recognize and reduce the risk of its developing. What Is ... bone mass sufficient to increase the risk of fracture. In a ... During the years of growth and for several years after- wards ..... C-21 progestogens adversely affect high- and low-density.
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A Practical Guide to Preventing Osteoporosis BRUCE ETTINGER, MD, San Francisco
Physicians should advise women reaching menopause about the risk of osteoporosis and what practical steps can be taken to reduce this risk. The average woman at menopause can expect to live to be 80 years old; during these years she will face a 15% risk of hip fracture and a 10% risk of vertebral fracture. These risks are increased in Asians and whites, in women who are short and thin, and in those with poorly developed musculature. General advice regarding the correction of certain unhealthy habits and changes in life-style may enhance skeletal health, but prompt restoration and long-term maintenance of physiologic levels of estrogen remain the only proved effective way of reducing bone loss and the risk of fracture. (Ettinger B: A practical guide to preventing osteoporosis, In Women and Medicine [Special Issue]. West J Med 1988 Dec; 149:691-695)
W idespread media exposure and intense commercial interest have heightened women's awareness of menopausal health issues. Many women are alarmed by the media's portrayal of osteoporosis as the "hidden epidemic" or the "great crippler." They may hear conflicting advice on the value of various preventive strategies. More than ever before, physicians are being asked to provide sound advice on the prevention of osteoporosis. The purpose of this review is to enhance practicing physicians' ability to provide necessary and practical information about osteoporosis: its etiology, its potential effect on women's health, and what can be done to recognize and reduce the risk of its developing.
What Is Osteoporosis? Osteoporosis is most easily understood as a reduction in bone mass sufficient to increase the risk of fracture. In a number of ways, osteoporosis is similar to hypertension. Both are common and both are asymptomatic; yet, left untreated, both can increase the risk of the development of serious clinical consequences, such as stroke and hip fracture. Furthermore, both conditions can be diagnosed at an early stage by relatively simple and safe measurements, allowing interventions that will alter the risk of a serious outcome.
Is Osteoporosis Worth Preventing? Although everyone would agree that strokes are serious and frequent enough to warrant widespread screening for and treatment of hypertension, many physicians and patients do not regard the threat of osteoporotic fracture serious and immediate enough to warrant prophylactic measures. Most articles on osteoporosis quote grim statistics: 1.5 million fractures occur each year among elderly women (including more than 250,000 hip fractures, which have a high mor-
bidity and a 15 % mortality); a third of women aged 65 years
or older will suffer vertebral and wrist fractures; the annual cost of fracture treatment in the United States is $6 to $8 billion. While these statistics are accurate, they appear to have little influence on physicians' choices to use estrogen, an effective prophylaxis.' Many women of menopausal age, when learning of their 15 % lifetime risk of hip fracture, may initially be concerned, but they may be reassured by the knowledge that two thirds of these fractures will occur after age 75 years. About a third of hip fracture victims will lose their independence for at least six months, and, for many, the fracture will mark the beginning of a progressive infirmity. Even the wrist fractures caused by osteoporosis may make self-care difficult for elderly women who live alone. Fortunately, wrist fractures heal completely within three to six months and carry no long-term disability. The impact of vertebral deformities is minimal for the vast majority of women. Although a wedge deformity of at least one vertebra may develop in 40% of women, the lifetime risk of a woman suffering a true compression fracture is only about 10%. The best estimates are that only 1 of every 100 vertebral deformities creates sufficient symptoms to require medical attention. Although commonly shown in advertisements, severe thoracic kyphosis, which is caused by multiple vertebral wedges and compressions, is, fortunately, a rare occurrence. In a study of physical and psychosocial consequences of vertebral deformities,2 we found significant disabilities only in women with more than one severe vertebral deformity. The discomfort and disability of kyphosis are related to the postural change, which causes muscle strain in the lower back. Even in such cases, the back has an excellent capacity to adjust to its new shape, and any disability may be self-limited. Although osteoporotic fractures create a major drain on our health resources, and although the number of fractures will increase with the "graying of America," one can understand the average menopausal woman's lack of concern. She
From the Department of Internal Medicine, Kaiser Permanente Medical Center, San Francisco. Dr Ettinger is Clinical Professor of Medicine at the University of
California, San Francisco, School of Medicine.
