THE METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS
Edward C. Reifenstein Jr., Fuller Albright
J Clin Invest. 1947;26(1):24-56. https://doi.org/10.1172/JCI101787.
Research Article
Find the latest version: https://jci.me/101787/pdf THE METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS BY EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT 1, 2, 8 (From the Medical Service of the Massachusetts General Hospital and the Department of Medicine of 'the Harvard Medical School, Boston) (Received for publication May 7, 1946) In a previous communication from this clinic last investigation had, in addition to post-meno- (1), three metabolic studies on the effect of es- pausal osteoporosis, Paget's disease. tradiol benzoate on the calcium and phosphorus The second objective is to publish metabolic metabolisms of patients with post-menopausal studies on the effect of testosterone propionate osteoporosis were published in abstract form. alone and in combination with estradiol benzoate The first objective of the present paper is to re- in a male patient with senile osteoporosis. port these studies in detail, supplemented by 2 ad- The third objective is to present studies on 3 pa- ditional studies: one in which testosterone pro- tients with the acute osteoporotic process which pionate by itself, and in combination with estradiol follows orthopedic operations, and the effect of benzoate, was used; and another in which di- estradiol benzoate on this process in 2 of these ethylstilbestrol by itself, and in combination with subjects. progesterone, was employed. The subject of the In another previous communication from this clinic (2), metabolic studies of the effect of es- 1 The expense of these studies was defrayed by grants tradiol benzoate, testosterone propionate, and from the Josiah Macy, Jr. Foundation, from the Rocke- progesterone on 3 patients with Cushing's syn- feller Foundation, and from the National Research Coun- drome were reported. The fourth objective is to cil (Committee for Research in the Problems of Sex). A bed supported by the Mallinckrodt Chemical Company present these data more completely in graphic on the Metabolic Ward was used for part of these studies. form, and especially to rectify an unwarranted 2 Presented in part at the twenty-sixth annual meeting conclusion as to the effect of estrogen on the cal- of the Association for the Study of Internal Secretions, cium balance. Atlantic City, New Jersey, June 8, 1942, in connection with a symposium on "Relation of Endocrines to Skeletal DEFINITION OF OSTEOPOROSIS Development"; an outline of this presentation may be found in: Reifenstein, E. C., Jr.; Albright, F.; Parson, Osteoporosis is not synonymous with demineral- W.; and Bloomberg, E.: The effect of estradiol benzoate ization of bone; it is that category of too-little- and of testosterone propionate and of combinations of bone where the primary disturbance is lack of bone both on post-menopausal osteoporosis and senile osteo- porosis, Endocrinology, 30: S1024 (1942). Also pre- matrix formation. It is not to be confused with sented in part at the first annual meeting of the Amnerican osteomalacia, where the primary disturbance is Federation for Clinical Research, Minneapolis, Minn., failure of mineralization of bone, or with osteitis April 20, 1942. Preliminary reports of part of these data fibrosa generalisata, where the primary disturb- may be found in: Albright, F.; Reifenstein, E. C., Jr.; ance is increased bone destruction. For further and Forbes, A. P.: Conferences on the Metabolic Aspects of Convalescence (Including Bone and Wound Healing), discussion, see (1, 3, 4). Transactions of the, First Meeting, Sept. 11-12, 1942, IXges 5-7, 37-38; Transactions of the Second Meeting, CONDITIONS ASSOCIATED WITH OSTEOPOROSIS December 11-12, 1942, pages 69, 96-98; Transactions of In clinical medicine one encounters the following the Third Meeting, March 12-13, 1943, pages 63-65; and Transactions of the Fourth Meeting, June 11-12, 1943, conditions associated with osteoporosis: (1) dis- pages 77-85. Transactions distributed by the Josiah use atrophy, where the normal stimulus to osteo- Macy, Jr. Foundation, New York, N. Y. blastic activity is absent (4, 5); (2) old age, where 8 The work described in this paper was done in part the bone tissue like other tissue (cf. hair, skin, under a contract, recommended by the Committee on muscles) atrophies; (3) where the Medical Research, between the Office of Scientific Re- malnutrition, search and Development and the Massachusetts General protein requirements are not fulfilled, and the Hospital. bone matrix, like other tissues, is depleted; (4) 24 Xb:o lll. 9 auN .4 ;Duox co I -- I 0 C> 4d t 4i go I to>t .2 la 0 a 0 0 16. -, -4 a d 10 3UON t, 4C) 4i _00 - I.., > cl 0 v 9 4.& I s 4) v v 9 bo 93 93 ti bio H m 1. o o o I IU)I Odn 0 I a I >b >b >b >b >b >b co d d go Ca .8 1010 vlov 0 Cd 4wo A 4U) 4i .2.0 -g-g-o6. d b -- 0 ;a 93 93 A r. .m >b 4i 44 " 4i 4i 4-A 00 ll'. t, L', t. t. t. t, 1 to v v a 0 9 v .-4 9 auoN Alop piTi ;Du°x 10 g, > 0 .4 AjaAa wuLgu 991 t 1-0 12 Va 1 d 9 9 I fi 1014 bso 10 a a 9 9 s1 s10 4) s s s a .o %O .o %0%0140 E 'IR Iq llq 'IR Iq 'IR 4 .4-4 4 -4..4
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FIG. 1. CASE 1 (F. F., M.G.H. 156453) : EFFECT OF ESTRADIOL BEN- ZOATE ON NITROGEN, PHOSPHORUS, AND CALCIUM BALANCES, ON SERUM METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 27 Cushing's syndrome where, we believe, an excess under estrogen therapy (less marked in this case than in of the adrenal cortical or "S" the others [vide infra]); (3) the slight improvement in "sugar" hormone nitrogen balance under estrogen therapy; (4) the strik- inhibits anabolism of protoplasm including bone ing and growing decrease in calcium excretion, both fecal matrix (2, 6); (5) adaptation syndrome of Selye and urinary, with estrogen treatment and the gradual (7), where, we believe, the pathological physi- return (40 days) in calcium excretion to pre-treatment ology is the same as in Cushing's syndrome; (6) levels following cessation of estrogen therapy; (5) a de- idiopathic where the cause of the crease with estrogen treatment in the phosphorus excre- osteoporosis, tion almost entirely confined to the urinary component, condition remains obscure; (7) acromegaly, and reasonably proportional to the changes in the calcium where the cause may be the increase of pituitary and nitrogen metabolisms (see "Theoretical Nitrogen hormone(s), or the secondary lack of gonadal Balance"); (6) failure of the serum phosphatase level, hormones (8); and (8) the post-menopausal the index of osteoblastic activity, to rise under estrogen where the therapy; (7) an increase in nitrogen, but not in calcium state, the commonest of all forms, diffi- and phosphorus, excretions in periods 11 and 12 with pro- culty is a deficiency in estrogen to stimulate the gesterone therapy; and (8) the tendency to retain extra- osteoblasts. Frequently 2 or more factors com- cellular fluids with estradiol therapy, as suggested by the bine in one individual; thus, after an orthopedic increase in the actual weight above the theoretical weight. operation (see Cases 7, 8, and 9, below) factors The apparent discrepancy in the effect of estrogen on the calcium and phosphorus balancys during periods 26 (1) and (5) probably both play a part. and 27 is probably to be explained by erroneously high METABOLIC STUDIES fecal excretions resulting from too short a period of observation (9). For the methods employed in the accumulation, inter- pretation and presentation of these data, see (9). Case Case 2. Post-Menopausal Osteoporosis; Physiological histories are abstracted in the appendix. Menopause; Question of Superimposed Atrophy of Dis- use; Estradiol Benzoate Therapy. A. Post-menopausal osteoporosis The metabolic data of Case 2 are shown in Figure 2 Case 1. Post-Menopausal Osteoporosis; Artificial and Table II. The study, conducted in 5-day periods, Menopause; Estradiol Benzoate Therapy. consisted of: (1) five control periods; (2) thirteen pe- The metabolic data of Case 1 are shown in Figure 1 riods during which the patient received estradiol benzoate and Table I. The first part of the study, conducted in 3.32 mgm. intramuscularly every other day. In addition, 5-day periods, consisted of: (1) three contr'ol periods; during the 3 periods 14, 15, and 16, testosterone propionate (2) five periods with estradiol benzoate 1.66 mgm. intra- 25 mgm. were administered intramuscularly every other muscularly every 3 days; (3) twenty-three days with the day. same therapy at home; (1) two periods with the same The data in Case 2 confirm the main observations made therapy; (5) two periods with progesterone 10 mgm. in- on Case 1. The fall in the serum phosphorus level after tramuscularly daily in addition to the estradiol; and (6) estradiol medication was more pronounced than in Case twelve periods after the cessation of both medications. 