DR DALEY: Mrs Z is a
73-year-old married grandmother who lives in a suburb of Boston, Mass,
with her husband. She works 4 days per week in her daughter's retail
business. Her gynecologist recently referred her for evaluation of
"thin bones." Mrs Z has medical insurance through Medicare and
Mrs Z underwent menarche at age 11 years and had normal menstrual
periods until menopause at age 50 years. She had 2 uncomplicated
pregnancies and took oral contraceptives for many years. After
menopause, she took hormone replacement therapy (HRT) for only 3 years,
then stopped because of fear of developing breast cancer. She smoked
for 1 year in her teens and quit; she does not drink alcohol. She has
never taken glucocorticoids, anticonvulsants, or thyroid medication.
Her mother fractured her hip twice. There is no family history of
breast cancer. The patient's daily dietary calcium intake is low,
about 300 mg/d, but she has taken supplemental calcium tablets of about
1200 mg/d for the past several years. She has never had a kidney stone.