USMLE STEP 3 MCQ 21 : What is the most effective way of preventing pathological fractures post-menopause?


A 55 year old woman who has just gone through her menopause is concerned that she may develop vertebral fractures. She has never had any surgery before and has no relevant medical history. What is the most effective way of preventing pathological fractures post-menopause?

a) Clonidine J Vaginal lubricant
b) Combined Oestrogen and progestogen replacement therapy
c) Oestrogen only HRT
d) Progestins
e) Mineral supplements


Correct Answer: B



Because established osteoporosis may not be significantly reversed, medical management should emphasize prophylaxis rather than treatment. Patients should be advised to stop smoking, reduce the intake of dietary phosphates, and exercise regularly to preserve bone mass. Estrogens have been shown to prevent the loss of bone mass and to reduce the incidence of osteoporotic fractures. They act by decreasing bone resorption , by increasing intestinal calcium absorption, and by reducing renal calcium excretion. The inclusion of progesterone or a progestogen in hormone replacement therapy (HRT) inhibits endometrial proliferation and minimizes the risk of endometrial hyperplasia and subsequently endometrial carcinoma caused by unopposed exogenous estrogens. Progestogens are therefore an essential part of HRT for women with an intact uterus. There are substantial differences between the currently available progestogens both in chemical structure and in pharmacological profile. It is important to consider these differences when HRT is prescribed Low doses of estrogen appear to be as effective as higher doses; 0.625 mg and 1.25 mg of conjugated equine estrogen (CEE) are equally effective in preventing bone loss and in reducing the incidence of fractures. Because bone loss is irreversible, estrogen treatment initiated shortly after menopause will maximize the amount of bone preserved. Treatment should be taken for at least 6 years to reduce substantially the lifetime risk for fracture. No method identifies all patients in whom osteoporosis will develop; hence, most postmenopausal women are potential candidates for this therapy. A measurement of baseline bone density may help patients for whom the decision to initiate estrogen replacement is difficult. However, normal bone density does not rule out the future development of


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