1, and in addition there was a fall in the serum calcium The patient was then discharged on estrogen therapy level. Again the serum phosphatase level failed to rise which was given continuously in varied dosage during with the improvement in the calcium balance. The dura- the next 3 years; during this interval she was brought tion of the testosterone propionate therapy was too short back to the metabolic ward for study (1 to 3 five-day to judge its effect on the calcium balance; it brought periods) on 3 occasions. about the expected increase in the nitrogen retention and The data (Figure 1) are self-explanatory. Attention rise in the urinary 17-ketosteroid excretion. The theo- should be called to: (1) nitrogen, phosphorus, and cal- retical nitrogen balance based on the phosphorus balance cium equilibria during the control periods (1 to 3); (2) after it had been corrected for the calcium balance agrees the high serum phosphorus level which tended to fall quite well with the measured nitrogen balance. CALCIUM, PHOSPHORUS, AND ALKALINE PHOSPHATASE LEvELS, AND ON BODY WEIGHT IN A FEMALE PATIENT WITH POST-MENOPAUSAL OSTEO- POROSIS For discussion, see text. The dotted line in the nitrogen metabolism data represents the "theoretical nitrogen balance." The fecal nitrogen was estimated as 10 per cent of the intake. The fecal calciuni and phosphorus values as charted are averages of 1, 2, 3, or 4 five-day periods as follows: 1 through 3, 4 through 5, 6 through 8, 9 through 10, 11 through 12, 13 through 16, 17 through 20, 21 through 24, 25, 26 through 27, 28 through 30; the individual values are given in Table I. 28 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT Case 3. Post-Menopausal Osteoporosis; Artificial Menopause; Estradiol Benzoate Therapy. The metabolic data of Case 3 are shown in Figure 3 and Table III. The study, conducted in 5-day periods, consisted of: (1) four control periods; (2) nine periods in which 1.66 mgm. of estradiol benzoate were admin- istered intramuscularly every 3 days; (3) ninety-three days at home on the same medication; (4) five periods on the same medication; (5) seven periods during which the estradiol dosage was doubled; and (6) five control periods of medication. During period 10 the patient was given in addition 10 mgm. of progesterone intramuscularly each day. It will be noted in Figure 3 that the improvement in the calcium balance in this case following estradiol ther- apy was almost entirely due to the fall in the urinary calcium excretion. It is further suggested that the posi- tive calcium balance tends to diminish with time (compare periods 14 to 18 with periods 11 to 13). Note, further- more, that the calcium balance was not improved, and possibly reduced, when estradiol therapy was doubled in periods 19 through 25. The fall in the serum phosphorus level with medication was especially striking in this case. The actual weight was greater than the theoretical weight during the therapy, which suggests retention of extra- cellular fluids. Case 4. Post-Menopausal Osteoporosis; Artificial Menopause; Methyl Testosterone, Estradiol Benzoate and Pregnenolone Therapy. The metabolic data of Case 4 are given in Figure 4 and Table IV. The study, conducted in 6-day periods, consisted of: (1) four control periods; (2) four periods on methyl testosterone, 40 mgm. by mouth daily; (3) five periods in which 1.66 mgm. of estradiol benzoate daily by injection were added to the methyl testosterone therapy; (4) five periods back on the methyl testosterone therapy alone; (5) four more control periods off medication; (6) three periods on pregnenolone, 30 mgm. intramuscu- larly daily; (7) four more control periods off medicatiob; (8) five periods back on methyl testosterone, 40 mgm. by mouth daily with a change in the nitrogen and phos- phorus intakes during the -last 3 of these; and (9) one final period where the methyl testosterone therapy was increased to 100 mgm. by mouth daily. The urinary determina- tions were made on 3-day periods throughout. In Figure 4 it should be noted first that the theo- retical nitrogen balance is consistently less than the actual NITROGEN, PHOSPHORUS, AND CALCIUM BALANCES, ON SERUM CALCIUM, PHOSPHORUS, AND ALKALINE PHOS- PHATASE LEVELS, ON BODY WEIGHT AND ON URINARY 17-KETOSTEROID EXCRETION For discussion, see text. The fecal nitrogen was estimated as 10 per cent of the intake. The fecal phosphorus and calcium values as charted are averages of 2, 3, 4, or 5 five-day periods as follows: 1 through 5, 6 through 9, 10 through 13, 14 FIG. 2. CASE 2 (E. P., M.G.H. 203540): EFFECT OF through 16, 17 through 18; the individual values are ESTRADIOL BENZOATE AND TESTOSTERONE PROPIONATE ON given in Table II. METABOLIC EFFECTS OF STEROIID HORMONES IN OSTEOPOROSIS 29
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Part of the error may be in the used the value of 1.283 grams per 24 hours, the average fecal nitrogen excretion which was not analyzed, but fecal nitrogen value for adults regardless of intake (9). taken as 10 per cent of the nitrogen intake. In the ab- The major part of the discrepancy is probably to be sence of analyzed values, it would have been preferable, attributed to errors in the intakes. 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REIFENSTEIN, JR., AND FULLER ALBRIGHT ,b v , d aU°N | w=Alm auoN So o ..; C3 - do lIaU°N 4i 0t32E | 0 cl V~~~ z-H - Eiv 4) 93 -I - 0 .0 b 0 4i auoN W 8 ci Apnep *auoeu :4 4i r) 0 &. "q * so!I^I eOR :eIq oq OrVa Ct snjolldsoqdl k s e |4|| .Eo 0. 4- croMr- (n E < ^ e ' e 1 t Inolaci 8 ||> > > Cl°- m Cd JO A'Ba I _0 8z %O mt O W 0 0 iIBUI]2$ %> _ e N~~~~~~~~~~N N01 N N N N N N C CC WO-95-t0 Ou t_ oOOw N >~~~~~~~~~~~~~~~~~~~~I WOU>o5W? L0 + N _ O-______O-NNESES NS _ u)<~~~~~~~~~~u)~~~~Nu ux v) ux ux uzl l -4eux l l S~~~~~~~~~~~~Iu n in t) In in In in In in)W in LOi) in In LOot u) In ) LO O-N00u0 OI CN > 2 a3u,eleq o-. . + ?° _ o N - ___ mpa.loaqj, o-_00esNc°~~° °o M7 M t a > rOO0o+N- +\O¢+-% In Nt-oM&OO%V>lO %r0%O8"MCNNO4 00 10 a3Purl-ea N OOOO O-- -;--.OOOOO -NNN"Mmm"" * 0 +11111111ll+++++ +++ I+++++++++++ ++l++ X*. bobQ .W~~~~~~~~~~~~~~.. 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The primary pathologic process crepancy would have been almost eliminated. Thus, if of the Paget's disease, bone destruction, was not being one recalculates on the basis of the 1944 analysis the responded to with the usual amount of increased bone theoretical nitrogen balance of period 4b, and in addition formation because of the menopause (4). Therefore, it uses the value of 1.283 grams for the fecal nitrogen in- was thought that any action of estrogen to stimulate bone stead of 10 per cent of the intake, one obtains the values formation would be magnified in this patient. + 0.65 and + 0.45 grams for the theoretical and actual Figure 5 is self-explanatory. To be noted are: (1) the nitrogen balances, respectively, in contrast to the values markedly negative calcium and phosphorus balances dur- of + 0.18 and + 1.71 grams. Since the above discrepancy ing the control periods; (2) the marked improvement of is fairly constant, it does not affect the trends induced these balances with 1 mgm. of diethylstilbestrol daily; (3) by treatment. the further improvement with 15 mgm. of diethylstilbestrol Figure 4 is self-explanatory. To be noted are: (1) the daily;' (4) the lack of effect of progesterone on the cal- decrease in the nitrogen, phosphorus, and calcium ex- cium and phosphorus balances; (5) the high serum phos- cretions with methyl testosterone therapy, and the re- phorus before treatment; (6) the tendency of the serum bound of nitrogen and phosphorus excretions on cessa- phosphorus to fall during treatment; (7) the failure of tion of therapy; (2) the fact that the fecal, as well as the the serum phosphatase to rise with improvement of the urinary, excretions of both calcium and phosphorus were calcium balance; (8) the tendency of the 17-ketosteroid reduced under methyl testosterone therapy; (3) the fact excretion to rise with progesterone; (9) the failure of the that there was not an immediate rebound of the calcium "11-oxysteroid" excretion 4 to fluctuate outside of the excretion following cessation of methyl testosterone normal