A 65-year-old woman comes to the office due to concerns about her risk for osteoporotic fractures. She reports that her sister takes medication for osteoporosis. Medical history is notable for hypothyroidism treated with levothyroxine and hypertension treated with hydrochlorothiazide. The patient underwent hysterectomy with salpingo-oophorectomy at age 51. She has a 10-pack-year history of cigarette smoking but quit at age 40, and she drinks 2 or 3 glasses of wine a week. Vital signs are normal. BMI is 23 kg/m². Examination of the heart, lungs, and abdomen is normal. Pelvic examination shows vaginal atrophy. Laboratory evaluation is normal. DXA reveals a T-score of −2.5 at the lumbar spine and −1.9 at the femoral neck, which is consistent with osteoporosis. In addition to calcium and vitamin D supplementation, which of the following is the most appropriate treatment for this patient?

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11ec25c8_d2f7_ba4c_bc81_199cea87b28f_MD0003_00 This woman has multiple risk factors for osteoporosis, including age ≥65, menopausal status, smoking history, and family history of osteoporosis. Her screening DXA shows a T-score of −2.5, which is consistent with osteoporosis. Initial management should address lifestyle factors including regular weight-bearing exercise, avoidance of tobacco and excessive alcohol use, and adequate intake of calcium and vitamin D (using supplements as needed). In addition, women with osteoporosis confirmed by DXA (ie, T-score ≤−2.5) or with an osteoporotic fragility fracture warrant pharmacologic antiresorptive therapy. Antiresorptive therapy is also appropriate for patients with osteopenia (T-score between −1 and −2.5) who are at high risk for fragility fracture. First-line treatment for most patients with postmenopausal osteoporosis is a bisphosphonate (eg, alendronate, risedronate). Bisphosphonates preserve bone density and decrease the risk of vertebral and hip fracture. After initiation, bone density is typically remeasured after 2 years to assess the response to therapy. Most experts recommend discontinuation after 5 years due to a risk of atypical fracture with prolonged use. (Choice A) Nasal calcitonin has relatively modest antiresorptive properties and is not recommended as first-line treatment for osteoporosis. However, it often has benefits for pain relief in patients with osteoporotic fracture. (Choice B) This patient has confirmed osteoporosis, warranting bisphosphonate therapy. Follow-up testing is typically performed within 2-5 years; shorter testing intervals (eg, 1 year) are used primarily for patients with accelerated bone loss (eg, glucocorticoid therapy). (Choice D) Raloxifene is a selective estrogen receptor modulator. Compared with bisphosphonates, it has relatively weak effects in maintaining bone density. However, it is associated with a decreased risk for breast cancer and may be useful in women with mild osteoporosis but elevated risk for breast cancer. (Choice E) Estrogen replacement therapy has moderate benefits in maintaining bone density but is associated with an increased risk for breast cancer. It is recommended primarily for women with severe vasomotor symptoms (eg, hot flashes) and low risk for breast cancer. This patient's vaginal mucosal atrophy is a common finding in postmenopausal women and does not warrant estrogen therapy in the absence of significant symptoms. Educational objective: Bisphosphonates (eg, alendronate, risedronate) are the first-line treatment for most women with postmenopausal osteoporosis. After initiation, bone density is typically remeasured after 2 years to assess response to therapy. Treatment is usually discontinued after 5 years due to a risk of atypical fracture with prolonged use.

A 65-Year-Old Woman Comes to the Office Due to Concerns