Effects of aerobic training on bone mineral density of postmenopausal women.

A total of 76 women were enrolled and 55 naturally postmenopausal women completed a 12 month study investigating the effects of aerobic training plus calcium supplementation on lumbar (L2-4) bone mineral density (BMD) and forearm BMD. Training was conducted on treadmills at 70-85% of maximal heart rate for 30 or 45 minutes, three times per week for 12 months. Lumbar BMD was measured with dual-photon absorptiometry and forearm BMD with single-photon absorptiometry. Groups were similar with respect to age, weight, months since menopause, height, maximal oxygen uptake (VO2max), and lumbar and forearm BMD upon entering the study. Following training, percentage changes in VO2max were significantly different between the control and exercise groups but not between exercise groups. ANOVA evaluating lumbar BMD revealed a nonsignificant interaction effect and no significant changes (p > 0.05) between groups or times. The control (N = 19), 30 minute (N = 20), and 45 minute (N = 16) groups percentage lumbar BMD changes (X +/- SD) over 12 months were -0.61 +/- 3.40, -0.48 +/- 3.63, and 0.81 +/- 4.53%, respectively. The 95% confidence limits for percentage changes in lumbar BMD for the control, 30 minute, and 45 minute groups were -2.25 to 1.02, -2.18 to 1.22, and -1.16 to 3.22%, respectively. Forearm BMD changes were also not significant. Improvement in lumbar BMD was weakly but positively correlated with improvements in VO2max, r = 0.28, p < 0.05. Women < or = 6 years of the onset of menopause had an accelerated lumbar BMD loss compared to subjects who were > 6 years postmenopausal, and this subset's BMD changes were examined.(ABSTRACT TRUNCATED AT 250 WORDS)

Estrogen therapy and variable-resistance weight training increase bone mineral in surgically menopausal women.

This study was undertaken to examine the effect of estrogen replacement therapy alone and estrogen replacement therapy plus variable-resistance weight training on the bone mineral content of surgically menopausal women. A total of 20 surgically menopausal women were randomized and treated with either 0.625 mg conjugated estrogen daily or the same dose of estrogen plus a closely monitored exercise program involving the use of Nautilus muscle strengthening/endurance equipment. After 1 year's observation, the bone mineral density (BMD) of the spine determined by dual-photon absorptiometry increased in the exercising subjects by 8.3 +/- 5.3% (p = 0.004), 95% confidence limits (CL) 3.9-12.8%; the group with estrogen replacement therapy alone maintained their BMD: 1.5 +/- 12.4% (p = 0.36; 95% CL = -6.9-9.8%). The total body BMD of the exercising group increased by 2.1 +/- 1.5% (p = 0.003; 95% CL = 0.8-3.3%); the nonexercising women had a nonsignificant 0.6 +/- 2.9% change (p = 0.30; 95% CL = -1.4-2.5%). A significant increase of 4.1 +/- 4.3% (p = 0.01; 95% CL = 0.8-7.4%) in the radial midshaft BMD of the exercising group was found; the estrogen alone group recorded a nonsignificant change of -0.3 +/- 3.1% (p = 0.33; 95% CL = -1.7-2.4%). The results of this study suggest that variable-resistance training in estrogen-replete women adds bone to both the axial and appendicular skeleton.

Axial and peripheral bone density and nutrient intakes of postmenopausal vegetarian and omnivorous women.

The study investigated whether differences exist between postmenopausal Caucasian vegetarian and omnivorous women regarding trabecular and cortical bone density measured with single- and dual-photon absorptiometry. Anthropometric measurements, blood and urine samples, and food intakes of the twenty-eight matched pairs were also compared. The Wilcoxon signed-rank test indicated no significant differences in bone measurements between vegetarians and omnivores at any sites except the skull. The vegetarians' serum globulin and total protein measured higher. Urine calcium and creatinine were similar between the groups. The vegetarians consumed greater quantities of carbohydrate, fiber, magnesium, ascorbic acid, copper, and energy as percent carbohydrate, and lower quantities of protein, niacin, alcohol, vitamin B-12, cholesterol, and energy as percent protein. Despite several differences in dietary intakes, the results indicate that neither cortical nor trabecular bone density in these postmenopausal women was affected by a lactoovovegetarian diet.

Hormone replacement therapy in postmenopausal women: urinary N-telopeptide of type I collagen monitors therapeutic effect and predicts response of bone mineral density.