range with therapy; (10) the striking fall 6 in therapy; (4) the further improvement in the calcium the urinary follicle-stimulating hormone (FSH) excre- balance, but not in the nitrogen balance, when estradiol tion with diethylstilbestrol therapy; and (11) the subse- benzoate therapy was added to the methyl testosterone quent rise in the FSH excretion when progesterone therapy (periods 9 to 13); (5) the fall in serum phos- therapy was superimposed on the diethylstilbestrol therapy. phorus level with methyl testosterone and especially with The increase in the positive nitrogen balance and the in- estradiol benzoate therapy; (6) the definite tendency of crease in weight during periods 22 to 24 may be indi- the serum calcium level to parallel the serum phosphorus cations that progesterone was acting unfavorably on the level (see also Figure 2); and (7) the failure of the nitrogen balance (12). Not explained is the rise in serum phosphatase level to show a significant change. FSH excretion in periods 23 and 24. The effect of the pregnenolone therapy is inconclusive; it did not significantly affect the very low 17-ketos- B. Senile osteoporosis teroid excretion. No explanation is forthcoming in pe- Case 6. Senile Osteoporosis in a Male of 72; Testos- riods 29 and 30 for the low fecal calcium excretions not terone Propionate and Estradiol Benzoate Therapy. associated with low nitrogen and phosphorus excretions; The metabolic data of Case 6, which comprise studies as a result, the data during periods 30 through 36 are done on 290 of 530 consecutive days, are shown in Figure difficult to interpret. The actual and theoretical weight 6 and Table VI. The study, conducted in 5-day periods, curves suggest that there was retention of extracellular consisted of: (1) five control periods; (2) five periods fluid with methyl testosterone therapy which was aug- on testosterone propionate, 25 mgm. by injection daily; mented when estradiol benzoate therapy was added. (3) five periods in which estradiol benzoate 1.66 mgm. Pregnenolone therapy had a minimal effect on extracel- by injection on alternate days was added to the testos- lular fluid retention. terone propionate therapy; (4) five periods back on testosterone propionate alone; (5) seven control periods Case 5. Post-Menopausal Osteoporosis; Artificial Men- off all medication; (6) five periods on estradiol benzoate opause; Paget's Disease; Diethylstilbestrol and Proges- 1.66 mgm. by injection twice daily; (7) ten days without terone Therapy. collections on the same medication; (8) two more pe- The metabolic data of Case 5 are given in Figure 5 riods on the same medication; (9) ninety-three days at and Table V. The study, conducted in 6-day periods, home on estradiol benzoate 3.32 mgm. by injection 3 times consisted of: (1) three control periods; (2) five periods on 1 mgm. of diethylstilbestrol by mouth daily; (3) seven 4These observations were carried out by Dr. Nathan periods on 15 mgm. of diethylstilbestrol by mouth daily, B. Talbot with his method (10). The normal range is with an increase in the diet in the last 3 of these; (4) 0.10 to 0.35 mgm. per 24 hours. six periods with the same dosage of diethylstilbestrol in 5 The level fell from 200-300 units per day to less than which progesterone by injection was given in addition (25 6 units per day. Normal range of FSH excretion is 6 to mgm. daily for the first 4 of these periods, and 100 mgm. 50 mouse units per day (11). 300- 250. 200- 150. loo. L7 I FIG. 5. CASE 5 (S. B., M.G.H. 430664): EFFECT OF DIETHYLSTILBESTROL ALONE AND IN COMBINATION WITH PROGESTERONE ON NITROGEN, PHOSPHORUS, AND CAL- CIUM BALANCES, ON SERUM CALCIUM, PHOSPHORUS, AND ALKALINE PHOSPHATASE LEVELS, ON BODY WEIGHT, AND ON URINARY 17-KETOSTEROID, "11-OXYSTEROID," AND FOLLICLE-STIMULATING HORMONE EXCRETION IN A FEMALE PATIENT WITH POST-MENOPAUSAL OSTEOPOROSIS AND PAGET'S DISEASE For discussion, see text. 36 METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 37 ns (uXl) cd 10100106 0) auosal OUON ::>4S1C 010SE OuoN -00)010 co U) U) In co co bo ('od) -0.- 0 auON p tuI jo11soqIpsg tualu I Alm p Sli - U 10.41 tl..-0 ~s~wqdooo1cI 0.Z 0I *'dO1 cl- c4 I.e.d4 V!RI,Vt0q0l)UUnu) el tlvVUa U)ael I" U) 'U)U):: 'eU)U) V . V. Oa I.tlua li Il rtt "? ~o. qolooq't .o 5.0 sTuoqdsoqdl L 0 sandous0uoqdsWd %a.-, |)Z o"v .| U)O',*'"n eeNrvc1U~7 1nnI-eq90. | +-oI|00.sIe a0 c Os _ oo. 000 1- if3m.J e" 00ad 0 1 0bo.0 oo00I0~V I 001C0 00I-00t11wV_cU00b00. 0000mm 000.00U 1 - po_md__ __ _ . . 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M)-41 - . U)100--40%4000 Z St . R%0000%000-4 t-0%to'-In 00% M0I-0 s 0t.'N0V)0coo -oo-N OM= -- ______~ ~ - I __~ I C'I--- Il~)i)f_____qaI __ ___ Et - NM4 c44 - C 0~1 I 00000U)~~C-4N ee)c-f)00 400 00000s- ClC0'0 00000I 00000000000Au00>ha t 04,oW)c t-ft- 94- iW) 0 CO CZ N -NMIOW) .ck-wchc -IC-IV)#V)'0C- 1 mv 4...... N . I0O0%M m>-a .^auunuppaja wNfr' ffi°ch° 404. .0 IN Imm METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 39 .6i A' 2U0N uZZZ auoN b')4 Iw 2 g AM s r Ea . .5 n t E-4 AO bo 4-b9 0 Is-I 1 la ' 1-4 ;~4 wa' sauzl aenfl 'm3uz auoN 3)4) 0.0 asmwTqdsoqd o |, |0.o.t0l| q | Iq | flew~I )N N U) N N U) N)) ) 00C 0~0 mnuoqdsoqjl C*eqeq eq e N N)c'0N UMU4)U) N N Ex |?"lolU |q| |?N f ci q 0 0 U1fnt3m '' 0 0 0000000 - o JO AI 8 _- spojao N - >1- 1 1- 1 1----1 lSaJOzo0-aq-L U) Z'. .4-I. 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H., M.G.H. 278511): EFFECT OF TESTOSTERONE PROPIONATE ALONE AND IN COMBINATION WITH ESTRADIOL BENZOATE AND VICE VERSA ON NITROGEN, PHOSPHORUS, AND CAL- CIUM BALANCES, ON SERUM CALCIUM, PHOSPHORUS, AND ALKALINE PHOSPHATASE LEVELS, ON BODY WEIGHT, AND ON URINARY 17-KETOSTEROID EXCRETION IN A MALE PATIENT WITH SENILE OSTEO- POROSIS For discussion, see text. 40 METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 41 a week; (10) five periods on the same therapy; (11) nine periods in which testosterone propionate 25 mgm. in- tramuscularly daily was added to the estradiol benzoate therapy, during the last 3 of which periods the intakes of nitrogen and phosphorus were markedly increased; (12) three periods on the same diet and the same estradiol benzoate therapy but off testosterone propionate therapy; (13) ninety-one days at home on the same estradiol benzoate therapy; (14) three periods on the original diet without change in the estradiol therapy; (15) forty-three days at home off all medication; and finally (16) four control periods on the original diet without medication. Figure 6 is self-explanatory. The observations as a whole confirm those noted in Cases 1 to 4 with post- menopausal osteoporosis. Again, as in Case 4, the theoretical nitrogen balance as charted is consistently less positive than the actual ni- trogen balance which suggests some constant error. This discrepancy is probably to be attributed to errors in the intakes and to estimation of the fecal nitrogen as 10 per cent of the nitrogen intake (see discussion under Case 4). Case 6 received the same diet as Case 4; this diet was analyzed twice with the results given in the discussion under Case 4. Figure 6 was constructed from the analysis of 1941; had it been constructed from the analysis of 1944, as is Table V, the discrepancy would have been almost eliminated. Thus, if one recalculates on the basis of the 1944 analysis, the theoretical nitrogen bal- ance of period 5, and in addition uses the value of 1.283 grams for the fecal nitrogen instead of 10 per cent of the intake, one obtains the values + 0.87 and + 1.30 grams for the theoretical and actual nitrogen balances, re- spectively, in contrast to the values of + 0.41 and + 2.21 grams. As was pointed out in connection with Case 4, since the above discrepancy is fairly constant, it does not affect the trends induced by treatment. To be noted especially in Figure 6 are: (1) the marked reduction in nitrogen, phosphorus, and calcium excretions with testosterone therapy; (2) the lack of rebound in the calcium excretion as opposed to nitrogen and phos- phorus following cessation of testosterone therapy; (3) the further reduction in the phosphorus and especially in the calcium excretion, but not in the nitrogen excretion, when estradiol benzoate therapy was added to testosterone propionate therapy (periods 16 to 20); (4) the improve- ment in all 3 balances when testosterone propionate was added to estradiol benzoate therapy (periods 40 to 45); (5) reduction in the fecal as well as the urinary calcium and phosphorus excretions by both testosterone propionate and estradiol benzoate therapy; (6) the effect of both testosterone propionate and estradiol benzoate therapy in lowering the serum phosphorus level; (7) the failure of marked increases in the nitrogen and phosphorus bal- J CC Q& X XX CIUM, PHOSPHORUS, AND ALKALINE PHOSPHATASE LEV- a I a I i 1ut I I 1 4 Ia IU6 I* pI *I I 11I to 1 1314 ELS; WEIGHT; AND URINARY 17-KETOSTEROID EXcRETION "DO IN A FEMALE PATIENT WITH OSTEOPOROTIC PROCESS IN- FIG. 7. CASE 7 (E. S., M.G.H. 360207): NITROGEN, DUCED BY OPERATION AND IMMOBILIZATION PHOSPHORUS, AND CALCIUM BALANCES; SERUM CAL- For discussion, see text. 42 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT IA ;auN SUON °uN 0 co ~s~tIasdsoqd 4 if k. 0 ) t 0o 0 c" N 0*if NN 'd L vu ") ifmII if N if> tf) N, if 00bOD 0'0 0~4 am IV amMlY ~N40_ N ) 4Oi) 4' N '0 N 1N umflejo S > o66Io o6o~ 6 6o ooo o o o _4 Co A= pouad _ I_4----- Jo ABU ~ 14J X~~~~~~~~~U S 00 08Oa m - (7 w a 0m k0 C N O- No '0' O ' w 0 if) N 0 0% NO 08e m 0 o'o U) U)UIan In in I ) in in I ~~~~~if).