Skip to main content
NCBI home page
CMAJ : Canadian Medical Association Journal logoLink to CMAJ : Canadian Medical Association Journal
. 1996 Oct 15;155(8):1113–1133.

Clinical practice guidelines for the diagnosis and management of osteoporosis. Scientific Advisory Board, Osteoporosis Society of Canada.

PMCID: PMC1335371  PMID: 8873639

Abstract

OBJECTIVE: To recommend clinical practice guidelines for the assessment of people at risk for osteoporosis, and for effective diagnosis and management of the condition. OPTIONS: Screening and diagnostic methods: risk-factor assessment, clinical evaluation, measurement of bone mineral density, laboratory investigations. Prophylactic and corrective therapies: calcium and vitamin D nutritional supplementation, physical activity and fall-avoidance techniques, ovarian hormone therapy, bisphosphonate drugs, other drug therapies. Pain-management medications and techniques. OUTCOMES: Prevention of loss of bone mineral density and fracture; increased bone mass; and improved quality of life. EVIDENCE: Epidemiologic and clinical studies and reports were examined, with emphasis on recent randomized controlled trials. Clinical practice in Canada and elsewhere was surveyed. Availability of treatment products and diagnostic equipment in Canada was considered. VALUES: Cost-effective methods and products that can be adopted across Canada were considered. A high value was given to accurate assessment of fracture risk and osteoporosis, and to increasing bone mineral density, reducing fractures and fracture risk and minimizing side effects of diagnosis and treatment. BENEFITS, HARMS AND COSTS: Proper diagnosis and management of osteoporosis minimize injury and disability, improve quality of life for patients and reduce costs to society. Rationally targeted methods of screening and diagnosis are safe and cost effective. Harmful side effects and costs of recommended therapies are minimal compared with the harms and costs of untreated osteoporosis. Alternative therapies provide a range of choices for physicians and patients. RECOMMENDATIONS: Population sets at high risk should be identified and then the diagnosis confirmed through bone densitometry. Dual-energy x-ray absorptiometry is the preferred measurement technique. Radiography can be adjunct when indicated. Calcium and vitamin D nutritional supplementation should be at currently recommended levels. Patients should be counselled in fall-avoidance techniques and exercises. Immobilization should be avoided. Guidelines for management of acute pain are listed. Ovarian hormone therapy is the therapy of choice for osteoporosis prevention and treatment in postmenopausal women. Bisphosphonates are an alternative therapy for women with established osteoporosis who cannot or prefer not to take ovarian hormone therapy.

Full text

PDF
1113

Selected References

These references are in PubMed. This may not be the complete list of references from this article.

  1. Adachi J., Cranney A., Goldsmith C. H., Bensen W. G., Bianchi F., Cividino A., Craig G. L., Kaminska E., Sebaldt R. J., Papaioannou A. Intermittent cyclic therapy with etidronate in the prevention of corticosteroid induced bone loss. J Rheumatol. 1994 Oct;21(10):1922–1926. [PubMed] [Google Scholar]
  2. Adinoff A. D., Hollister J. R. Steroid-induced fractures and bone loss in patients with asthma. N Engl J Med. 1983 Aug 4;309(5):265–268. doi: 10.1056/NEJM198308043090502. [DOI] [PubMed] [Google Scholar]
  3. Aloia J. F., Cohn S. H., Ostuni J. A., Cane R., Ellis K. Prevention of involutional bone loss by exercise. Ann Intern Med. 1978 Sep;89(3):356–358. doi: 10.7326/0003-4819-89-3-356. [DOI] [PubMed] [Google Scholar]
  4. Bauer D. C., Browner W. S., Cauley J. A., Orwoll E. S., Scott J. C., Black D. M., Tao J. L., Cummings S. R. Factors associated with appendicular bone mass in older women. The Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1993 May 1;118(9):657–665. doi: 10.7326/0003-4819-118-9-199305010-00001. [DOI] [PubMed] [Google Scholar]
  5. Bauer D. C., Glüer C. C., Genant H. K., Stone K. Quantitative ultrasound and vertebral fracture in postmenopausal women. Fracture Intervention Trial Research Group. J Bone Miner Res. 1995 Mar;10(3):353–358. doi: 10.1002/jbmr.5650100304. [DOI] [PubMed] [Google Scholar]
  6. Bergkvist L., Adami H. O., Persson I., Hoover R., Schairer C. The risk of breast cancer after estrogen and estrogen-progestin replacement. N Engl J Med. 1989 Aug 3;321(5):293–297. doi: 10.1056/NEJM198908033210505. [DOI] [PubMed] [Google Scholar]
