 year ago.  She initially had hot flashes which have gradually subsided.  Her past medical history is unremarkable.  The patient takes no medications, vitamins, or herbal supplements.  She does not smoke or drink alcohol.  Her father has premature coronary artery disease.  There is no history of cancer or osteoporosis in her family.  She jogs and does weight-training exercises for up to 1 hour daily.  Her mammogram and pelvic exam were normal last year.  The patient's vital signs are normal and her physical examination is unremarkable.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c0b4_13c0_8f63_5d212c78c872_MD0005_00 Menopause is an important risk factor for osteoporosis; most women lose considerable bone mass rapidly as estrogen declines after this period. The first step in prevention or treatment of osteoporosis is good nutrition and exercise. Adequate calcium and vitamin D intake is essential as calcium is the primary mineral in bone, and vitamin D facilitates intestinal calcium absorption. The recommended dietary allowance (RDA) for calcium is 1200 mg per day and is not to exceed 2000 mg per day. The RDA for vitamin D is 600-800 international units (IU) and is not to exceed 4000 IU per day. Dietary sources of calcium include milk, yogurt, and dark green leafy vegetables. Sources of vitamin D include milk and sunlight. Regular weight-bearing and anti-gravity exercises (eg, walking, hiking, jogging) also help maintain bone density. Supplements may be used to meet the RDA if the patient is unable to meet dietary and sunlight goals. However, dietary sources are preferred due to potential adverse effects of supplements. Side effects of excessive calcium and/or vitamin D intake include hypercalcemia, hypercalciuria, and nephrolithiasis (kidney stones). (Choice A) Hormone replacement therapy is used for menopausal symptoms (eg, hot flashes, vaginal dryness). It was previously used to prevent diseases such as osteoporosis and coronary artery disease but the current consensus is that the risks (eg, breast cancer, coronary artery disease, stroke, venous thromboembolism) outweigh the potential benefits. (Choices B and D) Bone density screening should begin at age 65 in women without risk factors. Postmenopausal women age <65 may be screened if they have risk factors such as body weight <58 kg (127 lb), chronic steroid use, smoking, malabsorptive disorders (eg, pancreatic insufficiency in cystic fibrosis), and parental history of hip fracture or personal history of low-impact fracture. Bone antiresorptive agents (eg, bisphosphonates, raloxifene) are approved for osteoporosis prevention in high-risk women. However, this patient is not at high risk and does not require further workup or prophylaxis. (Choice E) Routine vitamin D measurement is not recommended. Patients with osteoporosis or multiple risk factors (eg, chronic steroid use) should be evaluated for vitamin D deficiency. Educational objective: Adequate calcium and vitamin D intake is important for osteoporosis prevention. Dietary intake should be encouraged as vitamin supplements have increased risk of adverse effects. References: ACOG Practice Bulletin, No. 129 Osteoporosis (http://www.ncbi.nlm.nih.gov/pubmed/22914492) Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men. (http://www.ncbi.nlm.nih.gov/pubmed/24729336) Vitamin D and calcium supplementation to prevent fractures in adults: U.S. Preventive Services Task Force recommendation statement. (http://www.ncbi.nlm.nih.gov/pubmed/23440163)

A 53-Year-Old Woman Comes to the Physician for Her Annual