PURPOSE: To assess the ability of the urinary N-telopeptide of type I collagen (NTx) to monitor and predict therapeutic effects of hormone replacement therapy (HRT) in postmenopausal women. PATIENTS AND METHODS: To assess the relationship between baseline or change in NTx (predictive variable), and change in lumbar and hip bone mineral density (BMD; outcome variable), we conducted a 2-year randomized controlled study at academic university and private practice medical centers in 236 healthy women 1 to 3 years postmenopausal; 227 women completed the study. Women received estrogen plus progesterone plus calcium (treated group) or calcium alone (control group). RESULTS: In the treated group NTx significantly (P < 0.0001) decreased, and spine and hip BMD significantly (P < 0.00001 and P < 0.005, respectively) increased; in the control group NTx did not change but BMD decreased significantly (P < 0.01). Subjects in the highest quartiles for baseline NTx (67 to 188 units) or decreasing NTx (-66% to -87%) through 6 months demonstrated the greatest gain in BMD in response to HRT (P < 0.05 and P < 0.005). For every increase of 30 units in baseline NTx the odds of gain in BMD in response to HRT increased by a factor of 5.0 (95% confidence interval [CI] 1.9 to 13.3); for every 30% decrease in NTx through 6 months, the odds of gaining BMD in response to HRT increased by a factor of 2.6 (95% CI 1.6 to 4.4). In the control group an increase of 30 units in mean NTx across the study indicated a higher odds of losing BMD by a factor of 3.2 (95% CI 1.6 to 6.5). A high baseline NTx (> 67 units) indicated a 17.3 times higher risk of BMD loss if not treated with HRT. CONCLUSION: These data support the clinical utility of NTx to monitor the antiresorptive effect of HRT in recently postmenopausal women, and to predict changes in BMD in response to HRT.

Regulation of cytochrome P-450-dependent catechol estrogen formation in rat liver microsomes. Evidence for involvement of estrogen receptors.

Experiments were conducted to evaluate whether estrogen 2-hydroxylase activity in liver microsomes, the main pathway for oxidative metabolism of estrogens in the rat, is regulated by administration of synthetic estrogens. Ovariectomized rats were treated with ethinylestradiol (EE), 100 micrograms s.c. for 3 days. Liver microsomes from EE-treated animals showed a 2-fold increase over control in estrogen 2-hydroxylase activity measured over a substrate concentration range of 0.5 to 50 microM. Double-reciprocal plots of enzyme activity as a function of substrate concentration were linear; apparent Vmax values were 2-fold greater in microsomes from EE-treated animals while apparent Km values for control and EE preparations were not different. Administration of the triphenylethylene antiestrogen tamoxifen (TAM), 100 micrograms s.c. for 3 days, did not affect microsomal catechol estrogen formation activity, and apparent Km and Vmax values were comparable with controls. When EE and TAM were co-administered, no increase in microsomal estrogen 2-hydroxylase was observed, and apparent Km and Vmax values were not different from either control of TAM-treated preparations. Thus, acute administration of EE was associated with a specific increase in the apparent Vmax of estrogen 2-OHase activity, and this effect was not observed when TAM was co-administered with the estrogen.

Suppression of vasomotor and vulvovaginal symptoms with continuous oral 17beta-estradiol.

OBJECTIVES: To evaluate the efficacy and safety of different doses of 173-estradiol for the treatment of vasomotor and vulvovaginal symptoms. DESIGN: This was a randomized, double-blind, multicenter, parallel-group study. One hundred forty-five subjects, including naturally postmenopausal women aged 40-60 (who had not experienced menses for at least 12 months), women who had undergone hysterectomy, and women aged 25-60 who had undergone bilateral oophorectomy with or without hysterectomy were studied. Either placebo or 17beta-estradiol (1 mg or 0.5 mg) was given orally every day for 12 weeks, and vasomotor symptoms and vaginal epithelial cytology were evaluated. RESULTS: There were significant differences between placebo and the active treatments in the percentage change from baseline in the number of hot flushes (all hot flushes, 1 mg vs. placebo, p < 0.00 1; 0.5 mg vs. placebo, p = 0.007), with a more substantial proportion of subjects responding in the 1-mg group (mean change in mean number of hot flushes of 83.2%). Both doses were also more effective than placebo in increasing the proportion of mature vaginal cells (end-of-treatment mean values of 0%, 78.5%, and 21.5% for parabasal, intermediate, and superficial cells, respectively, in the 1-mg group; mean values of 0.3%, 80.8%, and 18.9% in the 0.5-mg group; and mean values of 15.2%, 74.7%, and 10.2% in the placebo group). The proportion of subjects reporting no vaginal dryness was greatest in the 1-mg group (mean percentage of days without dryness of 86.1% at weeks 9-12). CONCLUSIONS: For the relief of vasomotor and vulvovaginal symptoms, 17beta-estradiol I mg is effective and has an excellent safety profile.