  7. Bewtra C., Kable W. T., Gallagher J. C. Endometrial histology and bleeding patterns in menopausal women treated with estrogen and continuous or cyclic progestin. J Reprod Med. 1988 Feb;33(2):205–208. [PubMed] [Google Scholar]
  8. Blake A. J., Morgan K., Bendall M. J., Dallosso H., Ebrahim S. B., Arie T. H., Fentem P. H., Bassey E. J. Falls by elderly people at home: prevalence and associated factors. Age Ageing. 1988 Nov;17(6):365–372. doi: 10.1093/ageing/17.6.365. [DOI] [PubMed] [Google Scholar]
  9. Bruning P. F., Pit M. J., de Jong-Bakker M., van den Ende A., Hart A., van Enk A. Bone mineral density after adjuvant chemotherapy for premenopausal breast cancer. Br J Cancer. 1990 Feb;61(2):308–310. doi: 10.1038/bjc.1990.58. [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Cann C. E., Genant H. K., Ettinger B., Gordan G. S. Spinal mineral loss in oophorectomized women. Determination by quantitative computed tomography. JAMA. 1980 Nov 7;244(18):2056–2059. [PubMed] [Google Scholar]
  11. Cauley J. A., Seeley D. G., Ensrud K., Ettinger B., Black D., Cummings S. R. Estrogen replacement therapy and fractures in older women. Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1995 Jan 1;122(1):9–16. doi: 10.7326/0003-4819-122-1-199501010-00002. [DOI] [PubMed] [Google Scholar]
  12. Chapuy M. C., Arlot M. E., Duboeuf F., Brun J., Crouzet B., Arnaud S., Delmas P. D., Meunier P. J. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med. 1992 Dec 3;327(23):1637–1642. doi: 10.1056/NEJM199212033272305. [DOI] [PubMed] [Google Scholar]
  13. Chesnut C. H., 3rd, McClung M. R., Ensrud K. E., Bell N. H., Genant H. K., Harris S. T., Singer F. R., Stock J. L., Yood R. A., Delmas P. D. Alendronate treatment of the postmenopausal osteoporotic woman: effect of multiple dosages on bone mass and bone remodeling. Am J Med. 1995 Aug;99(2):144–152. doi: 10.1016/s0002-9343(99)80134-x. [DOI] [PubMed] [Google Scholar]
  14. Christiansen C., Christensen M. S., Larsen N. E., Transbøl I. B. Pathophysiological mechanisms of estrogen effect on bone metabolism. Dose-response relationships in early postmenopausal women. J Clin Endocrinol Metab. 1982 Dec;55(6):1124–1130. doi: 10.1210/jcem-55-6-1124. [DOI] [PubMed] [Google Scholar]
  15. Colditz G. A., Stampfer M. J., Willett W. C., Hennekens C. H., Rosner B., Speizer F. E. Prospective study of estrogen replacement therapy and risk of breast cancer in postmenopausal women. JAMA. 1990 Nov 28;264(20):2648–2653. [PubMed] [Google Scholar]
  16. Cooper C. Osteoporosis--an epidemiological perspective: a review. J R Soc Med. 1989 Dec;82(12):753–757. doi: 10.1177/014107688908201217. [DOI] [PMC free article] [PubMed] [Google Scholar]
  17. Cumming R. G., Miller J. P., Kelsey J. L., Davis P., Arfken C. L., Birge S. J., Peck W. A. Medications and multiple falls in elderly people: the St Louis OASIS study. Age Ageing. 1991 Nov;20(6):455–461. doi: 10.1093/ageing/20.6.455. [DOI] [PubMed] [Google Scholar]
  18. Cummings S. R., Black D. M., Nevitt M. C., Browner W. S., Cauley J. A., Genant H. K., Mascioli S. R., Scott J. C., Seeley D. G., Steiger P. Appendicular bone density and age predict hip fracture in women. The Study of Osteoporotic Fractures Research Group. JAMA. 1990 Feb 2;263(5):665–668. [PubMed] [Google Scholar]
  19. Cummings S. R., Black D. M., Nevitt M. C., Browner W., Cauley J., Ensrud K., Genant H. K., Palermo L., Scott J., Vogt T. M. Bone density at various sites for prediction of hip fractures. The Study of Osteoporotic Fractures Research Group. Lancet. 1993 Jan 9;341(8837):72–75. doi: 10.1016/0140-6736(93)92555-8. [DOI] [PubMed] [Google Scholar]
  20. Cummings S. R., Black D. Bone mass measurements and risk of fracture in Caucasian women: a review of findings from prospective studies. Am J Med. 1995 Feb 27;98(2A):24S–28S. doi: 10.1016/s0002-9343(05)80041-5. [DOI] [PubMed] [Google Scholar]
  21. Cummings S. R., Kelsey J. L., Nevitt M. C., O'Dowd K. J. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev. 1985;7:178–208. doi: 10.1093/oxfordjournals.epirev.a036281. [DOI] [PubMed] [Google Scholar]
  22. Cummings S. R., Nevitt M. C., Browner W. S., Stone K., Fox K. M., Ensrud K. E., Cauley J., Black D., Vogt T. M. Risk factors for hip fracture in white women. Study of Osteoporotic Fractures Research Group. N Engl J Med. 1995 Mar 23;332(12):767–773. doi: 10.1056/NEJM199503233321202. [DOI] [PubMed] [Google Scholar]