Reprint requests to Bruce Ettinger, MD, Department of Internal Medicine, Kaiser Permanente Medical Center, 2200 O'Farrell St, San Francisco, CA 94115.
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would rather take on an increased risk of fracture in the future than begin a long-term prevention program that requires compliance with possibly inconvenient or bothersome dietary, exercise, and pharmacologic regimens. Some women, however, are at a greatly increased risk of having osteoporosis develop. By identifying these selected women early, a concentrated effort can be made to educate and encourage them to follow recommended preventive strategies.
Achieving Peak Bone Mass During the years of growth and for several years afterwards, the skeleton accretes mineral. Peak skeletal mass, largely determined by genetic influence, is reached between ages 20 and 30 years. Certain environmental factors may alter peak bone mass; diet and exercise have been under intense investigation. Children growing up in an area of low calcium intake had lower bone mass than those having a high calcium intake because of a ready access to dairy foods.3 Women 25 to 35 years of age who exercised actively and whose calcium intake-achieved by calcium supplementation-was high had greater skeletal mass than sedentary women whose calcium intake was low.4 The daily skeletal calcium accretion during peak growth years averages 150 to 200 mg, while the average fractional gastrointestinal absorption of calcium is 25 %. For these reasons, the average growing child should ingest at least 800 mg daily. The Recommended Daily Allowance for calcium to meet the needs of the vast majority of children is 1,200 mg. Although calcium deficiency should be avoided at any age, little evidence exists that a high calcium diet has any bone-building effect. Muscle mass has been shown to correlate closely with bone mass; both are lost concurrently with aging. In healthy young people, strategies for increasing muscle mass have been shown to increase bone mass.5 Although various exercise regimens may augment bone mass during the period of training, it is not known what portion of the added skeletal mass will be maintained once intensive training has ceased. Other possible strategies for developing high peak bone mass include avoiding smoking and drinking. Pregnancy and using oral contraceptives both appear to correlate with a higher bone mass.
Prevention of Bone Loss Estrogen Replacement Therapy Women experience a slow, age-related bone loss after 35 years of age but have accelerated bone loss whenever estrogen deficiency develops. This loss is greatest in trabecular bone but occurs throughout the skeleton. The cause and severity of the estrogen deficiency can modify the rate of bone loss; for example, spinal mineral loss after an oophorectomy is about 50 % greater than that seen after spontaneous menopause. Restoring normal estrogen levels is an effective strategy to prevent bone loss in women. Numerous studies have documented the protection provided by estrogen replacement,6'0 and the dose response of several formulations has been defined. Regardless of the estrogen preparation or the route of administration, a serum estradiol level of 184 to 220 pmol per liter (50 to 60 pg per ml) assures protection. This is the level noted during the follicular phase of the normal menstrual cycle and the level associated with the alleviation of menopausal symptoms. Effective dosages of the commonly used estrogen preparations are conjugated estrogens, 0.625 mg a day6; micronized 17,B-estradiol, 1.0 mg
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a day 11; and transdermal 17f-estradiol, 0.05 .8 In a prospective study, Lindsay and co-workers compared the use of estrogen with that of placebo in women who had had an oophorectomy.9 Bone mineral levels fell progressively in the placebo group, whereas estrogen use prevented losses. After ten years of study, the structural integrity of the spine was significantly better in estrogen users. A retrospective study of 245 long-term estrogen users yielded additional evidence of estrogen's protection. 10 Compared with carefully matched controls, estrogen users suffered halfas many wrist and spine fractures for an average duration of 18 years. Bone mineral content measured at several skeletal sites was significantly greater in estrogen users, varying from 50% greater spinal trabecular mineral to 15 % to 20% greater peripheral cortical bone. Recently, technologic advances have allowed the quantitation of bone mass at the hip; a number of reports now confirm that estrogen use has a similar protective effect on bone mass at this site. It is more difficult to prove that using estrogen prevents hip fractures. Most women suffering hip fractures are older than 75 years, and few women in this age group have used estrogen regularly. Epidemiologists have circumvented this difficulty by applying case-control methods to the relationship of hip fracture and estrogen use. A review of the results of five case-control studies compared estrogen use in 590 patients with hip fracture and 2,021 controls without fracture. 10 The average risk ratio was 0.4, indicating an inverse relationship between estrogen use and hip fracture. A reasonable conclusion is that estrogen protects against fractures of the hip, reducing the risk by half. The incidence of hip fracture in the Framingham cohort was recently reported." The women who used estrogen had a significantly lower risk of fracture, similar to the degree of protection observed in case-control studies. Those who began estrogen therapy at menopause had the greatest degree of protection, but even those who began using estrogen later in life showed some