~~~~~~~~~~~~~ U) # 0 0 C' i 0 0 4-- _ 'IO in 00'' t- r- In co t- m __avuvq_\ --'0-~~~~~~~o. o0 oIn tr ~u) U-U 0' 00 OALIUI . Ict T .tn | > S W u | | e )Ne '4" C. '0 0 0- in___NO__ _ __ In *U0 N 4' 0' ) AXuf IiO0fifiOn 11o OO0Oli 0O |avff1uIeg|1I 3 -0'001- $ | | 100000$ 0 ~~~0' 'IO'0 if No0 4~~~~~~~~N1o%fiinN0'IO o v fio Iig 0tr-____.f _ _NO_____-4 In ' N0 in.0 00 0 if W)i) in In '0n U) 0 ifn '0 In V tIIXIeuW u I I u e w W 14 4-_ '|' E0 | o co '0 o cooco'0eoiI 1r W bo b o I'0'1'0'0InV0 0 n 1 I ) U) in to UUin I 3mul0*) QiauI| 1 W "> u " C.) C' C' i) Na U) C'. p I49 ~~ ~ ~ ~ ~ f N C. , VO A V'4)C4 I4 ___ __ | -_-N ----_0__0.- - _ 10000 S 10~~~~~~~~~~~4 ii ) * U) U) U) U)4 i U) U) I4. , , 4 ifif)40 U) ' [- . . |___ 13i- -11-,1-1 o ' I 1I0000 00 0000 I4______I'______1______.N0 if) p2 N0 N 0 0' 0 .-I N 10 W) v 1- 0 0. 0 - " "5 04 .4 W4 jaquinuppa.1a METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 43 ances by increased diet to affect the calcium balance (pe- riods 46, 47, 48); (8) the absence of any significant change in the serum phosphatase and calcium levels; (9) NITROGEN the fall in the urinary 17-ketosteroid level with estradiol ^sTHEORETICALsZea@" * (benzoate therapy; and (10) the tendency to accumulate ex- tracellular fluid during both testosterone propionate and estradiol benzoate therapy as suggested by the theoretical + URINARY weight curves, with a prompt loss following the cessation l ggjw M of therapy. ' C. Osteoporosis resulting from disuse and/or T'n-'-1'1"'T adaptation syndrome Case 7. "Normal" Female; Effect of Orthopedic o Op- ^ t/ m S 5 > ' - // L eration; No Specific Therapy. The metabolic data of Case 7 are shown in Figure 7 ,URINARYP"OSPNORU and Table VII. Throughout the entire experiment the patient was on a constant, neutral-ash, low calcium diet, except for the immediate post-operative period. She was FFCAL PNOSPU up and active during the pre-operative period, and im- mobilized in a cast from the foot to the hip after operation. She underwent an arthrodesis of the right foot on the sec- ond day of period 5; there were no analyses for metabolic data 5 and but the ffiloo 4oCC. during periods 6, 17-ketosteroid ex- * *_. cretion was followed. as . §Jg During the 4 control periods the patient was in nega- was iJ} t \o_o_O *tteW'tivecalcium and phosphorus balance; the former of 30_ the order of magnitude one would expect with patients on this diet (13). As expected, there was a marked increase in the calcium excretion after the operation, which per- 0 sisted unabated to the end of the investigation (58 days OLMZw after the operation) (14). The increase in calcium ex- cretion was not en,tirely in the urine. The 17-ketosteroid Cexcretion was normal pre-operatively, which confirms the contention that she was not debilitated; it rose immedi- * ately after operation, and then fell decidedly below the preoperative level for about 20 days. The pattern of re- sponse was thus similar to that encountered following any _ traumatizing event (15). The marked elevation in 17- ketosteroid excretion in period 11 coincided with the pa- *4.& ? / tient being allowed up in a wheel chair (16). s- *z;;aa_a_ _*_*_ **_* Periods 7 through 14 in this untreated case serve as a - control for similar studies in Cases 8 and 9, who received estradiol therapy during the post-operative period (Figure bcn4e 10). as Case 8. Multiple Traumatic Fractures with Operative 3 to 3 Reduction of One in a Previously "Normal" Male; Ef- 30 9 o fect of Estradiol Benzoate Therapy. * < S 9 / The are \ metabolic data of Case 8 shown in Figure 8 and Table VIII. The study, conducted in 3-day periods, consisted of; (1) six control periods; (2) six periods 4 in which 1.66 mgm. of estradiol benzoate was given CALcIuM BALANCES; ON SERUM CALCIUM, PHOSPHORUS, O * AND_ ;ALKALINE^ ^ x PHOSPHATASE^ LEVELS; AND ON URINARY 1213141516171.3I,nlOlaIIISII.lIslIela?IIsI 17-KEToSTEROID EXCRETION IN A MALE PATIENT WITH 3-OAY Maoos OSTEOPOROTIC PROCESS INDUCED BY MULTIPLE FRAcrUREs, 8. FIG. CASE 8 (H. D., M.G.H. 382395): EFFEcr OF OPERATION, AND IMMOBILIZATION ESTRADIOL BENZOATE ON NITROGEN, PHOSPHORUS, AND For discussion, see text. 44 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT Ti o0C'sQ E Ca0 CaTION wXwSIAwIp991I auoN Ca 1q ._ . bo C; 0 aula: 0W WuX0 - 0 ek~ ~0 snuoqdsold o o. qcl~~~~~~~~~~~~~~~~~~~~~k 60 o. ° cn ,u %000IU) _ ,* '0 ° tunpirc Co;d6 0000 0a) 1- 4 popad - - co '0 4-.CaU) 4-C JoACaU-4 -- 1- Ca . . .M__ * .-00c>0- +e0000 U)U00kN0 I %.. al-el4p AxreMuflto %O e 00)'00 Uc)0U)coUUc0 '00 a-k- (4 U) )o -4 C7- -4 t, N %O LO %O m tn Oo o co eollaloatl~~~~~~~~~~~~~UaQwe ux $++ ++$+U)°8 o al 0 U) + %O0%ot Vo%O m"O0 110. 01 Cr1 b,O 00 ule +++++ ++++++______+ ++-- ______bo fvl 0- Ca . O______ 4Creuplfl VU,R0~ ok oo-rU)t-0a,r0l amull 1oU0%O %O % Uo u) -a%0U)U)o a)0r t- 0v)_0 %Oes+ OXOO '0 04 k4-C 14 TI4 k. 0Cad Qa ..0 .0 .O % kk ( e-a .aaaa 0. co = b4NbOrtstsOIOrOrOrIr^rO'4k'e4k-ke-4 ('4 LO('4'4 C4 n4u NCat )U) - CDC InC - C- CIIIC- C-C-III 0 c9s c0-o(- *a)a N010QON IS N NIWN"Se 4> 4 88 ..00 'a Ar3euir'j;1 U U ) DBulin~~~~~~~Co4LO 0% > to 00 --er0°W) -0 .JuTe,"eo"-i 6 1 .6 --JJ-A-& 4iO-J-)J-A * Caa a) k'4 0 "U)U" k)4f4 U)U)(k)U)1 t.t )u e4 l~~~~~~~~CC) I4.4 C-4Nr---ux4C-40.4uNU) OCk4U)U)---C )u v zIuC=(4C4 )mU)U)..k ~ 0 .c°a ._ U. n ,O.- Id -000000c' 000000 000000 CII- 4 4 .('C4N ('t ('(4 _ C'sU- (2 o iaqwunu po°uad - 4 C -4 U) mU) 4U) t- ;^I. METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 45 daily by injection; and (3) six post-treatment control periods. The stool periods were analyzed 2 at a time. Figure 8 is self-explanatory. The most important ob- flt ,OM Figure 9 is self-explanatory. The theoretical nitrogen balance shows a constant deviation from the measured ni- "814 < / 1-> N°7 | trogen balance which suggests some constant error isb1--\---<--(vide~~supra).b ;;;;rThe~ calcium data, as in Case 8, are better shown in Figure 10, and will be discussed below. It should be noted that the serum phosphorus in this case, as op- posed to all of the other cases, did not fall during estradiol OL 24^MM ! therapy. The 17-ketosteroid excretion showed a ten- -0l ; dency to fall during the estradiol benzoate therapy, which =3] is also somewhat suggested in Figure 7. +0.33- Further analysis of calcium data of Cases 7,8, and 9 In Figure 10 the calcium data of Cases 8 and 9 with . \ s / \ estradiol benzoate therapy are compared with those of 4. \> \ / \^ Case 7 without such therapy. It is quite clear that es- tradiol benzoate therapy resulted in a decrease in the urinary calcium excretion, but had little effect on the 21 fecal calcium excretion during the 18 days of adminis- tration. However, the tendency for the fecal calcium to M&n4tMR.decrease in Case 9 after the therapy was stopped may well 12- 15t G have been a delayed response to the therapy. The urinary ,0 S _ = Z citric acid values carried out and interpreted by Dr. Ephraim Shorr confirm his finding (17) of a rise duiring 8 ~~~~~~~~~~~estrogen therapy. . I7-SETOSSTKI0 D. Osteoporosis of Cushing's syndrome 2 Case 10. Cushing's Syndrome; Nephrolithiasis; Es- 0 tradiol Benzoate and Testosterone Propionate Therapy. A4>CTUAL HTn* The metabolic data of Case 10 are shown in graphic 5S ° ^ i\ form in Figure 11. For data in tabular form for periods M | CALCIUM BALANCES; ON SERUM CALCIUM, PHOSPHORUS, 5.1 AND ALKALINE PHOSPHATASE LEVELS; ON URiNARY 17- II 12 131415161?ISI 10191O11111tsS4i5ir7161111 KETOSTEROID ExCRETION AND ON WEIGHT IN A MALE 3-053 PWO0S PATIENT WITH OSTEOPOROTC PROCESS INDUCED BY OP- FIG. 9. CASE 9 (C. M., M.G.H. 348774): EFFECT OF ERATION AND IMMOBILIZATION ESTRADIOL BENZOATE ON NITROGEN, PHOSPHORUS, AND For discussion, see text. 46 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT 4i r. v Ei A1IV auoN 9 ;)Uox *1UI= 99-1 0 ITaoiqdso,qd cWo in j-10 0 |N^ 4-r e t.0 _ t O b cd ".C' O~~~~~V 0 b o wnp~~~~~~C-o _ _-_ok o D-C"o_ 4- _ _ _ __1- ) J 'o '~~~~~~~~~~~~~~~CAxuaP°9-!Ni".