  23. Dalsky G. P., Stocke K. S., Ehsani A. A., Slatopolsky E., Lee W. C., Birge S. J., Jr Weight-bearing exercise training and lumbar bone mineral content in postmenopausal women. Ann Intern Med. 1988 Jun;108(6):824–828. doi: 10.7326/0003-4819-108-6-824. [DOI] [PubMed] [Google Scholar]
  24. Dauphine R. T., Riggs B. L., Scholz D. A. Back pain and vertebral crush fractures: an unemphasized mode of presentation for primary hyperparathyroidism. Ann Intern Med. 1975 Sep;83(3):365–367. doi: 10.7326/0003-4819-83-3-365. [DOI] [PubMed] [Google Scholar]
  25. Davies M. C., Hall M. L., Jacobs H. S. Bone mineral loss in young women with amenorrhoea. BMJ. 1990 Oct 6;301(6755):790–793. doi: 10.1136/bmj.301.6755.790. [DOI] [PMC free article] [PubMed] [Google Scholar]
  26. Dawson-Hughes B. Calcium supplementation and bone loss: a review of controlled clinical trials. Am J Clin Nutr. 1991 Jul;54(1 Suppl):274S–280S. doi: 10.1093/ajcn/54.1.274S. [DOI] [PubMed] [Google Scholar]
  27. Dawson-Hughes B., Dallal G. E., Krall E. A., Sadowski L., Sahyoun N., Tannenbaum S. A controlled trial of the effect of calcium supplementation on bone density in postmenopausal women. N Engl J Med. 1990 Sep 27;323(13):878–883. doi: 10.1056/NEJM199009273231305. [DOI] [PubMed] [Google Scholar]
  28. Diamond T., McGuigan L., Barbagallo S., Bryant C. Cyclical etidronate plus ergocalciferol prevents glucocorticoid-induced bone loss in postmenopausal women. Am J Med. 1995 May;98(5):459–463. doi: 10.1016/S0002-9343(99)80345-3. [DOI] [PubMed] [Google Scholar]
  29. Diamond T., Stiel D., Lunzer M., Wilkinson M., Posen S. Ethanol reduces bone formation and may cause osteoporosis. Am J Med. 1989 Mar;86(3):282–288. doi: 10.1016/0002-9343(89)90297-0. [DOI] [PubMed] [Google Scholar]
  30. Dupont W. D., Page D. L. Menopausal estrogen replacement therapy and breast cancer. Arch Intern Med. 1991 Jan;151(1):67–72. [PubMed] [Google Scholar]
  31. Ettinger B., Genant H. K., Cann C. E. Long-term estrogen replacement therapy prevents bone loss and fractures. Ann Intern Med. 1985 Mar;102(3):319–324. doi: 10.7326/0003-4819-102-3-319. [DOI] [PubMed] [Google Scholar]
  32. Finkelstein J. S., Klibanski A., Neer R. M., Greenspan S. L., Rosenthal D. I., Crowley W. F., Jr Osteoporosis in men with idiopathic hypogonadotropic hypogonadism. Ann Intern Med. 1987 Mar;106(3):354–361. doi: 10.7326/0003-4819-106-3-. [DOI] [PubMed] [Google Scholar]
  33. Fraser S. A., Anderson J. B., Smith D. A., Wilson G. M. Osteoporosis and fractures following thyrotoxicosis. Lancet. 1971 May 15;1(7707):981–983. doi: 10.1016/s0140-6736(71)91383-3. [DOI] [PubMed] [Google Scholar]
  34. Földes J., Tarján G., Szathmari M., Varga F., Krasznai I., Horvath C. Bone mineral density in patients with endogenous subclinical hyperthyroidism: is this thyroid status a risk factor for osteoporosis? Clin Endocrinol (Oxf) 1993 Nov;39(5):521–527. doi: 10.1111/j.1365-2265.1993.tb02403.x. [DOI] [PubMed] [Google Scholar]
  35. Gallagher J. C., Goldgar D. Treatment of postmenopausal osteoporosis with high doses of synthetic calcitriol. A randomized controlled study. Ann Intern Med. 1990 Nov 1;113(9):649–655. doi: 10.7326/0003-4819-113-9-649. [DOI] [PubMed] [Google Scholar]
  36. Gambacciani M., Spinetti A., Cappagli B., Taponeco F., Maffei S., Piaggesi L., Fruzzetti F., Fioretti P. Hormone replacement therapy in perimenopausal women with a low dose oral contraceptive preparation: effects on bone mineral density and metabolism. Maturitas. 1994 Aug;19(2):125–131. doi: 10.1016/0378-5122(94)90062-0. [DOI] [PubMed] [Google Scholar]
  37. Gambrell R. D., Jr, Bagnell C. A., Greenblatt R. B. Role of estrogens and progesterone in the etiology and prevention of endometrial cancer: review. Am J Obstet Gynecol. 1983 Jul 15;146(6):696–707. doi: 10.1016/0002-9378(83)91014-1. [DOI] [PubMed] [Google Scholar]
  38. Gambrell R. D., Jr, Massey F. M., Castaneda T. A., Ugenas A. J., Ricci C. A., Wright J. M. Use of the progestogen challenge test to reduce the risk of endometrial cancer. Obstet Gynecol. 1980 Jun;55(6):732–738. [PubMed] [Google Scholar]
  39. Gelfand M. M., Ferenczy A. A prospective 1-year study of estrogen and progestin in postmenopausal women: effects on the endometrium. Obstet Gynecol. 1989 Sep;74(3 Pt 1):398–402. [PubMed] [Google Scholar]
  40. Genant H. K., Cann C. E., Ettinger B., Gordan G. S. Quantitative computed tomography of vertebral spongiosa: a sensitive method for detecting early bone loss after oophorectomy. Ann Intern Med. 1982 Nov;97(5):699–705. doi: 10.7326/0003-4819-97-5-699. [DOI] [PubMed] [Google Scholar]