benefit. The timing and duration of estrogen therapy are important considerations. Even a few years before menopause, women have reduced estradiol levels and bone loss.'2 The spine may suffer a 5% to 10% loss during this transitional period. 13 Most experts agree that estrogen therapy could be initiated in a woman who is at high risk for osteoporosis and who shows signs of dwindling ovarian function (most reliably indicated by irregular menses, vasomotor symptoms, and an elevated level of follicle-stimulating hormone). Is there a time when it is too late to initiate estrogen therapy? Several factors come to bear on this decision. First, most postmenopausal bone loss occurs within ten years following estrogen deprival, after which the rate ofbone loss spontaneously slows. Second, estrogen administration merely prevents further loss; it does not rebuild the skeleton. Thus, beginning estrogen therapy for an elderly woman who has lost a third or more of her skeletal mass is less worthwhile than for a recently menopausal woman. Furthermore, evidence suggests that bone loss occurring 15 or more years after menopause has a different cause than that occurring soon after menopause. For this reason, later losses-socalled age-related rather than estrogen-dependent-may be prevented more easily by increasing calcium intake and enhancing its absorption. A regimen of calcium and low-dose vitamin D supplements is more acceptable to patients who are elderly and have never used estrogen.
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Finally, women want to know how long to continue taking estrogen. Epidemiologic studies can show a significant reduction in fracture risk in women who have used estrogen
than five years. Because the incidence of hip fracture doubles every five years, there should be a halving in the number of fractures in a population of women who had used estrogen for five years. On the other hand, once estrogen therapy is stopped, a rapid eroding of bone mass can follow. Also, epidemiologic studies have found a trend toward a slightly increased risk of breast cancer in women who have used estrogen for 20 or more years. 4' 15 Because of this risk, and because some elderly women find estrogen replacement inconvenient, I usually discontinue or modify it once a woman reaches the age of 65 years. At that time, reasonable alternatives include changing to a lower dosage or administering the estrogen vaginally. Estriol, a much less potent estrogen, is the usual form of estrogen prescribed to elderly women in Europe. more
Calcium Supplements The fear of cancer and concern over estrogen's side effects have prompted many physicians and patients to consider alternative strategies for preventing osteoporosis. Many women believe that a high calcium intake will protect them against osteoporosis. Most studies indicate that high calcium intake has no effect on estrogen-dependent bone loss. After treating postmenopausal women with 1,000 mg of calcium daily for three years, we found that it was totally ineffective in preventing bone loss at several sites. 16 Riis and associates, administering 2,000 mg of calcium, came to a similar conclusion, although some minimal protection of cortical bone was observed.17 The clear message of a recent international consensus meeting on osteoporosis was that supplementing calcium is not an effective alternative to using estrogen.18 Despite the lack of benefit from calcium when given alone, adding calcium supplements to suboptimal dosages of estrogen has allowed protection using half the dose (J. C. Gallagher, MD, D. Goldgar, MD, W. T. Kable, MD, unpublished data, November 1988).'1 9 Reducing the dosage of estrogen will reduce the incidence of side effects and will cause less menstrual bleeding, but beneficial effects on menopausal symptoms and lipoproteins will also be minimized. The usual recommendation for the total daily intake of calcium is 1,000 mg before menopause and 1,500 mg after. Women using standard dosages of estrogen do not require the higher intake. Assessing the adequacy of calcium intake is simple: a diet devoid of dairy products contains about 400 mg of calcium, and each dairy portion contributes about 300 mg. If dietary sources are insufficient to meet a patient's needs, then supplementing with calcium carbonate is appropriate. Oyster shell calcium is cheap and is absorbed well, especially if taken with a meal. Numerous foodstuffs are now supplemented with calcium and could serve as alternative sources.