The effect of site of application on the transcutaneous absorption of 17-beta estradiol from a transdermal delivery system (Climara).

OBJECTIVE: The effect of site of application on 17-beta estradiol bioavailability was assessed in an open-label, randomized, crossover study of a once-weekly transdermal estradiol patch (Climara). DESIGN: After placement of a transdermal patch delivering 0.1 mg/day of estradiol on either the buttocks or abdomen, serial plasma samples were obtained over 7 days and for the immediate 24 h after patch removal. Plasma estradiol concentrations were used to estimate pharmacokinetic parameters for the rate and extent of absorption between the two sites. RESULTS: Plasma estradiol concentrations were sustained at premenopausal levels over the week in most subjects. After application on the buttock, mean peak plasma concentration (Cmax) was 125.1% and mean relative bioavailability (AUC(0-168)) was 117.2% of that from the abdomen site. CONCLUSIONS: In summary, the buttocks seem to be an acceptable site for the application for this once-weekly 17-beta estradiol transdermal delivery system. Because the extent of absorption was significantly more for buttock than for abdomen application, this application site may provide an advantage in women who experience menopausal symptoms at the end of the week.

Plasma insulin response following oral and intravenous glucose in pregnant diabetic women.

The acute release of insulin in most pregnant diabetic patients is sluggish. A study was undertaken to determine whether this abnormality was due to a relative insensitivity of the beta cell to glucose or to an attenuation of the enteroinsular axis. The plasma insulin response to intravenous and oral glucose was studied in third trimester pregnant insulin-independent diabetic and normal control patients. The results suggest that the sensitivity of beta cell reaction to glucose in the diabetic group was reduced and that this may be related in part to a defective enteroinsular response. Quantitative endocrine hypofunction, as evidenced by lowered plasma insulin levels, was also noted among the pregnant diabetic patients. The results are discussed in relation to the pathogenesis of disturbed carbohydrate metabolism in insulin-independent pregnant diabetic patients.

Growth hormone secretion in insulin-independent pregnant diabetics.

A study was initiated to determine whether hypersecretion of growth hormone (HGH) was involved in the inhibition of normal glucose metabolism in pregnant insulin-independent diabetic (IID). A total of 25 patients was studied, of whom 13 had normal glucose tolerance and 12 were recently diagnosed IIDs. Hgh secretion was stimulated by insulin-induced hypoglycemia. The mean basal HGH levels and the plasma HGH pattern following the insulin stimulus were similar in the study group and the normal controls. Although it is unlikely that HGH participates to any significant degree in the diabetogenicity of normal and diabetic pregnancy, final proof depends on the assessment of the biologically active inhibitory polypeptide fraction of HGH and the growth-promoting protein, somatomedin.

Estradiol absorption from vaginal tablets in postmenopausal women.

OBJECTIVE: To evaluate absorption of estradiol (E2) and compare two low doses of 17 beta-E2 (25 microgram and 10 microgram) in postmenopausal women with atrophic vaginitis. METHODS: In a double-masked, randomized, parallel-group study, 58 postmenopausal women were treated with 25 microgram or 10 microgram of 17 beta-E2 for 12 weeks. We report data for 42 eligible subjects who had serum E2 concentrations below 20 pg/mL at baseline and complete data available at the baseline visit (30 minutes before tablet insertion) and weeks 2 and 12. Serum E2 and FSH concentrations were measured at specified intervals. The area under the curve, maximal concentration, and time to maximal concentration were measured for serum E2 concentrations. Maturation values of vaginal epithelial cells were assessed as indicators of change in vaginal epithelium condition in response to treatment. RESULTS: After 12 weeks of treatment, the area under the curve, maximal and average over 24-hour E2 concentration were higher in the 25-microgram (563 pg. hour/mL, 49 and 23 pg/mL) than in the 10-microgram (264 pg. hour/mL, 22 and 11 pg/mL) group. Seventy-four percent in the 25-microgram and 96% in the 10-microgram groups had low systemic absorption of E2, that is, area under the curve (0-24 hour) less than 500 pg/mL. All but three women who received 25 microgram had mean FSH levels below 35 mIU/mL. CONCLUSION: Treatment with 25 or 10 microgram of 17 beta-E2 vaginal tablets resulted in low absorption of estrogen without systemic effects often associated with hormone replacement therapy. After 12 weeks of therapy for atrophic vaginitis, absorption patterns remained consistent, and women did not have accumulations of circulating E2.

