MEDizzy - A 54-year-old woman is referred to the endocrinology clinic

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A 54-year-old woman is referred to the endocrinology clinic for evaluation of osteoporosis after a recent examination for back pain revealed a compression fracture of the T4 vertebral body. She is perimenopausal with irregular menstrual periods and frequent hot fashes. She does not smoke. She otherwise is well and healthy. Her weight is 70 kg, and height is 168 cm. She has lost 5 cm from her maximum height. A bone mineral density scan shows a T-score of –3.5 standard deviation (SD) and a Z-score of –2.5 SD. All of the following tests are indicated for the evaluation of osteoporosis in this patient EXCEPT:

ExplanationOsteoporosis is a common disease afecting 8 million women and 2 million men in the United States. It is most common in postmenopausal women, but the incidence is also increasing in men. Estrogen loss probably causes bone loss by activation of bone remodeling sites and exaggeration of the imbalance between bone formation and resorption. Osteoporosis is diagnosed by bone mineral density scan. Dual-energy x-ray absorptiometry (DXA) is the most accurate test for measuring bone mineral density. Clinical determinations of bone density are most commonly measured at the lumbar spine and hip. In the DXA technique, two x-ray energies are used to measure the area of the mineralized tissues, and results are compared to gender- and race-matched normative values. The T-score compares an individual’s results to a young population, whereas the Z-score compares the individual’s results to an age-matched population. Osteoporosis is diagnosed when the T-score is –2.5 standard deviations (SD) in the lumbar spine, femoral neck, or total hip. An evaluation for secondary causes of osteoporosis should be considered in individuals presenting with osteoporotic fractures at a young age and those who have very low Z-scores. Initial evaluation should include serum and 24-hour urine calcium levels, renal function panel, hepatic function panel, serum phosphorous level, and vitamin D levels. Other endocrine abnormalities including hyperthyroidism and hyperparathyroidism should be evaluated, and urinary cortisol levels should be checked if there is a clinical suspicion for Cushing syndrome. FSH and LH levels would be elevated but are not useful in this individual because she presents with a known perimenopausal state.