  41. Giannini S., D'Angelo A., Malvasi L., Castrignano R., Pati T., Tronca R., Liberto L., Nobile M., Crepaldi G. Effects of one-year cyclical treatment with clodronate on postmenopausal bone loss. Bone. 1993 Mar-Apr;14(2):137–141. doi: 10.1016/8756-3282(93)90240-b. [DOI] [PubMed] [Google Scholar]
  42. Gloth F. M., 3rd, Tobin J. D., Sherman S. S., Hollis B. W. Is the recommended daily allowance for vitamin D too low for the homebound elderly? J Am Geriatr Soc. 1991 Feb;39(2):137–141. doi: 10.1111/j.1532-5415.1991.tb01615.x. [DOI] [PubMed] [Google Scholar]
  43. Grady D., Rubin S. M., Petitti D. B., Fox C. S., Black D., Ettinger B., Ernster V. L., Cummings S. R. Hormone therapy to prevent disease and prolong life in postmenopausal women. Ann Intern Med. 1992 Dec 15;117(12):1016–1037. doi: 10.7326/0003-4819-117-12-1016. [DOI] [PubMed] [Google Scholar]
  44. Greenspan S. L., Neer R. M., Ridgway E. C., Klibanski A. Osteoporosis in men with hyperprolactinemic hypogonadism. Ann Intern Med. 1986 Jun;104(6):777–782. doi: 10.7326/0003-4819-104-6-777. [DOI] [PubMed] [Google Scholar]
  45. Harris S. T., Watts N. B., Jackson R. D., Genant H. K., Wasnich R. D., Ross P., Miller P. D., Licata A. A., Chesnut C. H., 3rd Four-year study of intermittent cyclic etidronate treatment of postmenopausal osteoporosis: three years of blinded therapy followed by one year of open therapy. Am J Med. 1993 Dec;95(6):557–567. doi: 10.1016/0002-9343(93)90350-x. [DOI] [PubMed] [Google Scholar]
  46. Heaney R. P., Avioli L. V., Chesnut C. H., 3rd, Lappe J., Recker R. R., Brandenburger G. H. Osteoporotic bone fragility. Detection by ultrasound transmission velocity. JAMA. 1989 May 26;261(20):2986–2990. doi: 10.1001/jama.261.20.2986. [DOI] [PubMed] [Google Scholar]
  47. Heaney R. P., Gallagher J. C., Johnston C. C., Neer R., Parfitt A. M., Whedon G. D. Calcium nutrition and bone health in the elderly. Am J Clin Nutr. 1982 Nov;36(5 Suppl):986–1013. doi: 10.1093/ajcn/36.5.986. [DOI] [PubMed] [Google Scholar]
  48. Heaney R. P. Thinking straight about calcium. N Engl J Med. 1993 Feb 18;328(7):503–505. doi: 10.1056/NEJM199302183280710. [DOI] [PubMed] [Google Scholar]
  49. Henderson B. E., Paganini-Hill A., Ross R. K. Estrogen replacement therapy and protection from acute myocardial infarction. Am J Obstet Gynecol. 1988 Aug;159(2):312–317. doi: 10.1016/s0002-9378(88)80074-7. [DOI] [PubMed] [Google Scholar]
  50. Herd R. J., Ramalingham T., Ryan P. J., Fogelman I., Blake G. M. Measurements of broadband ultrasonic attenuation in the calcaneus in premenopausal and postmenopausal women. Osteoporos Int. 1992 Sep;2(5):247–251. doi: 10.1007/BF01624149. [DOI] [PubMed] [Google Scholar]
  51. Horsman A., Gallagher J. C., Simpson M., Nordin B. E. Prospective trial of oestrogen and calcium in postmenopausal women. Br Med J. 1977 Sep 24;2(6090):789–792. doi: 10.1136/bmj.2.6090.789. [DOI] [PMC free article] [PubMed] [Google Scholar]
  52. Horsman A., Jones M., Francis R., Nordin C. The effect of estrogen dose on postmenopausal bone loss. N Engl J Med. 1983 Dec 8;309(23):1405–1407. doi: 10.1056/NEJM198312083092301. [DOI] [PubMed] [Google Scholar]
  53. Hui S. L., Slemenda C. W., Johnston C. C., Jr Baseline measurement of bone mass predicts fracture in white women. Ann Intern Med. 1989 Sep 1;111(5):355–361. doi: 10.7326/0003-4819-111-5-355. [DOI] [PubMed] [Google Scholar]
  54. Hurxthal L. M., Vose G. P., Dotter W. E. Densitometric and visual observations of spinal radiographs. Geriatrics. 1969 May;24(5):93–106. [PubMed] [Google Scholar]
  55. Hypothyroidism and enlarging thyroid mass in a young woman. Am J Med. 1993 Nov;95(5):534–541. doi: 10.1016/0002-9343(93)90338-p. [DOI] [PubMed] [Google Scholar]
  56. Johnston C. C., Jr, Slemenda C. W. Risk prediction in osteoporosis: a theoretic overview. Am J Med. 1991 Nov 25;91(5B):47S–48S. doi: 10.1016/0002-9343(91)90247-u. [DOI] [PubMed] [Google Scholar]
  57. Kanis J. A., McCloskey E. V. Epidemiology of vertebral osteoporosis. Bone. 1992;13 (Suppl 2):S1–10. doi: 10.1016/8756-3282(92)90189-4. [DOI] [PubMed] [Google Scholar]
  58. Kanis J. A., McCloskey E. V., Sirtori P., Khan S., Fern D., Eyres K., Aaron J., Beneton M. N. Rationale for the use of clodronate in osteoporosis. Osteoporos Int. 1993;3 (Suppl 2):S23–S28. doi: 10.1007/BF01623223. [DOI] [PubMed] [Google Scholar]
  59. Kaufman D. W., Miller D. R., Rosenberg L., Helmrich S. P., Stolley P., Schottenfeld D., Shapiro S. Noncontraceptive estrogen use and the risk of breast cancer. JAMA. 1984 Jul 6;252(1):63–67. [PubMed] [Google Scholar]