Coagulation and fibrinolysis in estrogen-treated surgically menopausal women.

The short-term effects of different types and doses of estrogen therapy on coagulation and fibrinolysis were studied in 35 surgically menopausal women. Dynamic tests of the coagulation cascade, tests indicative of ongoing, intravascular coagulation, and assessments of coagulation inhibition and fibrinolysis were performed. No clinically abnormal responses were found with the tested regimens--1 and 2 mg of 17 beta-estradiol and 0.625 and 1.25 mg of conjugated equine estrogens. Increased plasminogen antigen and activity were found with the conjugated estrogens but not with the 17 beta-estradiol preparations. The age of the woman had no effect on either the direction or magnitude of response to treatment. Estrogen therapy at the reported doses does not appear to adversely affect the coagulation-fibrinolysis systems of surgically menopausal women. Based on their ability to enhance plasminogen activity, conjugated estrogens may be preferred over the 17 beta-estradiol preparations for this clinical population.

Metabolic and hormonal effects of 25-mg and 50-mg 17 beta-estradiol implants in surgically menopausal women.

A prospective study involving 12 surgically menopausal women was undertaken to determine whether 17 beta-estradiol pellets could maintain bone mineral content without inducing adverse cardiovascular side effects. Surgically menopausal women were randomly selected to have either 25-mg or 50-mg pellets implanted subcutaneously. The bone mineral content of the midshaft of the nondominant radius in the combined group--measured by single photon absorptiometry--increased by 1.8% over the two-year period of observation (P less than .03); the distal bone mineral content of the radius was maintained at 0.8% per annum. No adverse effects were noted in the coagulation profiles or in the coagulation inhibition and fibrinolysis assays of both groups. Serum high-density lipoprotein cholesterol and triglycerides were unaltered, but serum cholesterol values decreased during the six-month period of observation by 14 mg/dL (P less than .05) and 11 mg/dL in the 25- and 50-mg groups, respectively. Carbohydrate and insulin metabolism was unaffected, as was the systolic and diastolic blood pressure. There were no significant intergroup differences in any of the parameters measured. The serum estradiol/estrone ratios of 1.45 and 1.59 reflected a physiologic estrogen milieu at the 25- and 50-mg dosages. Subcutaneous 17 beta-estradiol pellets can effectively maintain the bone mineral content of surgically menopausal women without inducing adverse cardiovascular side effects.

Effect of long-term triphasic oral contraceptive use on glucose tolerance and insulin secretion.

This study was designed to compare the effects of two low-dose triphasic oral contraceptives (OCs) on glucose tolerance and insulin secretion. Fifty-seven women were randomized to receive OCs containing ethinyl estradiol and either levonorgestrel or norethindrone. Ten subjects using nonhormonal contraception served as controls. Glucose tolerance and insulin secretion were measured at baseline and at 6 and 12 months after an oral glucose stimulus. Both preparations produced a relative hyperglycemia at 6 and 12 months compared with baseline, but within the norms for glucose tolerance. The insulin response, measured in 48 treated and eight control subjects, also increased over 12 months in both treated groups, but the total insulin area was within the range of the reference laboratory. Such minor changes have not been associated with cardiovascular diseases and support the safety of low-dose triphasic preparations.

Painless abruptio placentae.

Three cases of abruption of a posteriorly inserted fundal placenta are described. This condition is characterized by vaginal bleeding associated with backache, a nontender uterus, and if unrecognized, high fetal mortality. Ultrasonography permits early recognition and definitive diagnosis. Fetal survival is ensured by closely supervised monitoring and early recourse to cesarean section.

Combination estrogen and progestogen replacement therapy does not adversely affect coagulation.

