Reproductive health in Turner syndrome: A narrative review.

Turner syndrome (TS), a common chromosomal abnormality affecting females, is associated with partial or complete loss of the second sex chromosome. Although the classic karyotype is 45, X, the detection of mosaic TS is increasing. TS is a multi-system disorder with significant endocrine, cardiovascular and reproductive impacts. Accelerated ovarian follicular loss leads to primary amenorrhoea or premature ovarian insufficiency and infertility. Early diagnosis and counselling regarding hormone replacement therapy and future reproductive capacity, including fertility preservation, are essential to improve reproductive outcomes. Pubertal induction or estrogen replacement is usually required to optimise long-term health outcomes; however, initiation may be delayed due to delayed diagnosis. Spontaneous pregnancy occurs in a small number of women; however, many require donor oocytes and assisted reproductive technology to achieve a pregnancy. Pregnancy is a high risk especially when associated with congenital heart disease. Prepregnancy counselling by the multidisciplinary team (MDT) to identify contraindications and optimise pre-existing health issues is essential. Pregnancy management should be led by a maternal-fetal medicine unit with input from the MDT. This review examines reproductive health outcomes in women with TS and how best to manage them to reduce health risks and improve maternal and neonatal outcomes.

The impact of COVID-19 on a specialised menopause clinic: Changes in practice and women's experiences.

AIMS: The COVID-19 pandemic necessitated the rapid change in a dedicated multidisciplinary menopause clinic from in-person consultations to telehealth. The aim of this study was to explore the impact of COVID-19 on menopause service delivery and consumer experiences. METHODS: Two-part study involving the following. (i) Clinical audit conducted June-July 2019 (pre-COVID-19) and June-July 2020 (COVID-19) assessing practice and service delivery changes. Assessment outcomes included: patient demographics, cause of menopause, presence of menopause symptoms, appointment attendance, medical history, investigations and menopause treatments. (ii) A post-clinic online survey exploring the acceptability and experience of telehealth, once telehealth models of care had been routinely used in the menopause service (2021). RESULTS: Pre-COVID (n = 156) and COVID-19 (n = 150) clinic consultations were audited. Menopause care delivery changed significantly from 100% face-to-face consultations in 2019 to 95.4% telehealth consultations in 2020. In 2020, fewer women had investigations performed vs 2019 (P < 0.001), although use of menopausal therapies was similar (P < 0.05). Ninety-four women completed the online survey. Most women (70%) were satisfied with their telehealth consultation and perceived that the doctor effectively communicated with them (76%). Women preferred face-to-face consultations for their first menopause clinic visit (69%) and telehealth for review consultations (65%). The majority of women (62%) viewed the continuation of telehealth consultations as 'moderately' to 'extremely useful' post-pandemic. CONCLUSION: The COVID-19 pandemic caused significant changes to menopause service delivery. Telehealth was perceived as feasible and acceptable by women, supporting the continuation of a hybrid service delivery model incorporating telehealth and face-to-face consultation to meet the needs of women.

Dual Energy X-ray Absorptiometry Reports Fail to Adhere to International Guidelines.

INTRODUCTION: Bone mineral density, measured by dual X-ray absorptiometry (DXA), is the gold standard for diagnosis of osteoporosis. The utility of DXA relies on the accuracy of scan acquisition, interpretation of data, and the adequacy of reports. The International Society for Clinical Densitometry (ISCD) has published guidelines regarding minimum reporting guidelines. This study assessed whether DXA reports for patients receiving care at an academic teaching hospital adhere to these reporting standards, and determine whether differences exist depending on patient factors and the imaging service. METHODS: Patients aged ≥18 years, receiving care at specialist outpatient clinics between January 1, 2018 and December 31, 2019, with a DXA report available, were eligible for inclusion. DXA reports were manually reviewed for adherence to ISCD guidelines, with each criterion scored as one point, giving a total score of 14 for baseline DXA scans and 18 for repeat DXA scans. The score was then converted to a percentage. RESULTS: Of 459 DXA scans included, 214 were performed internally at our hospital and 245 performed at 23 external imaging services. Mean (SD) patient age was 60 (16.3) years, and 75.8% were female. The overall median (IQR) report score was 57.1% (42.9, 82.4). ISCD criteria with the lowest scores were recommendation and timing of future DXA scans (included in 1.1% of reports) and investigation for secondary causes of osteoporosis (included in 1.2% of reports). Reports performed internally had significantly higher scores than those performed externally, after adjusting for age, sex, indication, and type of scan (incidence rate ratio 1.83, 95% confidence interval 1.77, 1.89). Baseline DXA reports had slightly higher scores than repeat DXA scans, and, among external imaging services, rural services had higher scores than metropolitan services. CONCLUSION: This study, the largest comprehensive evaluation of DXA reports, highlights significant deficiencies and variation in report standards between imaging services. This has potential implications for osteoporosis diagnosis and management.

Dilatation of the Ascending Aorta in Turner Syndrome: Influence of Bicuspid Aortic Valve Morphology and Body Composition.