____.- 8o misv.a M _ _ ~_-w_ ux Ins W)finin in-W) in t W in _)ino t in in W *punp cd 0-% 114- t". b. 001>0. in _ 0__n v to0h'" _cd CV) r 4_ >~~~~~~~~s2 ffi 6 666 N- _; _;- .i e,3 00 m -N.l 48 co0to- W--e v>O to %4 N. ftR Ci _%'I0u 'Il It 04 Axeu!jfl. C. m .j e 4 I.-, Spasoal|,L~~~~~~++++~~~~~~ND__ooo(I. c+ t 1-4 0. :1.3v C4 - V 4n . 14,1 F avueleg 0 N w Ol ++I+l 1+°O t0 -. 1.11 a amUI $ . 0 3 00. 0. 0 0. 0. . 0. co co o o co co e 94 V- 4i o0 )s %OWV>^)W nWo ao 1 _o 0 Ino,*o-- - m-00 4 'I_O0In Cho w C -~ ~ ~ -NN 4= 4-J :4 v ~ ~~ WbSC4 N sN0wM N+ 0s0 d 'O Cs IS 0000000 1000000o 000000 X~~~~~~~~~6"a.|i""o"°" ,,*A ,," ,"oa&J "+a)|>>-W g~~~~~~~)0- - NNNN|Nq* r- *NN-NotNNN- 16, 00e00e 1 tuNo0VZ I 00to0o~~~C =n,^^N00-IN-o-"o1~4C4 40b e -N > b 0 jaqtunu pol,04-4 4 PIA24NR. OPERATION .30 2..C 55020? -too 50 Ai 50. FI L 150 3. A,,,,,L,,,AB,t -lP["loasaYsE-0t. P05T-OP. PTE00 R 2 H. UH1t.._ +150 +2 PR4+200JlIft ~~~~ ~~~~~~~~~~~~~~~0I 240a STRE 2S l PHSOHEAY. ANDIMMOBILIZATION~~~CITATI - ~~~~~~~~~~~~~~~~~~~~50 4.4icsin~ ~ ~ ~ o e et 4.100 ~ ~ ~ ~ 4 0 1150 +2 PPE-OP. PERIODS3-OAT5 POST-OP. PEPIOODS: 3-OATS FIG. 10. METABoLIc DATA FOR CALCIUM OF CASEs 7, 8, AND 9. 'EFFECT OFESTRADIOL BENZOATE AS COMPARED WITH No THERAPY ONq THE CALCIUM BALANCES IN PATIENTS WITH OSTEOPOROTIC PROCESS DUE TO OPERATION AND IMMOBILIZATION For discussion, see text. 47 48 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT SM ?4372 oQsomG SYD FIG. 11. CASE 10 (B. V., M.G.H. 74372): EFFECr OF ESTRADIOL BENZOATE AND TESTOSTERONE PROPIONATE ON NITRO- GEN, PHOSPHORUS, AND CALCIUM BALANCES, AND ON SERUM CALCIUM, PHOSPHORUS AND ALKALINE PHOSPHATASE IN A FEMALE PATIENT WITH OSTEOPOROSIS DUE TO CUSHING'S SYNDROME For discussion, see text. At the bottom of the chart, the urinary calcium is shown separately on an enlarged scale. 1 through 33, see (2). The study covers 37 five-day error in the first 14 periods, probably the value for the periods obtained on 4 hospital admissions. Two diets nitrogen intake. A more detailed analysis to emphasize were used: one for periods 1 through 14, and a second for the close agreement between the nitrogen, potassium, periods 15 through 37. The nitrogen intake shown in phosphorus, and sulphur balances of periods 15 through Figure 11 for periods 17 through 33 is an analyzed value, 33 has already been published (9). Although Albright and differs from that previously published which was et al (2) concluded from these studies that estrogen was taken from a table. The data in Figure 11 are self-ex- without beneficial effect, this was true with respect to planatory. It should first be noted that the phosphorus the nitrogen balance but not altogether true with respect to balance corresponds reasonably well with the sum of the the calcium balance. Thus, with the larger dose of es- nitrogen and calcium balances during the last 23 pe- tradiol benzoate in periods 13 to 14 there is an increase, riods, but not the first 14. This suggests some constant probably significant, in the calcium balance. Further- METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 49 more, when estradiol benzoate was added to testosterone The study, conducted in 5-day periods, consisted of: (1) propionate therapy in periods 30 through 33, there was five control periods; (2) seven periods on progesterone a further fall in the urinary calcium excretion and an in- therapy, 25 mgm. per day; and (3) four periods on testos- crease in the positive calcium balance. Other observations terone propionate therapy, 25 mgm. intramuscularly per to be underlined in Figure 11 are: (1) the marked de- day. crease in the urinary nitrogen, phosphorus, and calcium The data in Figure 13 are self-explanatory. As pointed excretions with testosterone propionate therapy; (2) the out by Albright, et al (2), the progesterone therapy, if marked rise in the serum phosphatase level when the in- anything, had a slightly beneficial effect on nitrogen, crease in calcium balance became appreciable (see pe- phosphorus, and calcium. The effect was not nearly so riods 30 through 33). Whereas Figure 11 suggested that marked as that obtained in periods 13 to 16 with testos- insulin had a marked effect on calcium balance (see pe- terone propionate therapy. Of interest is the rise in the riods 28 and 29) the authors are inclined to discount this alkaline phosphatase level in period 16, when the calcium because of the essentially negative result in a second pa- balance became appreciable. It should be noted that the tient with Cushing's syndrome so treated (18). 17-ketosteroid excretion was not lowered by progesterone Case 11. Cushing's Syndrome with Osteoporosis; Es- or elevated by testosterone propionate; the latter finding tradiol Benzoate, Testosterone Propionate, and Methyl is surprising, and not in agreement with other studies. Testosterone Therapy. CERTAIN THERAPEUTIC ASPECTS CONCERNING POST- The metabolic data on Case 11 are shown in graphic form in Figure 12. For data in tabular form for periods MENOPAUSAL OSTEOPOROSIS 1 through 36, see (2). The study covers 55 five-day A large number of cases, many complicated by periods obtained on 6 hospital admissions. The data in fractures, have been treated with estrogens alone Figure 12 are self-explanatory. It should first be noted that the phosphorus balance corresponds reasonably well and in combination with testosterone compounds with the sum of the nitrogen and calcium balances during the past 5 years. As a group, these pa- throughout. As in Case 10, one cannot conclude, as did tients have responded very satisfactorily. Within Albright, et al (2), that estrogen therapy is without weeks to months, the pain in the spine and other beneficial effect. It was started before the metabolic bones usually has been considerably or completely study was initiated; so its initial effect is hard to evaluate (see periods 1 through 7); however, further studies eliminated. There has frequently been an in- undertaken 35 days after omitting estrogen show that the crease in weight, apparently an increase in the calcium balance has changed from positive to negative thickness of the skin and an improvement in the (compare periods 8 and 9 with 6). Other points to be general well-being Whereas the study is impos- noted in Figure 12 are: (1) the loweiing of the urinary sible to control, we nitrogen, phosphorus, and calcium excretions with testo- have the impression that frac- sterone propionate therapy (periods 10 through 18, and tures, especially of the hip, in old ladies have re- 23 through 36) and with methyl testosterone therapy sponded better than they would have otherwise. (periods 50 through 55); (2) the fact that the fecal However, in spite of these favorable clinical mani- phosphorus and calcium excretions were also lowered with festations, it has been difficult to produce un- these 2 testosterone compounds; (3) the quick rebound in the nitrogen and phosphorus and not the calcium metab- disputed evidence that the bones (excluding frac- olisms on cessation of testosterone propionate therapy (see ture-sites) as visualized by x-ray have become periods 19 through 22); (4) the steady improvement in more calcified than before the therapy was in- calcium metabolism with continued administration of stituted. Nevertheless, the recent films of several testosterone propionate therapy; (5) the elevation of the of the longest-treated cases are fairly serum phosphatase with improvement in the calcium convincing. balance; and (6) the rise in the serum phosphorus level Dosages have ranged as follows: diethylstil- following omission of estradiol benzoate therapy in pe- bestrol 0.5 to 1 mgm. daily p.o., estrone sulfate 6 riod 6. The marked improvement in calcium balance 2.50 to 3.75 mgm. daily p.o., estradiol benzoate in periods 29 through 36 is probably to be attributed to 1.66 to 3.32 mgm. 3 times a week i.m., and es- continued testosterone propionate therapy, but the initia- tradiol dipropionate 5 mgm. weekly i.m. A tion of vitamin D therapy in period 29 makes the exact few interpretation difficult. Dehydroisoandrosterone acetate patients have been treated by implantation of pel- in periods 42 to 46 did not prevent the rebound in nitro- lets. Excessive estrogenic effect on the endo- gen and phosphorus metabolisms from omission of testos- metrium has been controlled whenever a respon- terone propionate