Coagulation and fibrinolysis profiles of naturally menopausal women receiving conjugated estrogens (0.625 or 1.25 mg for 21 of 28 days) and medroxyprogesterone acetate (10 mg for seven of 28 days) for 18 months were compared with those of similar women receiving no hormone therapy. Tests indicative of the dynamics of the coagulation cascade, ongoing intravascular coagulation, and anticoagulation were performed. Hormone therapy had no effect on prothrombin times, activated partial thromboplastin times, or thrombin times. There was no evidence of intravascular coagulation in any of the groups as assessed by platelet counts, fibrinogen antigen and activity, and fibrin degradation products. Antithrombin III antigen and activity, alpha 1-antitrypsin antigen, and alpha 2-macroglobulin antigen, the natural inhibitors of coagulation, were also unaffected by hormone therapy. Plasminogen antigen levels were unaffected, but plasminogen activity was enhanced in the hormone-treated groups, suggesting a stimulatory effect on fibrinolysis. These data indicate that in terms of the coagulation system, healthy women can safely use a combined regimen of conjugated estrogens and medroxyprogesterone acetate.

Initial 17beta-estradiol dose for treating vasomotor symptoms.

OBJECTIVE: To compare the efficacy of different doses of 17beta-estradiol (E2) for relief of vasomotor symptoms in menopausal women. METHODS: This was a randomized, double-masked, placebo-controlled, 12-week study in which 333 menopausal women with moderate or severe hot flushes were assigned to treatment with 0.25 mg, 0.5 mg, 1 mg, or 2 mg oral micronized 17beta-E2, or placebo. The number and severity of hot flushes were recorded daily. RESULTS: There was a significant linear correlation between increased dosage of 17beta-E2 and decreased moderate to severe hot flushes per week (P <.001). Rapid reduction in moderate to severe hot flushes was only achieved with 1 and 2 mg, showing a significant difference from placebo at week 4 (P <.05). At week 4, half the women on placebo had reduced moderate to severe hot flushes of at least 52%; the corresponding figures were 56%, 69%, 86%, and 91% for 0.25, 0.5, 1, and 2 mg, respectively. At week 12, all doses except 0.25 mg were significantly better than placebo for reducing moderate to severe hot flushes (P <.001). Although there were no significant differences, twice as many women in the 2-mg group discontinued treatment due to adverse events, compared with the placebo group. CONCLUSION: Oral micronized 17beta-E2 showed a dose-response effect for reducing moderate and severe hot flushes in menopausal women. 17beta-E2 1 mg appeared to be the most useful initial dose.

The independent effects of exercise and estrogen on lipids and lipoproteins in postmenopausal women.

OBJECTIVE: To assess the effects of a moderate exercise program with and without oral estrogen replacement on levels of lipids and lipoproteins in postmenopausal women. METHODS: One hundred one postmenopausal women were randomized into four groups: control or sedentary (N = 20), exercise alone (N = 25), estrogen replacement using 0.625 mg conjugated equine estrogen (N = 28), and exercise supplemented with conjugated equine estrogen (N = 28). The exercise groups were placed on a moderate exercise program. Following baseline testing, each group returned at 3 and 6 months for cardiorespiratory fitness testing and serum lipid and lipoprotein profiles. RESULTS: We found a significant decrease in systolic blood pressure (P < .05) in all treatment groups. The maximum oxygen uptake increased by 9.0 and 7.8% in the exercise and conjugated equine estrogen/exercise groups, respectively, compared to the other groups (P < .05). These responses were seen at both 3 and 6 months. Total exercise time (time spent on the treadmill until exhaustion during testing) significantly increased in the exercise group by 21% (P < .01). Exercise alone was associated with significant decreases in total cholesterol (5.2%, P < .05), triglycerides (2%, P < .05), and low-density lipoprotein (LDL) cholesterol (10%, P < .01), and a significant increase in the high-density lipoprotein (HDL) cholesterol-LDL ratio (17.2%, P < .01). Significant changes were noted in these values, as well as increases in HDL cholesterol (16 and 14.8%; P < .01) and apolipoprotein A1 (25.6 and 26.5%; P < .001) in the conjugated equine estrogen and conjugated equine estrogen/exercise groups, respectively. However, there were no differences in the changes observed in the conjugated equine estrogen groups with versus without exercise. No direct correlation was seen between measures of exercise performance and the changes seen in lipids and lipoproteins. CONCLUSIONS: Estrogen therapy alone had the greatest beneficial effect on lipids and lipoproteins. Exercise alone resulted in a significant reduction in cholesterol, triglycerides, and LDL cholesterol, and an increase in the HDL-LDL ratio. However, combined conjugated equine estrogen and exercise did not demonstrate an added improvement in lipid metabolism. Physical fitness levels increased in the exercise groups, but not in the control group or the estrogen-alone treated women.