  60. Kelly P. J., Eisman J. A., Sambrook P. N. Interaction of genetic and environmental influences on peak bone density. Osteoporos Int. 1990 Oct;1(1):56–60. doi: 10.1007/BF01880417. [DOI] [PubMed] [Google Scholar]
  61. Kelsey J. L., Berkowitz G. S. Breast cancer epidemiology. Cancer Res. 1988 Oct 15;48(20):5615–5623. [PubMed] [Google Scholar]
  62. Kreiger N., Kelsey J. L., Holford T. R., O'Connor T. An epidemiologic study of hip fracture in postmenopausal women. Am J Epidemiol. 1982 Jul;116(1):141–148. doi: 10.1093/oxfordjournals.aje.a113388. [DOI] [PubMed] [Google Scholar]
  63. Liberman U. A., Weiss S. R., Bröll J., Minne H. W., Quan H., Bell N. H., Rodriguez-Portales J., Downs R. W., Jr, Dequeker J., Favus M. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. N Engl J Med. 1995 Nov 30;333(22):1437–1443. doi: 10.1056/NEJM199511303332201. [DOI] [PubMed] [Google Scholar]
  64. Lindsay R., Hart D. M., Aitken J. M., MacDonald E. B., Anderson J. B., Clarke A. C. Long-term prevention of postmenopausal osteoporosis by oestrogen. Evidence for an increased bone mass after delayed onset of oestrogen treatment. Lancet. 1976 May 15;1(7968):1038–1041. doi: 10.1016/s0140-6736(76)92217-0. [DOI] [PubMed] [Google Scholar]
  65. Lindsay R., Hart D. M., Clark D. M. The minimum effective dose of estrogen for prevention of postmenopausal bone loss. Obstet Gynecol. 1984 Jun;63(6):759–763. [PubMed] [Google Scholar]
  66. Lindsay R., Hart D. M., Forrest C., Baird C. Prevention of spinal osteoporosis in oophorectomised women. Lancet. 1980 Nov 29;2(8205):1151–1154. doi: 10.1016/s0140-6736(80)92592-1. [DOI] [PubMed] [Google Scholar]
  67. Lindsay R., Tohme J., Kanders B. The effect of oral contraceptive use on vertebral bone mass in pre- and post-menopausal women. Contraception. 1986 Oct;34(4):333–340. doi: 10.1016/0010-7824(86)90086-7. [DOI] [PubMed] [Google Scholar]
  68. Long R. G., Meinhard E., Skinner R. K., Varghese Z., Wills M. R., Sherlock S. Clinical, biochemical, and histological studies of osteomalacia, osteoporosis, and parathyroid function in chronic liver disease. Gut. 1978 Feb;19(2):85–90. doi: 10.1136/gut.19.2.85. [DOI] [PMC free article] [PubMed] [Google Scholar]
  69. Lukert B. P., Raisz L. G. Glucocorticoid-induced osteoporosis: pathogenesis and management. Ann Intern Med. 1990 Mar 1;112(5):352–364. doi: 10.7326/0003-4819-112-5-352. [DOI] [PubMed] [Google Scholar]
  70. Mamelle N., Meunier P. J., Dusan R., Guillaume M., Martin J. L., Gaucher A., Prost A., Zeigler G., Netter P. Risk-benefit ratio of sodium fluoride treatment in primary vertebral osteoporosis. Lancet. 1988 Aug 13;2(8607):361–365. doi: 10.1016/s0140-6736(88)92834-6. [DOI] [PubMed] [Google Scholar]
  71. Manning P. J., Evans M. C., Reid I. R. Normal bone mineral density following cure of Cushing's syndrome. Clin Endocrinol (Oxf) 1992 Mar;36(3):229–234. doi: 10.1111/j.1365-2265.1992.tb01437.x. [DOI] [PubMed] [Google Scholar]
  72. Matkovic V., Fontana D., Tominac C., Goel P., Chesnut C. H., 3rd Factors that influence peak bone mass formation: a study of calcium balance and the inheritance of bone mass in adolescent females. Am J Clin Nutr. 1990 Nov;52(5):878–888. doi: 10.1093/ajcn/52.5.878. [DOI] [PubMed] [Google Scholar]
  73. Matsuoka L. Y., Ide L., Wortsman J., MacLaughlin J. A., Holick M. F. Sunscreens suppress cutaneous vitamin D3 synthesis. J Clin Endocrinol Metab. 1987 Jun;64(6):1165–1168. doi: 10.1210/jcem-64-6-1165. [DOI] [PubMed] [Google Scholar]
  74. Mellström D., Johansson C., Johnell O., Lindstedt G., Lundberg P. A., Obrant K., Schön I. M., Toss G., Ytterberg B. O. Osteoporosis, metabolic aberrations, and increased risk for vertebral fractures after partial gastrectomy. Calcif Tissue Int. 1993 Dec;53(6):370–377. [PubMed] [Google Scholar]
  75. Melton L. J., 3rd, Chrischilles E. A., Cooper C., Lane A. W., Riggs B. L. Perspective. How many women have osteoporosis? J Bone Miner Res. 1992 Sep;7(9):1005–1010. doi: 10.1002/jbmr.5650070902. [DOI] [PubMed] [Google Scholar]
  76. Melton L. J., 3rd, Eddy D. M., Johnston C. C., Jr Screening for osteoporosis. Ann Intern Med. 1990 Apr 1;112(7):516–528. doi: 10.7326/0003-4819-112-7-516. [DOI] [PubMed] [Google Scholar]
  77. Melton L. J., 3rd, Kan S. H., Frye M. A., Wahner H. W., O'Fallon W. M., Riggs B. L. Epidemiology of vertebral fractures in women. Am J Epidemiol. 1989 May;129(5):1000–1011. doi: 10.1093/oxfordjournals.aje.a115204. [DOI] [PubMed] [Google Scholar]