therapy. sive uterus was present, by interrupting the es- Case 12. Cushing's Syndrome with Osteoporosis; trogenic therapy periodically (every 4 to 6 weeks Progesterone and Testosterone Propionate Therapy. The metabolic data of Case 12 are shown in graphic 6 Conjugated equine estrogens (Premarin [Ayerst, Mc- form in Figure 13. For data in tabular form, see (2). Kenna and Harrison]). so EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT 1 4 1 c I I V V v 0-6- O_ ~~~~~~~tESTOSrtRm EEStTD SEAM CALCIUMN POSITIVE SALANCE _ P¶Oa¶c STOOTE 0-0-0 SE UFAYEXCJEf 1EiSTE6 CU0 X~~JIPATASE - NORMAL PEL4.ITS iffanTAL£ETCQt4OEMY^OSSLA0EXMET0%STER ACEATATELEVLrT FIG. 12. CASE 11 (R. B., M.G.H. 3397): EFFEcT OF ESTRADIOL BENZOATE, TESTOSTERONE PROPIONATE AND METHYL TESTOSTERONE ON NITROGEN, PHOSPHORUS, AND CALCIUM BALANCES; AND ON SERUM CALCIUM, PHOSPHORUS, AND ALKALINE PHOSPHATASE IN A FEMALE PATIENT WITH OSTEOPOROSIS DUE TO CUSHING'S SYNDROME For discussion, see text. for 1 to 2 weeks), or by administering at regular not be given in most patients with the impunity intervals (every 4 to 6 weeks) a course of proges- suggested from Case 4; she was remarkably free terone (5 mgm. daily i.m. for 5 days) or of an- from the masculinizing effect of such medication. hydro-hydroxyprogesterone (40 to 60 mgm. daily Most women will not tolerate more than 300 mgm. p.o. for 5 days). Testosterone compounds can- per month of androgen. We have given methyl V - PROGESTERONED * T?fiESTOTERONE~ ee25MG,LD *.0 ..- - *- I=PROPu . 25SMGAD.F ...1%. .- V 4 THEORETICALm=%NITROGEN ram GM./24 HR. .r5'4on ,.u a , m-a mlr A., "el -.. -le m 3, a a O." I a r 7,/-X, =or UMNARY NITROGE 64 ------L z lIFl - - " - /X, 94 6 A A 4 6 xxxxxx r,IFAr I I I I ------GM/Z4HR F7Lwm 0.1 .- IZ3 7 RINARY PHOSHORU-.JZ3 02j ECAL PHOSP?HORUS~ MGJAO00G. SERUM PHOSPHORUS 441 SERUMCA-Z GM./240.41 HF LRIAYCLIM,, :1aoj B.UNITS SERUM PHOSPHIATASE AVERAGE NORMAL LEVEL am m m m m m m ~ m m m m m mS m I I MG./24HF R. 3.a on I I I 1 2 I 3 I 4 I 5 I 6 I 7 1 8 I 9 1 10 IiI I 12 1 13 1 14 I 15 I 16__ 5-DAY PERIODS FIG. 13. CAsE 12 (B. A., M.G.H. 234190): EFFECT OF PROGESTERONE AND TESTOSTERONE PROPIONATE. ON NITROGEN, P,HOSPHORUS, AND CALcium BALANCES; ON SERUM CALCIUM, PHOSPHORUS, AND ALKALINE PHOSPHATASE; AND ON URINARY 17-KEToSTEROID EXCRETION IN A FEmALE PATIENT WITH OSTEOPOROSIS DUE Tro CUSIHING'S SYNDROME For discussion, see text. 51 52 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT testosterone 10 to 20 mgm. daily p.o., and testo- zoate and diethylstilbestrol) decreased the calcium sterone propionate 10 to 20 or 25 mgm. a week i.m. and phosphorus excretions in the 4 types of One of the most successful methods of administer- osteoporosis studied. Additional observations on ing testosterone compounds to these patients is to estrogen therapy follow. implant one or two pellets of testosterone (75 We a. The fecal as well as the urinary calcium and mgm. each [Schering]) every 3 to 4 months. phosphorus excretions were decreased in usually give some form of testosterone at least for most instances. the first 6 to 12 weeks. b. The effects were usually manifested within 6 Since many of the steroids cause sodium reten- did not reach a maximum until after 30 cause days; tion, the above endocrine therapy may days; and persisted for 30 to 50 cays after edema in certain elderly patients, especially if cessation of therapy. they have low serum protein levels. If this is c. The synthetic estrogen, diethylstilbestrol, not controlled by a low sodium chloride diet, and/ be as effective as the naturally- therapy may appeared to or ammonium chloride, the steroid occurring estrogen, estradiol. have to be modified. d. The ranges of dosages employed were for Because of the possible danger that continued estradiol benzoate 3.32 mgm. daily to 1.66 estrogenic medication may lead to cancer, it has mgm. every 3 days intramuscularly, and for been our practice to interrupt the medication for diethylstilbestrol 1 to 15 mgm. daily by 7 to 14 days every 4 to 6 weeks, even though the mouth. There was no convincing evidence uterus is out. An examination of the vaginal that the larger doses of estradiol benzoate smear every 6 months provides a further safe- were more effective than the smaller; in one guard (19). If the uterus is in, a record should instance (Figure 3) 3.32 mgm. seemed less be kept of the vaginal bleeding; any bleeding not effective than 1.66 mgm. every third day. according to plan (that is, not following estrogen In the one case studied, 15 mgm. of diethyl- or progesterone withdrawal) should promptly be stilbestrol daily was probably more effective investigated further. than 1 mgm. daily. Since osteoporosis is a deficiency in bone matrix e. The serum phosphorus levels, which tend to protoplasm, a high protein diet is probably indi- be high in the post-menopausal group, fell cated; since it is not a disease of calcium and in almost all instances. phosphorus metabolism, excessively high intakes f. The serum alkaline phosphatase levels, con- of these minerals and of vitamin D are probably trary to expectations, did not rise. not indicated. Prolonged immobilization should, g. The urinary nitrogen excretion showed a of course, be avoided if possible, because of the poorly-sustained decrease. danger of superimposed atrophy of disuse. h. The urinary 17-ketosteroid excretion showed a moderate decrease with estradiol. SUMMARY 4. Androgens in the 2 forms used (testosterone 1. Osteoporosis is defined as that form of under- propionate and methyl testosterone) likewise de- mineralization of bone in which the primary de- creased the calcium and phosphorus excretions in fect is a hypofunction of the osteoblasts in laying the 3 types of osteoporosis (post-menopausal, down bone matrix; eight etiological subgroups are senile, and Cushing's syndrome) studied. Addi- listed. tional observations on androgen therapy follow. 2. The effect of certain steroid hormones (no- tably estrogens, androgens, and progesterone) has a. As in the case of estrogens, the fecal as well been studied in 11 cases of osteoporosis: 5 cases as the urinary calcium and phosphorus ex- of the post-menopausal type, 1 case of the senile cretions were decreased; the effect of the type, 2 cases of the type seen following orthopedic therapy on the calcium metabolism was slow operations (atrophy of disuse), and 3 cases of in reaching its maximum, and persisted for the Cushing's syndrome type. a long time after cessation of therapy; the 3. Estrogens in the 2 forms used (estradiol ben- serum phosphorus levels tended to fall; the METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 53 serum alkaline phosphatase levels failed to APPENDIX rise except in the three cases of Cushing's Case histories syndrome. Case 1. F. F. (M.G.H. 156453), a 42-year-old woman, b. In contrast to estrogens, the decrease in the had a bilateral oophorectomy at the age of 41 for endo- urinary nitrogen excretion was marked and metriosis; following the operation she had "nocturnal seizures," the exact nature of which was not determined. prolonged. During the following year there was a gradual onset of c. The ranges of dosages employed were for back pain with increasing dorsal kyphosis and a loss of testosterone propionate 25 to 50 mgm. daily energy. On admission one year after operation, the intramuscularly, and for methyl testosterone patient was in good physical condition except for the deformities of her spine; her blood pressure was 130/80. 40 to 100 mgm. daily by mouth. X-rays revealed typical codfish deformity of many of the d. Methyl testosterone appeared to be as effec- dorsal and lumbar vertebrae, a collapse of some vertebrae, tive as testosterone propionate. and anterior wedging of others. Laboratory studies: serum calcium 10.5 mgm. per cent, serum phosphorus 5. Progesterone, in the dosages of 10, 25, and 4.2 mgm. per cent, serum alkaline phosphatase 3.6 Bo- dansky units, serum total protein 7.3 grams per cent, 100 mgm. daily, had no definite effect whether normal glucose tolerance test, some hypoglycemia un- given alone or in combination with estrogen. responsiveness in an insulin tolerance test, basal meta- 6. The effect on the calcum metabolism of es- bolic rate of minus 6, follicle-stimulating hormone test trogen and androgen in combination was greater positive for 25 mouse units per 100 ml., and 17-keto- steroid excretion of 4.3 mgm. per 24 hours. This case than that of either alone in the post-menopausal was mentioned in previous communications (1 [Case 1], and senile groups. 3 [Case 37], 20 [Case 82], 21). 