Exercise Amenorrheic athletes are subject to bone loss despite intensive training20; yet, if their endogenous estrogen production is restored by a reduction in exercise, these athletes may regain bone mass.21 While a few short-term studies have suggested a beneficial effect of exercise on postmenopausal bone loss, most have failed to show any benefit. In a prospective study, women just after menopause (6 to 36 months) who
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chose higher levels of physical activity did not have diminished skeletal mineral losses. 19 A cohort of sedentary women eight years postmenopausal on the average was prescribed seven miles of walking each week. During the three years of study, these women showed a 28 % increase in energy expenditure but no reduction in skeletal losses.22 The bone mass of postmenopausal endurance runners, average age 62 years, tended to be lower than that of sedentary women of the same age. 23 In older women, various exercise prescriptions, evaluated for brief intervals, have shown increases in bone mass. Unfortunately, short-term gains induced by vigorous exercise are rapidly lost once the training is discontinued.24 Notelovitz and co-workers found that an intensive program of muscle conditioning increased the osteotrophic effect of a regimen of 0.625 mg of conjugated estrogens for more than a year (M. Notelovitz, MD, PhD, D. Martin, PhD, R. Tesar, PhD, L. McKenzie, RN, and C. Fields, RN, unpublished data, November 1988). It remains to be proved whether adding exercise, like adding calcium, could augment the osteotrophic effects of suboptimal levels of estrogen.
Other Pharmacologic Agents Agents that may be effective in reducing the rapid loss of bone in the period immediately after menopause include calcitonin, thiazide diuretics, progestogens, and a combination of cyclically used agents. Christiansen and colleagues in a two-year study found that thiazide therapy appeared to reduce the rate of bone loss slightly, largely because of transient stabilization during the first six months of treatment.25 Although no long-term prospective studies have been done, one cross-sectional study of hypertensive postmenopausal women showed that bone mass was higher in thiazide users.26 Women using estrogen had greater bone mass than thiazide users, but women using both agents had the highest bone mass of all. In this study, the prevalence of fractures was inversely related to bone mineral; the prevalence of fractures was halved in women using either thiazides or estrogen and was 84% less in women using both drugs compared with those using neither. In another retrospective study, thiazide users carefully matched to nonusers did not show such benefits.27 Because thiazide therapy is associated with significant side effects in normotensive persons, widespread use by normotensive postmenopausal women cannot be recommended. Calcitonin is a polypeptide hormone secreted by the C cells of the thyroid. Human and salmon calcitonin preparations are commercially available and have been widely used for the treatment of Paget's disease. Like estrogen, calcitonin acts to prevent bone loss through a reduction in bone resorption. Calcitonin has not been widely accepted as an alternative to estrogen because of its cost ($2,000 to $3,000 per year) and difficulties in its administration (daily injections). The intranasal administration of calcitonin is being evaluated, and preliminary results are encouraging.28 Although some experimental evidence has suggested that progestogens have an intrinsic osteotrophic effect, most clinical trials have shown equivocal or no protection against bone loss. Lindsay and associates found that the use of 19-nor17,B-hydroxyprogesterone protected ten menopausal women against cortical bone loss.29 This study, because it used few subjects (with only one year of follow-up) and examined a relatively insensitive skeletal site, may have lacked statistical power to show losses. Hart and co-workers studied two other progestogens, norgestrel and norethisterone, finding only the