  78. Nabulsi A. A., Folsom A. R., White A., Patsch W., Heiss G., Wu K. K., Szklo M. Association of hormone-replacement therapy with various cardiovascular risk factors in postmenopausal women. The Atherosclerosis Risk in Communities Study Investigators. N Engl J Med. 1993 Apr 15;328(15):1069–1075. doi: 10.1056/NEJM199304153281501. [DOI] [PubMed] [Google Scholar]
  79. Nachtigall L. E., Nachtigall R. H., Nachtigall R. D., Beckman E. M. Estrogen replacement therapy I: a 10-year prospective study in the relationship to osteoporosis. Obstet Gynecol. 1979 Mar;53(3):277–281. [PubMed] [Google Scholar]
  80. Nevitt M. C., Johnell O., Black D. M., Ensrud K., Genant H. K., Cummings S. R. Bone mineral density predicts non-spine fractures in very elderly women. Study of Osteoporotic Fractures Research Group. Osteoporos Int. 1994 Nov;4(6):325–331. doi: 10.1007/BF01622192. [DOI] [PubMed] [Google Scholar]
  81. Obrant K. J., Bengnér U., Johnell O., Nilsson B. E., Sernbo I. Increasing age-adjusted risk of fragility fractures: a sign of increasing osteoporosis in successive generations? Calcif Tissue Int. 1989 Mar;44(3):157–167. doi: 10.1007/BF02556558. [DOI] [PubMed] [Google Scholar]
  82. Orwoll E. S., Bauer D. C., Vogt T. M., Fox K. M. Axial bone mass in older women. Study of Osteoporotic Fractures Research Group. Ann Intern Med. 1996 Jan 15;124(2):187–196. doi: 10.7326/0003-4819-124-2-199601150-00001. [DOI] [PubMed] [Google Scholar]
  83. Ott S. M., Chesnut C. H., 3rd Calcitriol treatment is not effective in postmenopausal osteoporosis. Ann Intern Med. 1989 Feb 15;110(4):267–274. doi: 10.7326/0003-4819-110-4-267. [DOI] [PubMed] [Google Scholar]
  84. Overgaard K., Hansen M. A., Jensen S. B., Christiansen C. Effect of salcatonin given intranasally on bone mass and fracture rates in established osteoporosis: a dose-response study. BMJ. 1992 Sep 5;305(6853):556–561. doi: 10.1136/bmj.305.6853.556. [DOI] [PMC free article] [PubMed] [Google Scholar]
  85. Overgaard K., Riis B. J., Christiansen C., Pødenphant J., Johansen J. S. Nasal calcitonin for treatment of established osteoporosis. Clin Endocrinol (Oxf) 1989 Apr;30(4):435–442. doi: 10.1111/j.1365-2265.1989.tb00443.x. [DOI] [PubMed] [Google Scholar]
  86. Paganini-Hill A., Ross R. K., Gerkins V. R., Henderson B. E., Arthur M., Mack T. M. Menopausal estrogen therapy and hip fractures. Ann Intern Med. 1981 Jul;95(1):28–31. doi: 10.7326/0003-4819-95-1-28. [DOI] [PubMed] [Google Scholar]
  87. Pak C. Y., Sakhaee K., Adams-Huet B., Piziak V., Peterson R. D., Poindexter J. R. Treatment of postmenopausal osteoporosis with slow-release sodium fluoride. Final report of a randomized controlled trial. Ann Intern Med. 1995 Sep 15;123(6):401–408. doi: 10.7326/0003-4819-123-6-199509150-00001. [DOI] [PubMed] [Google Scholar]
  88. Persson I., Adami H. O., Bergkvist L., Lindgren A., Pettersson B., Hoover R., Schairer C. Risk of endometrial cancer after treatment with oestrogens alone or in conjunction with progestogens: results of a prospective study. BMJ. 1989 Jan 21;298(6667):147–151. doi: 10.1136/bmj.298.6667.147. [DOI] [PMC free article] [PubMed] [Google Scholar]
  89. Podsiadlo D., Richardson S. The timed "Up & Go": a test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991 Feb;39(2):142–148. doi: 10.1111/j.1532-5415.1991.tb01616.x. [DOI] [PubMed] [Google Scholar]
  90. Prior J. C., Vigna Y. M., Schechter M. T., Burgess A. E. Spinal bone loss and ovulatory disturbances. N Engl J Med. 1990 Nov 1;323(18):1221–1227. doi: 10.1056/NEJM199011013231801. [DOI] [PubMed] [Google Scholar]
  91. Prough S. G., Aksel S., Wiebe R. H., Shepherd J. Continuous estrogen/progestin therapy in menopause. Am J Obstet Gynecol. 1987 Dec;157(6):1449–1453. doi: 10.1016/s0002-9378(87)80242-9. [DOI] [PubMed] [Google Scholar]
  92. Province M. A., Hadley E. C., Hornbrook M. C., Lipsitz L. A., Miller J. P., Mulrow C. D., Ory M. G., Sattin R. W., Tinetti M. E., Wolf S. L. The effects of exercise on falls in elderly patients. A preplanned meta-analysis of the FICSIT Trials. Frailty and Injuries: Cooperative Studies of Intervention Techniques. JAMA. 1995 May 3;273(17):1341–1347. [PubMed] [Google Scholar]
  93. Ray W. A., Griffin M. R., Baugh D. K. Mortality following hip fracture before and after implementation of the prospective payment system. Arch Intern Med. 1990 Oct;150(10):2109–2114. [PubMed] [Google Scholar]
  94. Recker R. R., Davies K. M., Hinders S. M., Heaney R. P., Stegman M. R., Kimmel D. B. Bone gain in young adult women. JAMA. 1992 Nov 4;268(17):2403–2408. [PubMed] [Google Scholar]