7. In Cushing's syndrome estrogen probably Case 2. E. P. (M.G.H. 203540), a 60-year-old patient, had a physiological menopause at 53. Thirteen months does have a beneficial effect on the calcium balance, before admission she fell down 6 steps and fractured her previous statements to the contrary from this clinic first lumbar vertebra; she was kept in bed 5 months for notwithstanding! However, testosterone com- this injury, and then allowed up with a brace. Eight pounds have a much more striking effect in this months before admission the 9th dorsal vertebra col- condition, as opposed to other types of osteo- lapsed. Except for back and chest pain, the patient had no complaints, and was in good general health upon ad- porosis. mission. Her blood pressure was 120/90. X-ray exam- 8. The data contain observations on the effect ination revealed the fractures of the first lumbar and the of pregnenolone and dehydroisoandrosterone ace- 9th dorsal vertebrae, marked osteoporosis of the spine and pelvis, but not of the skull, and gall stones. Laboratory tate. studies: serum calcium 10.1 mgm. per cent; serum phos- 9. A short discussion of certain therapeutic phorus 3.5 mgm. per cent; serum alkaline phosphatase 3.7 aspects of post-menopausal osteoporosis is in- Bodansky units; serum total protein 7.6 grams per cent; cluded. no Bence-Jones protein in the urine. This case was mentioned in previous communications (1 [Case 2], The authors are grateful to Drs. Max Gilbert and 3 [Case 13], 20 [Case 85], 21). Erwin Schwenk of the Schering Corporation, Bloomfield, Case 3. A. M. R. (M.G.H. 29358), a 60-year-old phy- sician, developed menopause at 45 following radium treat- New Jersey, for generous supplies of estradiol benzoate ment of submucous fibroids. Four before admission estradiol dipropionate years (Progynon-B), (Progynon-DP), she experienced pain in the back while trying to raise a testosterone propionate (Oreton), methyl testosterone window, and in the ensuing 4 years developed several (Oreton-M), progesterone (Proluton), anhydro-hydroxy- fractures of vertebrae and progressive deformity of the progesterone (Pranone), dehydroisoandrosterone acetate, spine. Physical examination on admission revealed the pregnenolone, and other steroids. deformity of the spine and otherwise no abnormalities. The authors are indebted to Drs. Charles H. Burnett, Her blood pressure was 148/90. X-ray examination Russell W. Fraser, Anne Pappinheimer Forbes, Laurence showed deformities of several thoracic and the first lum- W. Kinsell, Harry F. Klinefelter, Jr., William Parson, bar vertebrae, and osteoporosis of the bones of the spine Patricia H. Smith, and Hirsh W. Sulkowitch for pro- and pelvis but not of the skull. Laboratory studies: fessional assistance; and to Esther Bloomberg, Dorothy serum calcium 10.1 mgm. per cent; serum phosphorus F. Bryant, Evelyn Caroll, Lowell D. Cox, Eleanor F. 3.0 mgm. per cent; serum phosphatase 3.7 Bodansky Dempsey, Elizabeth C. Donaldson, Grace C. Griswold, units; serum total protein 6.3 grams per cent. This case Marion MacAulay, Robin M. Suby, Shirley L. Wells, has been mentioned in previous communications (1 [Case and Priscilla White for technical assistance. 3], 3 [Case 32], 20 [Case 84], 21). 54 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT Case 4. R. W. (M.G.H. 319940), a 56-year-old woman, hours. The venous pressure was 65 mm. of water; the had a cholecystectomy at 26, and thyroidectomy for thyro- vital capacity was 1,200 ml. toxicosis at 46. At 48, an artificial menopause was in- Case 6. M. H. (M.G.H. 278511), a male of 72 years, duced with radium forf metropathia hemorrhagica. Three developed pain in the back after a minor. injury 1 year years before admission the patient strained her back open- before admission (1-141). The symptoms persisted in ing a heavy window, and thereafter had several episodes spite of local therapy, and he was referred to the hospital. of sharp pain in the back when lifting. Physical examina- The only abnormal findings on physical examination were tion showed a nervous woman with a tremor of her head, a thin skin and deformities of the spine; his blood pres- and considerable deformity of her back. Her blood pres- sure was 140/80. X-ray examination of the spine showed sure was 115/75. X-ray examination revealed extensive marked decrease in density of the vertebrae with a cod- osteoporosis with multiple fractured vertebrae; bones of fish deformity of some, and wedging or collapse of others. skull were approximately normal in density. Laboratory Laboratory studies: serum calcium 10.0 mgm. per cent; studies: no abnormalities of the urine, stools, or blood serum phosphorus 3.1 mgm. per cent; serum alkaline cells; urine calcium 2 to 4 plus by the Sulkowitch test; phosphatase 4.2 Bodansky units; serum total protein 7.0 serum calcium 10.6 mgm. per cent; serum phosphorus 3.1 grams per cent; non-protein nitrogen 18 mgm. per cent; mgm. per cent; serum alkaline phosphatase 3.7 Bodansky urinary 17-ketosteroid excretion 7.2 and 6.9 mgm. per 24 units; serum chloride 93.2 m.eq. per 1.; serum carbon hours; follicle-stimulating hormone excretion in the urine dioxide combining power 28.1 m.eq. per 1.; non-protein normal; gastric acidity normal. The normal level of the nitrogen level 26 mgm. per cent; and total protein 7.8 follicle-stimulating hormone excretion is evidence against grams per cent with an albumin/globulin ratio of 1.7. the idea of the osteoporosis having been due to the "male Electrocardiographic tracing was normal; follicle-stimu- menopause." This case has been mentioned in previous lating hormone excretion in the urine was high (consistent communications (6, 9, 21). with the menopause). This case has been mentioned in Case 7. E. S. (M.G.H. 360207), a female of 35 years, a previous communication (21). had poliomyelitis at the age of 9 involving the left leg Case 5. S. B. (M.G.H. 430664), a 58-year-old woman, alone, and since the age of 14 had worn a 6-pound brace had at the age of 28 a bilateral oophorectomy with a on the left leg. She had always been very active. For hysterectomy for pelvic lacerations following childbirth. the 10 years prior to study she had had metatarsal pain For some years she had occasional hot flashes and attacks in the right foot, and for 3 years had turned her right of palpitation and nervousness. At the age of 50 she be- ankle frequently. She was admitted for a triple arthro- gan to notice weakness and the gradual onset of skeletal desis and muscle transplant to strengthen the right ankde. deformities involving the skull, shoulder girdle, lower The menstrual history was normal. From the point of ribs, pelvis, and bones of the legs. At 54 she had acute view of the experiment the patient can be considered a tonsillitis, and then a tonsillectomy. At 57 she had pneu- normal adult female in every respect, except for the resi- monia, and after 3 weeks in bed, increased weakness and duals of the poliomyelitis of the left leg; her blood pres- pain in her tibiae. About this time she used braces on her sure was 120/80. Laboratory studies: serum calcium 9.8 legs because of difficulty in walking. Shortly afterward mgm. per cent; serum phosphorus 3.5 mgm. per cent; she developed low-back pain on weight-bearing. serum alkaline phosphatase 2.4 Bodansky units; and On admission, the patient was undernourished and de- serum total protein 4.7 grams per cent; urinary 17-ketos- formed with atrophic skin and muscles, dorsal kyphosis teroid excretion 7.6 mgm. per 24 hours. This case has and right cervical-dorsal scoliosis, enlarged parietal bosses, been mentioned briefly elsewhere (22). bowing of the femora and tibiae, and collapse of the lumbar Case 8. H. D. (M.G.H. 382395), a male fireman of 50 spine so that the ribs touched the wings of the iliae. The years, fell 3 stories and suffered fractures of ribs, pelvis, chest was distorted; veins of the neck were distended; cor right tibia and right fibula, and multiple contusions and pulmonale was present; blood pressure was 156/80. abrasions. The patient was in shock on admission, but X-rays of the skull, shoulder girdle, lower ribs, pelvis, responded promptly to a blood transfusion. On physical femora, tibiae, and entire thoracic and lumbar spine ex- examination he was found to be a well-preserved man cept for the upper three dorsal vertebrae showed Paget's without organic disease; blood pressure was 110/60. A disease; in addition there were marked generalized de- Kirschner wire was inserted through the os calcis and creased density of bones and typical codfish deformity of a Zimmer bow applied. During