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latter to be effective during a two-year trial. 30 Gallagher and co-workers found that giving medroxyprogesterone acetate, 20 mg daily, did not protect against mineral loss in the spine but may have had a partially protective effect on appendicular cortical bone (J. C. Gallagher, MD, D. Goldgar, MD, and W. T. Kable, MD, unpublished data, November 1988). Our experience with giving medroxyprogesterone acetate, 10 mg daily, substantiates a minimal protective effect on spinal mineral. Unfortunately, 19-nor progestogens and high doses of C-21 progestogens adversely affect high- and low-density lipoprotein cholesterol, making it likely that their long-term use will increase the risk of cardiovascular disease. An adverse effect on mood and energy, similar to the premenstrual syndrome, is commonly observed when these agents are given in large doses, especially without estrogen. Coherence therapy, first proposed by Frost,31 involves cyclic treatment with a series of agents. The acronym ADFR stands for the four phases ofthe regimen: Activation of osteoclasts, Depression of these same cells before their resorption potential is fully realized, a drug-Free period to allow bone to be formed at these activated sites, and Repetition of the cycle. The goal of this approach is to tip the balance between bone resorption and formation toward increased formation. This exciting area of skeletal research is still in its primitive stages, but a number of agents and schedules are being evaluated. Patient compliance is good because these agents are administered for only a few days every few months. Preliminary reports of maintenance or increases in trabecular bone volume and bone density have been greeted with enthusiasm, but other reports have failed to show beneficial effects.32
Selecting Women at High Risk for Osteoporosis Certain clinical factors seem highly protective. Being obese, for example, greatly reduces a woman's risk of hip fracture. The Framingham group reported that women who were 25 % or more above ideal weight had half the incidence of hip fracture.'1 Blacks and Latinos are much less prone to osteoporosis; Asians have about the same risk as whites. Women who are petite and who have a poorly developed muscle mass are likely to have a poorly developed skeletal mass. Heavy smoking and a heavy intake of alcohol are also associated with an increased risk; smoking reduces the levels of estrogen (both endogenous and exogenous) and is associated with both lower body weight and an earlier menopause; alcohol appears to have a direct toxic effect on bone, as well as increasing the likelihood of falls and injury. While the quantity of bone mineral accounts for a large part of the risk of fracture, another important factor may be the way in which mechanical forces are applied to the skeleton. For example, women with spinal curvature seem especially prone to vertebral compression fractures, while women with inadequate defenses against falling are at high risk for hip fracture. Life expectancy is one factor that rarely receives consideration in osteoporosis counseling. Age is the most powerful predictor of risk, and prophylactic measures should be greatest in those women whose health and family history enhance their chances of living beyond the age of 80 years. Epidemiologic studies have suggested numerous other risk factors but these, singly or in combination, lack any discriminatory power in individual women. In discussing osteoporosis with patients, I find it useful to apply the analogy of a "bone bank account"; most "deposits" are made in adolescence and most "withdrawals" are
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made in the several years after menopause. Ultimately-after 30% to 50% of skeletal mass is lost-will the skeleton become "bankrupt" and unable to meet simple physical demands put on it? Noninvasive bone density measurements developed over the past two decades allow a safe and accurate quantification of bone mass. Bone mass is the best predictor of a subsequent fracture risk.33 The best predictor of what the bone mass will be at age 75 years is the bone mass at menopause. Measuring the spinal density is preferred over
