Extensive personal experience: the clinical evaluation and management of osteoporosis.

T HIS REVIEW reflects my own clinical experience over a number of years, and it seems appropriate to describe this practice setting, at least briefly. Until recently, as a member of the Bone and Mineral Division of the Henry Ford Health System in Detroit, Michigan, I worked with a group of specialists, all but one of whom was an endocrinologist, but our clinical practice was restricted to disorders of bone and mineral metabolism: no diabetes, no thyroid, just bones. Consequently, many of our referrals were from fellow endocrinologists seeking consultation for what they regarded as out of the ordinary in our field or patients who were potential participants in clinical research trials. It was uncommon, unfortunately, for us to see patients with established osteoporosis, for example, who were “virginal” with respect to evaluation or therapy. The other source of referral to my personal practice within this group was from gynecologists whose perimenopausal patients wanted further discussion about hormone replacement therapy. More specifically, these women requested an analysis of their risk of developing osteoporosis to complete the hormone replacement “risk/benefit” equation. My admittedly extremist views on hormone replacement, that the benefits far outweigh the risks for most women, are well known in my community, and this was reflected in the referral pattern. Recently, I was fortunate to have joined the Division of Endocrinology and Metabolism at Wayne State University, still in Detroit. My metabolic bone disease clinic is conducted in the rheumatology section of the university’s major women’s hospital (Hutzel Hospital), with a significant impact on the source and type of referral. The nation’s largest obstetrics and gynecology residency program, with a long-standing active menopause program, is in the same facility. Referrals for skeletal management of perimenopausal women focuses more directly on that segment for whom hormone replacement is absolutely or relatively contraindicated. Working with rheumatologists (who as a specialty are making an increasingly aggressive attempt to move into the osteoporosis area), a major new source of referral is patients whom these rheumatologists are treating with corticosteroids. Fortunately, the outstanding group with whom I am associated recognizes this major clinical problem, and together we are moving toward a program of addressing the skeletal complications of steroids at the initiation of therapy rather than after the third or fourth osteoporotic fracture. It is worth noting that in neither facility were orthopedists or primary care providers a major source of new patient referral to a specialty bone program. From my personal experience, general endocrinologists are more likely to receive referrals from these sources, even in a major metropolitan area with acknowledged clinical expertise in bone and mineral disorders. Thus, osteoporosis has already outstripped thyroid disease and is overtaking diabetes as “bread and butter” endocrinology. This first person, biased contribution to the Journal offers some perspectives on patient evaluation and management. The current accepted definition of osteoporosis is low bone mass and microarchitectural deterioration of the skeleton, leading to an increased risk of fracture after minimal trauma (1). In practice, however, patients are seen by a clinician because of one of the following distinct clinical situations: 1) the patient concerned about her or his individual risk of developing osteoporosis; 2) the patient with diagnosed osteoporosis who has not yet sustained a fracture or in whom there is concern that a vertebral deformity seen on x-ray may have resulted from an osteoporotic fracture; and 3) the patient with established osteoporosis complicated by fractures after minimal trauma. In this review I will focus on each of these situations separately, recognizing that there will be substantial overlap in the approaches.