the next 2 weeks the frac- many vertebrae. There were pulmonary fibrosis, cardiac tures were reduced by traction and by several manipula- enlargement and displacement, and tortuosity of the tions under anesthesia. The patient was transferred to aorta. Laboratory studies: serum calcium 10.5 mgm. per the metabolic ward where studies were begun 44 days cent, serum phosphorus 4.2 mgm. per cent, serum alkaline after the accident. Laboratory studies: serum calcium phosphatase 34.3 Bodansky units, serum total protein 7.3 10.7 mgm. per cent; serum phosphorus 3.3 mgm. per cent; grams per cent, serum non-protein nitrogen 31 mgm. per serum alkaline phosphatase 2.7 Bodansky units; serum cent, serum sodium 140.0 m.eq. per 1., serum potassium total protein 6.7 grams per cent. This case has been 4.7 m.eq. per 1., serum chloride 101 m.eq. per 1., serum mentioned briefly elsewhere (23). carbon dioxide content 34.2 m.eq. per 1., follicle-stimulat- Case 9. C. M. (M.G.H. 348774), a male of 24 years, ing hormone test positive for 192 mouse units per 24 sustained a fracture of the pelvis and of the right femur in hours, and 17-ketosteroid excretion of 2.6 mgm. per 24 an automobile accident 9 months before study. The fe- METABOLIC EFFECTS OF STEROID HORMONES IN OSTEOPOROSIS 55 mur failed to unite properly and, although the patient was delphia, 1940, 15. Also, Selye, H., The general active and able to walk about with a cane, he had un- adaptation syndrome and the diseases of adapta- usual motion and instability in his right femur because of tion. J. Clin. Endocrinol., 1946, 6, 117. the poor union. He was readmitted for bone grafting. 8. Reifenstein, E. C., Jr., Kinsell, L. W., and Albright, Physical examination revealed a young adult male who F., Observations on the use of the serum phos- was normal in all respects except for the incomplete un- phorus level as an index of pituitary growth hor- ion of his right femur; his blood pressure was 105/60. mone activity; the effect of estrogen therapy in Laboratory studies: serum calcium 10.3 mgm. per cent; acromegaly. Endocrinol., 1946, 39, 71. Also Con- serum phosphorus 4.5 mgm. per cent; serum alkaline ference on Metabolic Aspects of Convalescence In- phosphatase 2.9 Bodansky units, and serum total protein cluding Bone and Wound Healing. Trans. of 12th 6.0 grams per cent. This case has been mentioned briefly Meeting, February 4-5, 1946, p. 97; distributed by elsewhere (24). Josiah Macy, Jr. Foundation, New York. Case 10. B. V. (M.G.H. 74372), a female of 25 years, 9. Reifenstein, E. C., Jr., Albright, F., and Wells, S. L., with Cushing's syndrome of 5 years duration. The case The accumulation, interpretation, and presentation history of this patient has been published elsewhere (2 of data pertaining to metabolic balances, notably [Case 1]). This case has been mentioned also in other those of calcium, phosphorus, and nitrogen. J. previous communications (6, 9, 20 [Case 37]). Clin. Endocrinol., 1945, 5, 367. Case 11. R. B. (M.G.H. 3397), a female of 50 years, 10. Talbot, N. B., Saltzman, A. H., Wixom, R. L., and with Cushing's syndrome of 5 years duration. The case Wolfe, J. K., The colorimetric assay of urinary history of this patient has been published elsewhere (2 corticosteroid-like substances. J. Biol. Chem., 1945, [Case 2]). This case has been mentioned also in other 160, 535. previous communications (6, 9, 20 [Case 36], 25 [Case 11. Klinefelter, H. F., Jr., Albright, F., and Griswold, 2]). G. C., Experience with a quantitative test for Case 12. B .A. (M.G.H. 234190), a female of 43 years, normal or decreased amounts of follicle stimulating with Cushing's syndrome of 6 years duration. A complete hormone in the urine in endocrinological diagnosis. case history with autopsy findings is reported elsewhere J. Clin. Endocrinol., 1943, 3, 529. (26). This case has also been mentioned in previous 12. Abels, J. C., and Dobriner, K., Conference on Meta- communications (2 [Case 3], 20 [Case 38]). bolic Aspects of Convalescence Including Bone and Wound Healing, Transactions of Seventh Meeting, June 9-10, 1944, p. 122; distributed by Josiah Macy, BIBLIOGRAPHY Jr. Foundation, New York. 1. Albright, F., Bloomberg, E., and Smith, P. H., Post- 13. Farquharson, R. F., Salter, W. T., Tibbets, D. M., menopausal osteoporosis. Tr. Assoc. Am. Physi- and Aub, J. C., Studies of calcium and phosphorus cians, 1940, 55, 298. metabolism. XII. The effect of the ingestion of 2. acid-producing substances. J. Clin. Invest., 1931, Albright, F., Parson, W., and Bloomberg, E., Cush- 10, 221. ing's syndrome interpreted as hyperadrenocorticism 14. leading to hypergluconeogenesis; results of treat- Howard, J. E., Parson, W., and Bigham, R. S., Jr., ment with testosterone propionate. J. Clin. Endo- Studies on fracture convalescence. III. The uri- crinol., 1941, 1, 375. nary excretion of calcium and phosphorus. Bull. Johns Hopkins Hosp., 1945, 77, 291. 3. Albright, F., Smith, P. H., and Richardson, A. M., 15. Forbes, A. P., Donaldson, E. C., Reifenstein, E. C., Post-menopausal osteoporosis: its clinical features. Jr., and Albright, F., The effect of trauma and J. A. M. A., 1941, 116, 2465. disease on the urinary 17-ketosteroid excretion in 4. Reifenstein, E. C., Jr., and Albright, F., Paget's man. J. Clin. Endocrinol. To be published. disease: its pathologic physiology and the impor- 16. Browne, J. S. L., Conference on Metabolic Aspects of tance of this in the complications arising from Convalescence Including Bone and Wound Heal- fracture and immobilization. New Eng. J. Med., ing, Transactions of the Fifth Meeting, October 1944, 231, 343. 8-9, 1943, p. 91; distributed by Josiah Macy, Jr. 5. Albright, F., Burnett, C. H., Cope, O., and Parson, Foundation, New York. W., Acute atrophy of bone (osteoporosis) simulat- 17. Shorr, E., Bernheim, A. R., and Taussky, H., The ing hyperparathyroidism. J. Clin. Endocrinol., relation of urinary citric acid excretion to the 1941, 1, 711. menstrual cycle and the steroidal reproductive hor- 6. Albright, F., Cushing's syndrome. Its pathological mones. Science, 1942, 95, 606. physiology, its relationship to the adrenogenital 18. Reifenstein, E. C., Jr., and Albright, F., Conferences syndrome, and its connection with the problem of on Metabolic Aspects of Convalescence Including the reaction of the body to injurious agents ("alarm Bone and Wound Healing, Transactions of the reaction" of Selye). The Harvey Lecture Series, Fifth Meeting, October 8-9, 1943, p. 79; distributed 1942-1943, 38, 123. by Josiah Macy, Jr. Foundation, New York. 7. Selye, H., The alarm reaction. Cyclopedia Med. 19. Fremont-Smith, M., Graham, R. M., Janzen, L. T., Surg. and Spec., F. A. Davis Company, Phila- and Meigs, J. V., The vaginal smear in the diag- 56 EDWARD C. REIFENSTEIN, JR., AND FULLER ALBRIGHT nosis of uterine cancer. J. Clin. Endocrinol., 23. Reifenstein, E. C., Jr., and Albright, F., Conferences 1945, 5, 40. on Metabolic Aspects of Convalescence Including 20. Fraser, R. W., Forbes, A. P., Albright, F., Sulko- Bone and Wound Healing, Transactions of Third witch, H., and Reifenstein, E. C., Jr., Colorimetric Meeting, March 12-13, 1943, p. 63; and Transac- assay of 17-ketosteroids in urine; a survey of the tions of Fourth Meeting, June 11-12, 1943, p. 77; use of this test in endocrine investigation, diagno- distributed by Josiah Macy, Jr. Foundation, New sis, and therapy. J. Clin. Endocrinol., 1941, 1, 234. York. 21. Reifenstein, E. C., Jr., Albright, F., Parson, W., and 24. Reifenstein, E. C., Jr., and Albright, F., Conferences Bloomberg, E., The effect of estradiol benzoate, on Metabolic Aspects of Convalescence Including of testosterone propionate, and of combinations of Bone and Wound Healing, Transactions of Fourth both on post-menopausal osteoporosis and senile Meeting, June 11-12, 1943, p. 77; distributed by osteoporosis. Endocrinol., 1942, 30, S1024. Josiah Macy, Jr. Foundation, New York. 22. Reifenstein, E. C., Jr., and Albright, F., Conferences E. on Metabolic Aspects of Convalescence Including 25. Reifenstein, C., Jr., Forbes, A. P., Albright, F., Bone and Wound Healing, Transactions of First Donaldson, E., and Carroll, E., Effect of methyl Meeting, September 11-12, 1942, p. 37; Transac- testosterone on urinary 17-ketosteroids of adrenal tions of Second Meeting, December 11-12, 1942, p. origin. J. Clin. Invest., 1945, 24, 416. 69 and 96; and Transactions of Fourth Meeting, 26. Albright, F., and MacMahon, H. E., Clinical Patho- June 11-12, 1943, p. 77; distributed by Josiah Macy, logical Conference. Bull. New Eng. Med. Center, Jr. Foundation, New York. 1941, 3, 35.