appendicular sites; quantitative computed tomography, dual-photon absorptiometry, or the newly developed dualenergy x-ray absorptiometry can all serve this purpose; each costs about $150 to $250. These tests should be reserved for women who are ambivalent about beginning prophylactic therapy. With wise counseling from physicians, they can consider their chances of osteoporosis developing based on objective data and weigh this risk against the potential risks, cost, and inconveniences of prophylaxis. Evaluating the risks and benefits of estrogen replacement therapy is beyond the scope of this review. A considerable body of epidemiologic data indicates that the long-term use of postmenopausal estrogen confers a major health benefit by reducing cardiovascular disease. Physicians who intend to prescribe estrogen should become familiar with current recommendations for formulation, dosage, route, schedule, and progestogen cotherapy. Up-to-date comprehensive reviews appear in the May 1987 issue of the American Journal of Obstetrics and Gynecology34 and in the November 1988 supplement to Obstetrics and Gynecology. 35 Although it is reasonable to alter habits that could adversely affect bone mass-smoking, drinking alcohol, a sedentary life-style, and low calcium intake-the skeletal benefits of such changes have not been adequately evaluated. Correcting estrogen deficiency remains the best way for menopausal women to reduce their risk of osteoporosis. REFERENCES 1. Holzman GB, Ravitch MM, Metheny W, et al:
Physicians' judgments about estrogen replacement therapy for menopausal women. Obstet Gynecol 1984; 63:303-311 2. Ettinger B, Block JE, Smith R, et al: An examination of the association between vertebral deformities, physical disabilities and psychosocial problems. Maturitas, in press 3. Matkovi6 V, Kostial K, Simonovid I, et al: Bone status and fracture rates in two regions of Yugoslavia. AmJ Clin Nutr 1979; 32:540-549 4. Kanders B, Dempster DW, Lindsay R: Interaction of calcium nutrition and physical activity on bone mass in young women. J Bone Mineral Res 1988; 3:145-149 5. Block JE, Genant HK, Black DM: Greater vertebral bone mineral mass in exercising young men. West J Med 1986; 145:39-42 6. Lindsay R, Hart DM, Clark DM: The minimum effective dose of estrogen for prevention of postmenopausal bone loss. Obstet Gynecol 1984; 63:759-763 7. Ettinger B, Genant HK: Low-dosage micronized estradiol, combined with calcium, protects against postmenopausal bone loss (Abstr), In Laurence and Dorothy Fallis International Symposium: Clinical Disorders of Bone and Mineral Metabolism, Detroit, May 8-13, 1988. New York, M Liebert, 1988, p 40 8. Ribot C, Tremollieres F, Pouilles JM, et al: Transdermal administration of 17f3-estradiol in post menopausal women: Preliminary results of a longitudinal Proceedings of Osteoporosis: study, In Christiansen C, Johansen JS, Riis BJ (Eds):27-Oct 2, 1987. Copenhagen, the International Symposium on Osteoporosis, Sep Denmark, Osteopress ApS, 1987, pp 546-548 9. Lindsay R, Hart DM, Forrest C, et al: Prevention of spinal osteoporosis in oophorectomised women. Lancet 1980; 2:1151-1154 10. Ettinger B, Genant HK, Cann CE: Long-term estrogen replacement therapy prevents bone loss and fractures. Ann Intern Med 1985; 102:319-324 1 1. Kiel DP, Felson DT, Anderson JJ, et al: Hip fracture and the use of estrogens in postmenopausal women: The Framingham study. N Engl J Med 1987; 317:11691174 12. Falch JA, Oftebro H, Haug E: Early postmenopausal bone loss is not associated with a decrease in circulating levels of 25-hydroxyvitamin D, 1 ,25-dihydroxyvitamin D, or vitamin D-binding protein. J Clin Endocrinol Metab 1987; 64: 836-841 13. Smith R, Block JE, Steiger P, et al: Models of spinal trabecular bone loss as determined by quantitative computed tomography. J Bone Mineral Res, in press
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14. Brinton LA, Hoover R, Fraumeni JF Jr: Menopausal oestrogens and breast cancer risk: An expanded case-control study. BrJ Cancer 1986; 54:825-832 15. Wingo PA, Layde PM, Lee NC, et al: The risk of breast cancer in postmenopausal women who have used estrogen replacement therapy. JAMA 1987; 257: 209-215 16. Ettinger B, Genant HK, Cann CE: Low-dosage estrogen combined with calcium prevents postmenopausal bone loss: Results of a 3-year study, In Cohn DV, Martin TJ, Meunier PJ (Eds): Calcium Regulation and Bone Metabolism: Basic and Clinical Aspects, Vol 9. Amsterdam, Elsevier, 1987, pp 918-922 17. Riis B, Thomsen K, Christiansen C: Does calcium supplementation prevent postmenopausal bone loss? N Engl J Med 1987; 316:173-177 18. Consensus