  95. Reginster J. Y., Lecart M. P., Deroisy R., Sarlet N., Denis D., Ethgen D., Collette J., Franchimont P. Prevention of postmenopausal bone loss by tiludronate. Lancet. 1989 Dec 23;2(8678-8679):1469–1471. doi: 10.1016/s0140-6736(89)92927-9. [DOI] [PubMed] [Google Scholar]
  96. Reid I. R., King A. R., Alexander C. J., Ibbertson H. K. Prevention of steroid-induced osteoporosis with (3-amino-1-hydroxypropylidene)-1,1-bisphosphonate (APD). Lancet. 1988 Jan 23;1(8578):143–146. doi: 10.1016/s0140-6736(88)92721-3. [DOI] [PubMed] [Google Scholar]
  97. Riggs B. L., Melton L. J., 3rd Involutional osteoporosis. N Engl J Med. 1986 Jun 26;314(26):1676–1686. doi: 10.1056/NEJM198606263142605. [DOI] [PubMed] [Google Scholar]
  98. Riggs B. L., Melton L. J., 3rd The prevention and treatment of osteoporosis. N Engl J Med. 1992 Aug 27;327(9):620–627. doi: 10.1056/NEJM199208273270908. [DOI] [PubMed] [Google Scholar]
  99. Ross P. D., Davis J. W., Epstein R. S., Wasnich R. D. Pre-existing fractures and bone mass predict vertebral fracture incidence in women. Ann Intern Med. 1991 Jun 1;114(11):919–923. doi: 10.7326/0003-4819-114-11-919. [DOI] [PubMed] [Google Scholar]
  100. Ross P. D., Davis J. W., Vogel J. M., Wasnich R. D. A critical review of bone mass and the risk of fractures in osteoporosis. Calcif Tissue Int. 1990 Mar;46(3):149–161. doi: 10.1007/BF02555036. [DOI] [PubMed] [Google Scholar]
  101. Ross P., Huang C., Davis J., Imose K., Yates J., Vogel J., Wasnich R. Predicting vertebral deformity using bone densitometry at various skeletal sites and calcaneus ultrasound. Bone. 1995 Mar;16(3):325–332. doi: 10.1016/8756-3282(94)00045-x. [DOI] [PubMed] [Google Scholar]
  102. Rubin C. T., Lanyon L. E. Regulation of bone formation by applied dynamic loads. J Bone Joint Surg Am. 1984 Mar;66(3):397–402. [PubMed] [Google Scholar]
  103. Rubin S. M., Cummings S. R. Results of bone densitometry affect women's decisions about taking measures to prevent fractures. Ann Intern Med. 1992 Jun 15;116(12 Pt 1):990–995. doi: 10.7326/0003-4819-116-12-990. [DOI] [PubMed] [Google Scholar]
  104. Sattin R. W. Falls among older persons: a public health perspective. Annu Rev Public Health. 1992;13:489–508. doi: 10.1146/annurev.pu.13.050192.002421. [DOI] [PubMed] [Google Scholar]
  105. Seeman E., Hopper J. L., Bach L. A., Cooper M. E., Parkinson E., McKay J., Jerums G. Reduced bone mass in daughters of women with osteoporosis. N Engl J Med. 1989 Mar 2;320(9):554–558. doi: 10.1056/NEJM198903023200903. [DOI] [PubMed] [Google Scholar]
  106. Sernbo I., Johnell O. Consequences of a hip fracture: a prospective study over 1 year. Osteoporos Int. 1993 May;3(3):148–153. doi: 10.1007/BF01623276. [DOI] [PubMed] [Google Scholar]
  107. Shapiro S., Kelly J. P., Rosenberg L., Kaufman D. W., Helmrich S. P., Rosenshein N. B., Lewis J. L., Jr, Knapp R. C., Stolley P. D., Schottenfeld D. Risk of localized and widespread endometrial cancer in relation to recent and discontinued use of conjugated estrogens. N Engl J Med. 1985 Oct 17;313(16):969–972. doi: 10.1056/NEJM198510173131601. [DOI] [PubMed] [Google Scholar]
  108. Skingle S. J., Crisp A. J. Increased bone density in patients on steroids with etidronate. Lancet. 1994 Aug 20;344(8921):543–544. doi: 10.1016/s0140-6736(94)91932-1. [DOI] [PubMed] [Google Scholar]
  109. Stampfer M. J., Willett W. C., Colditz G. A., Rosner B., Speizer F. E., Hennekens C. H. A prospective study of postmenopausal estrogen therapy and coronary heart disease. N Engl J Med. 1985 Oct 24;313(17):1044–1049. doi: 10.1056/NEJM198510243131703. [DOI] [PubMed] [Google Scholar]
  110. Steiger P., Cummings S. R., Black D. M., Spencer N. E., Genant H. K. Age-related decrements in bone mineral density in women over 65. J Bone Miner Res. 1992 Jun;7(6):625–632. doi: 10.1002/jbmr.5650070606. [DOI] [PubMed] [Google Scholar]
  111. Steinberg K. K., Thacker S. B., Smith S. J., Stroup D. F., Zack M. M., Flanders W. D., Berkelman R. L. A meta-analysis of the effect of estrogen replacement therapy on the risk of breast cancer. JAMA. 1991 Apr 17;265(15):1985–1990. [PubMed] [Google Scholar]
  112. Stevenson J. C., Cust M. P., Gangar K. F., Hillard T. C., Lees B., Whitehead M. I. Effects of transdermal versus oral hormone replacement therapy on bone density in spine and proximal femur in postmenopausal women. Lancet. 1990 Aug 4;336(8710):265–269. doi: 10.1016/0140-6736(90)91801-g. [DOI] [PubMed] [Google Scholar]
