Measurements of BUA in the Calcaneus

251

19. Hui SL, Slemenda CW, Johnston CC, Appledorn CR. Effects of age and menopause on vertebral bone density. Bone Miner 1987;2:141-6. 20. Nilas L, Christiansen C. Bone mass and its relationship to age and the menopause. J Clin Endocrinol Metab 1987;65:697-702. 21. Agren M, Karellas A, Leahey D, et al. Ultrasound attenuation of

the calcaneus: a sensitive and specific discriminator of osteopenia in postmenopausal women. Calcif Tissue Int 1991;48: 240-4. 22. Baran DT, Kelly AM, Karellas A, et al. Ultrasound attenuation of the os calcis in women with osteoporosis and hip fractures. Calcif Tissue Int 1988;43:138-42.

Received for publication 22 August 1991 Accepted in revised form 17 March 1992

Correspondence SIR,--I applaud your decision to publish the article by Dr Bush [1] concerning the cardioprotective effect of estrogen, but the information in this article is of more direct relevance to management strategy in osteoporosis than you indicate, particularly in the determination of policy for the use of bone densitometry in perimenopausal women. If Dr Bush's conclusions are correct, as I believe them to be, then bone densitometry has no place in decisions concerning estrogen replacement therapy (ERT), since it may deprive some women of the cardiovascular benefit of estrogen for the wrong reason [2]. On the other hand, if Dr Bush's conclusions are either incorrect or premature, then a low bone density is the only reason for recommending long term estrogen use [3]. In the former case, no woman should have densitometry at menopause, unless she makes it a condition for accepting ERT. In the latter case, every woman should have densitometry at menopause, unless she unconditionally refuses ERT. I can see reasonable arguments in support of both of these extreme views, but no logically defensible basis for any intermediate position [4]. A. M. PARFITT,MD

Henry Ford Hospital Detroit, Michigan

References: 1. Bush TL, Extraskeletal effects of estrogens and the prevention of atherosclerosis. Osteoporosis Int 1991;2:5-11. 2. Hillner BE, Hollenberg JP, Pauker SG. Postmenopausal estrogens in prevention of osteoporosis. Benefits virtually without risk if cardiovascular effects are considered. Am J Med 1986;80:1115-27. 3. Johnston CC Jr, Melton LJ, Lindsay R, Eddy DM. 1989 Clinical indications for bone mass measurements: A report from the Scientific Advisory Board on the National Osteoporosis Foundation. J Bone Miner Res 4 (Suppl 2):1-28. 4. Parfitt AM. Idiosyncratic comments on the state of knowledge in osteoporosis with particular emphasis on it's limitations. In: Christiansen C, Overgaard K, eds. Osteoporosis. 1990 Third International Symposium. Osteopress ApS, Denmark: 1845-51.

Dr Parfitt's letter was shown to Dr Bush, who replied as" follows: SIR--I thank Dr Parfitt for his kind comments, but disagree somewhat with his conclusions. I would argue that the issue of routine bone densitometry at menopause may be dependent on the degree to which E R T protects against cardiovascular diseases and not whether there is protection. A reduction in risk of 50% or greater is certainly a more compelling reason to advocate universal treatment than is a risk reduction of 5% to 15%. Having definitive data on the degree of protection E R T affords against cardiovascular diseases would be helpful, but results from such clinical trials are years away. Nonetheless, I am a believer in universal bone densitometry at menopause for several reasons. First, risk factors for osteoporosis/fracture predict well in the aggregate, but not for the individual. Thus, obese women can and do lose bone, black women suffer from hip fracture, and runners get osteoporosis. Second, E R T is only 50% effective in preventing fracture and may not be entirely effective at preventing bone loss. Monitoring a patient's bone density on E R T (which implies a baseline examination) may be necessary in order to assure an adequate dose of ERT, or to consider additional boneconserving therapies. Finally, many women are not aware of and do not fear cardiovascular diseases. They would choose to take E R T only because of their risk of osteoporosis/fracture. I believe this fraction of the population to be sufficiently large to warrant routine screening. TRUDY BusH, PhD, MHS

Johns Hopkins University Baltimore, Maryland

Cardioprotective effect of estrogen.

Measurements of BUA in the Calcaneus 251 19. Hui SL, Slemenda CW, Johnston CC, Appledorn CR. Effects of age and menopause on vertebral bone density...
116KB Sizes 0 Downloads 0 Views