Development Conference: Prophylaxis and treatment of osteoporosis. Br Med J [Clin Res] 1987; 295:914-915 19. Ettinger B, Genant HK, Cann CE: Postmenopausal bone loss is prevented by treatment with low-dosage estrogen with calcium. Ann Intern Med 1987; 106:40-45 20. Drinkwater BL, Nilson K, Chesnut CH III, et al: Bone mineral content of amenorrheic and eumenorrheic athletes. N Engl J Med 1984; 311:277-281 21. Lindberg JS, Powell MR, Hunt MM, et al: Increased vertebral bone mineral in response to reduced exercise in amenorrheic runners. West J Med 1987; 146:39-42 22. Sandler RB, Cauley JA, Hom DL, et al: The effects of walking on the cross-sectional dimensions of the radius in menopausal women. Calcif Tissue Int 1987; 41:65-69 23. Nelson ME, Meredith CN, Dawson-Hughes B, et al: Hormone and bone mineral status in endurance-trained and sedentary postmenopausal women. J Clin Endocrinol Metab 1988; 66:927-933 24. Dalsky GP, Stocke KS, Ehsani AA, et al: Weight-bearing exercise training and lumbar bone mineral content in postmenopausal women. Ann Intern Med 1988; 108:824-828 25. Christiansen C, Christensen MS, McNair P, et al: Prevention of early post-
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menopausal bone loss: Controlled 2-year study in 315 normal females. Eur J Clin Invest 1980; 10:273-279 26. Wasnich RD, Benfante RJ, Yano K, et al: Thiazide effect on the mineral content of bone. N Engl J Med 1983; 309:344-347 27. Adland-Davenport P, McKenzie MW, Notelovitz M, et al: Thiazide diuretics and bone mineral content in postmenopausal women. Am J Obstet Gynecol 1985; 152:630-634 28. Reginster JY, Denis D, Albert A, et al: Role of nasal salmon calcitonin in the prevention of postmenopausal osteoporosis, In Christiansen C, Johansen JS, Riis BJ (Eds): Osteoporosis: Proceedings of the International Symposium on Osteoporosis, Sep 27-Oct 2, 1987. Copenhagen, Denmark, Osteopress ApS, 1987, pp 1268-1270 29. Lindsay R, Hart DM, Purdie D, et al: Comparative effects of oestrogen and a progestogen on bone loss in postmenopausal women. Clin Sci Mol Med 1978; 54:193-195 30. Hart DM, Abdalla H, Clarke D, et al: Preservation of bone mass in postmenopausal women during therapy with estrogen and progestogens, In Christiansen C, Arnaud CD, Nordin BEC, et al (Eds): Osteoporosis: Proceedings of the Copenhagen International Symposium on Osteoporosis, Jun 3-8, 1984. Copenhagen, Denmark, Department of Clinical Chemistry, Glostrup Hospital/Aalborg Stiftsbogtrykken, 1984, pp 697-699 31. Frost HM: The ADFR concept revisited (Editorial). Calcif Tissue Int 1984; 36:349-353 32. Pacifici R, McMurtry C, Vered I, et al: Coherence therapy does not prevent axial bone loss in osteoporotic women: A preliminary comparative study. J Clin Endocrinol Metab 1988; 66:747-753 33. Ross PD, Wasnich RD, Vogel JM: Detection of prefracture spinal osteoporosis using bone mineral absorptiometry. J Bone Mineral Res 1988; 3: 1-1 1 34. Symposium on Current Perspectives in the Management of the Menopausal and Postmenopausal Patient. Am J Obstet Gynecol 1987; 156:1279-1356 35. Estrogen Replacement Therapy Symposium. Obstet Gynecol 1988; 72(suppl): lS-36S
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trle Last Wonts of MY EN4,IiS1J gnaNOMOtt1C:R There were some dirty plates and a glass of milk beside her on a small table near the rank, disheveled bedWrinkled and nearly blind she lay and snored rousing with anger in her tones to cry for food, Gimme something to eatThey're starving meI'm all right I won't go to the hospital. No, no, no Give me something to eat Let me take you to the hospital, I said and after you are well you can do as you please. She smiled, Yes you do what you please first then I can do what I please-
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Oh, oh, oh! she cried as the ambulance men lifted her to the stretcherIs this what you call making me comfortable? By now her mind was clearOh you think you're smart you young people, she said, but I'll tell you you don't know anything. Then we started. On the way we passed a long row of elms. She looked at them awhile out of the ambulance window and said, What are all those fuzzy-looking things out there? Trees? Well, I'm tired of them and rolled her head away. WilliaM Canlos WilliaMs
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