  113. Storm T., Thamsborg G., Steiniche T., Genant H. K., Sørensen O. H. Effect of intermittent cyclical etidronate therapy on bone mass and fracture rate in women with postmenopausal osteoporosis. N Engl J Med. 1990 May 3;322(18):1265–1271. doi: 10.1056/NEJM199005033221803. [DOI] [PubMed] [Google Scholar]
  114. Tilyard M. W., Spears G. F., Thomson J., Dovey S. Treatment of postmenopausal osteoporosis with calcitriol or calcium. N Engl J Med. 1992 Feb 6;326(6):357–362. doi: 10.1056/NEJM199202063260601. [DOI] [PubMed] [Google Scholar]
  115. Tinetti M. E., Speechley M., Ginter S. F. Risk factors for falls among elderly persons living in the community. N Engl J Med. 1988 Dec 29;319(26):1701–1707. doi: 10.1056/NEJM198812293192604. [DOI] [PubMed] [Google Scholar]
  116. Tosteson A. N., Rosenthal D. I., Melton L. J., 3rd, Weinstein M. C. Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy. Ann Intern Med. 1990 Oct 15;113(8):594–603. doi: 10.7326/0003-4819-113-8-594. [DOI] [PubMed] [Google Scholar]
  117. Turner C. H., Peacock M., Timmerman L., Neal J. M., Johnson C. C., Jr Calcaneal ultrasonic measurements discriminate hip fracture independently of bone mass. Osteoporos Int. 1995 Mar;5(2):130–135. doi: 10.1007/BF01623314. [DOI] [PubMed] [Google Scholar]
  118. Watts N. B., Harris S. T., Genant H. K., Wasnich R. D., Miller P. D., Jackson R. D., Licata A. A., Ross P., Woodson G. C., 3rd, Yanover M. J. Intermittent cyclical etidronate treatment of postmenopausal osteoporosis. N Engl J Med. 1990 Jul 12;323(2):73–79. doi: 10.1056/NEJM199007123230201. [DOI] [PubMed] [Google Scholar]
  119. Webb A. R., Kline L., Holick M. F. Influence of season and latitude on the cutaneous synthesis of vitamin D3: exposure to winter sunlight in Boston and Edmonton will not promote vitamin D3 synthesis in human skin. J Clin Endocrinol Metab. 1988 Aug;67(2):373–378. doi: 10.1210/jcem-67-2-373. [DOI] [PubMed] [Google Scholar]
  120. Weinstein L. Efficacy of a continuous estrogen-progestin regimen in the menopausal patient. Obstet Gynecol. 1987 Jun;69(6):929–932. [PubMed] [Google Scholar]
  121. Weinstein R. S., Bryce G. F., Sappington L. J., King D. W., Gallagher B. B. Decreased serum ionized calcium and normal vitamin D metabolite levels with anticonvulsant drug treatment. J Clin Endocrinol Metab. 1984 Jun;58(6):1003–1009. doi: 10.1210/jcem-58-6-1003. [DOI] [PubMed] [Google Scholar]
  122. White B. L., Fisher W. D., Laurin C. A. Rate of mortality for elderly patients after fracture of the hip in the 1980's. J Bone Joint Surg Am. 1987 Dec;69(9):1335–1340. [PubMed] [Google Scholar]
  123. Whitehead M. I., Townsend P. T., Pryse-Davies J., Ryder T., Lane G., Siddle N. C., King R. J. Effects of various types and dosages of progestogens on the postmenopausal endometrium. J Reprod Med. 1982 Aug;27(8 Suppl):539–548. [PubMed] [Google Scholar]
  124. Whitehead M. I., Townsend P. T., Pryse-Davies J., Ryder T., Lane G., Siddle N. C., King R. J. Effects of various types and dosages of progestogens on the postmenopausal endometrium. J Reprod Med. 1982 Aug;27(8 Suppl):539–548. [PubMed] [Google Scholar]
  125. Williams J. K., Adams M. R., Klopfenstein H. S. Estrogen modulates responses of atherosclerotic coronary arteries. Circulation. 1990 May;81(5):1680–1687. doi: 10.1161/01.cir.81.5.1680. [DOI] [PubMed] [Google Scholar]
  126. Wolf S. L., Kutner N. G., Green R. C., McNeely E. The Atlanta FICSIT study: two exercise interventions to reduce frailty in elders. J Am Geriatr Soc. 1993 Mar;41(3):329–332. doi: 10.1111/j.1532-5415.1993.tb06713.x. [DOI] [PubMed] [Google Scholar]
  127. Yendt E. R., Cohanim M., Jarzylo S., Jones G., Rosenberg G. Reduced creatinine clearance in primary osteoporosis in women. J Bone Miner Res. 1993 Sep;8(9):1045–1052. doi: 10.1002/jbmr.5650080904. [DOI] [PubMed] [Google Scholar]
  128. el-Hajj Fuleihan G., Brown E. M., Curtis K., Berger M. J., Berger B. M., Gleason R., LeBoff M. S. Effect of sequential and daily continuous hormone replacement therapy on indexes of mineral metabolism. Arch Intern Med. 1992 Sep;152(9):1904–1909. doi: 10.1001/archinte.152.9.1904. [DOI] [PubMed] [Google Scholar]
  129. von der Recke P., Hansen M. A., Overgaard K., Christiansen C. The impact of degenerative conditions in the spine on bone mineral density and fracture risk prediction. Osteoporos Int. 1996;6(1):43–49. doi: 10.1007/BF01626537. [DOI] [PubMed] [Google Scholar]

Articles from CMAJ: Canadian Medical Association Journal are provided here courtesy of Canadian Medical Association

RESOURCES