Effect of cyclic estrone sulfate treatment on lipid profiles of postmenopausal women with elevated cholesterol levels.

The effects of two doses of cyclic unopposed estrone sulfate therapy on the lipid profiles of 153 healthy postmenopausal women with baseline total cholesterol levels above 219 mg/dL were compared in a multicenter, double-blind, placebo-controlled study. Patients were assigned randomly to one of three treatment groups: estrone sulfate 0.625 mg (N = 59) or 1.25 mg (N = 43), or placebo (N = 51). The median baseline total cholesterol levels of the three treatment groups were 262, 269, and 262 mg/dL, respectively. Total cholesterol, triglycerides, high-density lipoprotein cholesterol (HDL), low-density lipoprotein cholesterol (LDL), and the HDL/LDL ratio were assessed after 6, 9, and 12 months of treatment. There was a significant monotonic dose-response relationship of estrone sulfate in raising HDL levels, lowering LDL levels, and raising the HDL/LDL ratio at all intervals measured. These results indicate that estrone sulfate is effective in creating a beneficial change in the lipid profile of postmenopausal women with elevated baseline total cholesterol.

Comparison of oral estrogens and estrogens plus androgen on bone mineral density, menopausal symptoms, and lipid-lipoprotein profiles in surgical menopause.

OBJECTIVE: To compare an oral estrogen-androgen combination with estrogens alone on bone, menopausal symptoms, and lipoprotein profiles in postmenopausal women. METHODS: Surgically menopausal women received oral esterified estrogens (1.25 mg), or esterified estrogens (1.25 mg) and methyltestosterone (2.5 mg) daily, for 2 years. Bone mineral density of the lumbar spine and hip, menopausal symptoms, lipoprotein profiles, and biochemical and hematologic indices were evaluated. RESULTS: Sixty-six patients were enrolled in the study. Both treatment regimens prevented bone loss at the spine and hip; combined estrogen-androgen therapy was associated with a significant increase in spinal bone mineral density compared with baseline (n = 24; mean score +/- standard error 3.4 +/- 1.2%, P < .01). In the estrogen group, high-density lipoprotein (HDL) cholesterol increased significantly and low-density lipoprotein cholesterol decreased significantly. Cholesterol, HDL cholesterol, and triglycerides decreased significantly in the estrogen-androgen group. Menopausal symptoms of somatic origin (hot flashes, vaginal dryness, and insomnia) were improved significantly by both treatments. Neither adverse hepatic effects nor significant safety or tolerance problems were reported in either group. CONCLUSION: Oral estrogen-androgen increased vertebral bone mineral density compared with pre-treatment values and relieved somatic symptoms. Safety indices, including lipoprotein levels, indicated that the combination was well tolerated over the 2 years of treatment.

Osteoporosis: screening, prevention, and management.

OBJECTIVE: To present clinical recommendations for osteoporosis prevention that include new support for routine bone mass screening of asymptomatic perimenopausal high-risk women. Technological advances make it conceivable that osteoporosis, a metabolic bone disorder rather than a true disease, can be prevented on a wide scale and eventually eliminated. Effective prevention requires that advanced screening procedures be easily accessible and reimbursable as a wise healthcare investment. STUDY SELECTION: This article reviews research bearing on clinical management of women potentially at risk for osteopenia and osteoporosis. Background includes the pathogenesis of osteoporosis and known risk factors such as heredity, life-style, gynecological history, eating disorders, endocrinopathies, and scoliosis. Studies of bone mass measurement favor dual-energy roentgenographic absorptiometry as the bone densitometry method of choice for screening women at risk and for use with roentgenograms in evaluating bone health. The balance between bone formation and resorption can be assessed by a number of biochemical markers, which are reviewed. Other factors known to affect bone mass are discussed. CONCLUSIONS: Primary care physicians, especially gynecologists, can play a pivotal role by [1] identifying women with higher risks for osteoporosis at earlier ages; [2] stressing the importance of developing maximal bone mass before menopause; and [3] developing individualized patient prescriptions for bone mass determinants under personal control: exercise, nutrition (e.g., calcium and vitamin D), life-style, and hormone replacement therapy.