Discussion: Hormone replacement therapy

PATIENT CASE Patient’s Chief Complaints “I’ve had back pain now for more than 5 weeks and I can’t stand it anymore. I’ve tried extra-strength ibuprofen, naproxen, and acetaminophen, and I’ve visited a chiropractor, but I don’t get any long-term relief.” History of Present Illness Mrs. I.A. is a very pleasant 63-year-old white woman of slight stature who has been referred to an orthopedic specialist by her PCP. She has been experiencing insidious back pain for 5–6 weeks. OTC analgesics provide temporary relief, but the pain is otherwise constant and aggravated by activity. She denies any obvious acute injury to her back, although she reports that she had a case of the flu with a prolonged and severe cough approximately one month ago. She also reports a vertebral fracture approximately five years ago. The patient has been an avid gardener for many years. Following the death of her husband 18 months ago, she has continued to live in her house and do all the household chores. Since her back pain began, she has been limited in her ability to do her household chores and gardening.

Past Medical History The patient entered natural menopause at 52 years and has never used hormone replacement therapy. Currently, she has mild hot flashes and vaginal dryness. At age 58, she suffered a vertebral fracture at T10 by simply carrying a shopping bag. DEXA scans conducted at that time revealed the onset of osteoporosis. Her bone mass density T-scores at that time were: −3.33 lumbar spine, −2.24 right femoral neck, and −2.44 right radius. These scans represented a 6.1%, 6.9%, and 6.2% decrease in bone mass density in the previous 19 months in the lumbar spine, right femoral neck, and right radius, respectively. Her serum calcium concentration was low-normal at 8.5 mg/dL and serum alkaline phosphatase level was moderately increased at 290 IU/L. She was prescribed alendronate and a calcium supplement daily. The patient was diagnosed with a seizure disorder at age 22 years and is currently well controlled with phenytoin. She has had asthma since childhood. Her current asthma medications include a bronchodilator that she uses when needed, a daily steroid inhaler, and an oral corticosteroid that she uses about four times per year for 3–6 weeks when symptoms worsen. She also takes a daily multivitamin tablet and has 1–2 dairy servings every day. She has noticed a slight reduction in height in recent years, but denies any significant changes in weight. She had an appendectomy at 11 years of age.

Patient Case Question 1. Following her vertebral fracture at T10, the patient was prescribed alendronate and calcium. Which additional pharmacotherapeutic agent should have been prescribed? Patient Case Question 2. At the time of her previous DEXA scans 19 months ago, was osteoporosis present in the spine, femur, and radius? Patient Case Question 3. Based on the information provided so far, which type or types of osteoporosis does this patient have? Discussion: Hormone replacement therapy

Family History The patient has a positive family history of osteoporosis. Her older sister has experienced a hip fracture and her paternal aunt was diagnosed with an osteoporosis-related wrist fracture following a fall. Her mother was diagnosed with breast cancer at age 56, but died from lung cancer at age 69. She also suffered from high blood pressure and “high blood sugar.” Her father died at age 54 from AMI. Her brother (age 65) has HTN and high cholesterol, and her younger sister (age 57) has no known medical problems. Social History The patient smokes four cigarettes a day (down from 1 ½ ppd eight years ago) and drinks one glass of wine daily. Her main sources of dietary calcium are milk with her breakfast cereal and “some” cheese about three times a week. The patient is widowed and was married for 39 years until the death of her husband 1 ½ years ago. She has one son who is healthy. She had a miscarriage at age 19. She does most of her cooking and “watches what she eats.” She denies non-compliance with her medications. She gets very little weight-bearing exercise. She uses SPF 30 sunscreen to protect herself from sunburn and skin cancer every time that she spends more than 15 minutes in the sun. Review of Systems The patient denies any unusual bleeding, weakness, back spasms, shortness of breath, chest pain, fever, chills, heat or cold intolerance, and changes in her hair, skin, and nails. She reports vaginal dryness, occasional hot flashes and night sweats “maybe once every 6 months.” Medications Alendronate 10 mg po QD Calcium carbonate 1.25 g (500 mg calcium) po BID Multivitamin tablet po QD Phenytoin 100 mg po TID Albuterol MDI 2 puffs BID PRN Triamcinolone MDI 2 puffs QID Prednisolone 5 mg po BID PRN

Allergies Codeine intolerance (nausea, vomiting) Sulfa drugs (rash) Aspirin (hives, wheezing) Cats (wheezing)

Patient Case Question 4. Which risk factors does this patient have that have made her susceptible to bone loss? Physical Examination and Laboratory Tests General The patient is an alert and oriented, cooperative 63-year-old white female of slight stature who walks with a normal gait and is in no apparent distress. She appears somewhat anxious. VS See Patient Case Table 79.1

Skin Fair complexion Color and turgor good No lesions

Head Normocephalic No areas of tenderness Slight hair thinning Eyes Conjunctiva clear PERRLA EOMI Funduscopic exam unremarkable Ears TMs pearly without bulging or retraction Throat Mucous membranes moist Clear without drainage or erythema Neck and Lymph Nodes No obvious nodes Thyroid non-tender without thyromegaly and no masses palpable (−) JVD No bony tenderness Full ROM without pain elicited Chest Normal chest excursion Clear to A & P Breasts WNL Mammography normal (3 months ago) Cardiac RRR (−) murmurs Normal S1 and S2 No S3 or S4 Abdomen Soft, NT/ND (+) BS (−) organomegaly or masses Genitalia/Rectum: Deferred Musculoskeletal/Extremities Good peripheral pulses bilaterally Point tenderness with palpation of bony prominence at L2 Limited flexion and extension of the back Significant lumbar lordosis Lateral bending unlimited and non-painful (−) kyphosis (−) deformity or swelling of joints Neurologic A & O × 3 Recent and remote memory intact Cranial nerves intact No focal motor deficits No gross sensory deficits DTRs 1 + and symmetric throughout Toes downgoing Patient Case Question 5. Which findings in the physical examination above are consistent with a diagnosis of osteoporosis

Discussion: Hormone replacement therapy

Patient Case Question 6. Is osteopenia or osteoporosis the appropriate diagnosis in the…

a. lumbar spine

b. right femoral neck

c. right radius

Spinal Radiographs

Significant radiographic lucency suggestive of poor bone density Recent compression fracture at L2 Healed compression fracture at T10 Thoracic vertebrae are wedge shaped, consistent with progressive osteoporosis Lumbar vertebrae are biconcave, consistent with progressive osteoporosis

Patient Case Question 7. Which single laboratory test in Table 79.2 was significantly high? Patient Case Question 8. Provide three reasons for this patient’s abnormal serum 25, OH-vitamin D concentration. Patient Case Question 9. Provide one good reason for why this patient is not taking hormone replacement therapy for vaginal dryness and hot flashes and as prophylactic therapy for post-menopausal osteoporosis. Patient Case Question 10. Distinguish between lordosis and kyphosis. Patient Case Question 11. Is this patient’s thyroid function normal or abnormal?

Patient Case Question 12. Is this patient’s parathyroid function normal or abnormal? Patient Case Question 13. Are there any indications that this patient also has type 2 osteoporosis?

Bruyere, Harold J.. 100 Case Studies in Pathophysiology (Kindle Locations 7221-7222). Wolters Kluwer Health. Kindle Edition.