• Family history, Caucasian, thyrotoxicosis (both endogenous and exogenous) menopause and being thin.
  
  

2. What was the reason l-thyroxine was reduced in this patient? 

• Because the subclinical hyperthyroidism has been shown to reduce bone density.
  
  

3. What was the significance of the low urinary calcium excretion and how does therapy with 1,25(OH)2 vitamin D3 correct this problem?

•  It was a marker suggesting that calcium was being poorly absorbed - possible causes being low calcium intake, malabsorption syndromes such as sprue, etc. Vitamin D therapy increases gastrointestinal calcium absorption.
  
  

4. What are some reasons for use of hormone replacement therapy in this woman? Is therapy with estrogen and progesterone sufficient? 

• Reduction of cardiovascular event risk. 
• Reduction of osteoporosis-induced new fracture risk.
•  Prevention of other more subjective aging phenomena. 
• In addition to estrogen the patient needs progesterone therapy to reduce the risk of uterine carcinoma.
  
  

5. Is the patient’s concern regarding breast carcinoma valid? 

• Yes. Relative risk increases with years of use, increasing dose, or family history of breast cancer. 
• Overall risk estimated at about 1.4 after 4 years of estrogen replacement plus or minus progesterone.
  
  

6. Discuss the benefits and side effects of alendronate used to treat osteoporosis in this patient. If she had esophageal emptying problems, would you use it? 

• There is an approximate 50% reduction in vertebral and hip fractures with three years of use. 
• Side effects include hypocalcemia and esophageal ulcers. No.