BACKGROUND: Aortic dilatation and bicuspid aortic valve (BAV) are frequent in Turner syndrome (TS). Due to short stature, aortic size index (ASI)-ascending aortic diameter (AD)/body surface area (BSA)-is used to identify aortic dilatation in TS patients. We sought to: 1) describe echocardiographic findings in the largest cohort of Australian women with TS; 2) assess if ASI progresses differently with age in TS BAV compared to non-syndromic BAV; and 3) determine whether adjustment of AD for body composition may be superior to BSA indexation. METHODS: Transthoracic echocardiography (TTE) data were retrospectively collected on 125 women with TS. Body composition was quantified by dual energy X-ray absorptiometry (DXA) in 60 women within 6 months of baseline TTE. Age-matched females with non-syndromic BAV (n=170) were used as controls for TS patients with BAV. RESULTS: Mean age of TS women was 28±16 years, and mean height and BSA were 141.6±21.7 cm and 1.4±0.4 m2, respectively. Mean AD was 2.5±0.8 cm, and ASI 2.0±0.6 cm/m2. Aortic dilatation (ASI >2.0 cm/m2) was present in 42 (34%) patients. Turner syndrome women with BAV (n=34; 27%) had a larger ASI than those with tri-leaflet AV (2.2±0.4 cm/m2 vs. 1.7±0.3 cm/m2, p<0.001). In the pooled BAV cohort, TS patients had a higher baseline ASI (2.2±0.4 cm/m2 vs. 2.1±0.3 cm/m2, p=0.02) and greater increase in ASI with age (0.21 mm/m2/year vs. 0.10 mm/m2/year, p=0.01) compared to non-syndromic BAV patients. DXA fat-free mass (r=0.33, p=0.01) and lean mass (r=0.32, p=0.02) correlated with AD, as did BSA (r=0.62, p<0.001). CONCLUSION: Turner syndrome women with BAV have a greater degree of baseline aortic dilatation and a twofold faster increase in aortic dimension with age when compared to matched women with non-syndromic BAV. Several DXA-derived body composition parameters correlate with aortic size in TS, however BSA appears to be the most robust method of indexation.

Realities of offering advice to governments on CITES.

What happens when those who provide conservation advice are required to take policy and management action based on that advice? Conservation advocates and scientists often try to prompt regulatory change that has significant implications for government without facing the challenge of managing such change. Through a case study, we placed ourselves in the role of the government of Thailand, facing obligations to seahorses (Hippocampus spp.) under the Convention on International Trade in Endangered Species of Wild Fauna and Flora (CITES). These obligations include ensuring that its exports of seahorses do not damage wild populations. We applied a CITES-approved framework (which we developed) to evaluate the risks of such exports to 2 seahorse species. We used the framework to evaluate the pressures that put wild populations of the species at risk; whether current management mitigates the risk or offsets these pressures; and whether the species is responding as hoped to management policy. We based our analysis on information in published and grey literature, local knowledge, citizen science data, results of government research, and expert opinion. To meet CITES obligations, exports of both species would need to be prohibited until more precautionary adaptive management emerged. The risk of any exports of Hippocampus trimaculatus was above a tolerable level because of a lack of appropriate management to mitigate risks. In contrast, the risk of any exports of Hippocampus kuda could become tolerable if monitoring were put in place to assess the species' response to management. The process we developed for Authorities to determine risk in response to CITES guidelines was challenging to implement even without the need for government to consider social implications of conservation action. Despite the imperfections of our risk evaluation, however, it still served to support adaptive management. Conservationists need to keep implementation in mind when offering advice.

Realidades al Ofrecerle Consejos sobre CITES a los Gobiernos Resumen ¿Qué ocurre cuando se requiere que quienes proporcionan consejos para la conservación realicen acciones políticas y de manejo basadas en aquellos consejos? Los científicos y partidarios de la conservación tratan con frecuencia de provocar cambios legislativos que tienen implicaciones significativas para el gobierno sin enfrentar el reto que implica manejar ese cambio. Mediante un estudio de caso, nos colocamos en el papel del gobierno de Tailandia, el cual enfrenta obligaciones con los caballitos de mar (Hippocampus spp.) bajo la Convención sobre el Comercio Internacional de Especies Amenazadas de Flora y Fauna Silvestre (CITES). Estas obligaciones incluyen asegurar que las exportaciones de caballitos de mar no causen daño a las poblaciones silvestres de este grupo. Aplicamos un marco de trabajo aprobado por CITES (el cual desarrollamos) para evaluar los riesgos de dichas exportaciones para dos especies de hipocampos. Usamos el marco de trabajo para valorar las presiones que ponen a las poblaciones silvestres de ambas especies en riesgo; si el manejo actual mitiga o compensa el riesgo de estas presiones; y si las especies están respondiendo como se esperaba a las políticas de manejo. Basamos nuestro análisis en información tomada de literatura publicada y de la literatura gris, del conocimiento local, los datos de la ciencia ciudadana, los resultados de investigaciones realizadas por el gobierno y de la opinión de expertos. Para cumplir con las obligaciones de CITES, las exportaciones de ambas especies necesitarían estar prohibidas hasta que existiera un manejo adaptativo más preventivo. El riesgo de cualquier exportación de H. trimaculatus quedó por encima de un nivel tolerable debido a la falta de un manejo apropiado para mitigar los riesgos. Como contraste, el riesgo de cualquier exportación de H. kuda podría volverse tolerable si se realizaran monitoreos para evaluar la respuesta de la especie al manejo. Fue todo un reto implementar el proceso que desarrollamos para que las autoridades determinen el riesgo siguiendo la pauta de CITES incluso sin la necesidad de que el gobierno considerara las implicaciones sociales de la acción de conservación. Sin embargo, a pesar de las imperfecciones de nuestra evaluación de riesgo, todavía funcionó como apoyo para el manejo adaptativo. Los conservacionistas necesitan seguir considerando la implementación cuando ofrecen consejos.

'My relationships have changed because I've changed': biographical disruption, personal relationships and the formation of an early menopausal subjectivity.

Early menopause (EM) or premature ovarian insufficiency (POI) can disrupt gendered and age-related expectations associated with perceived 'normative' biographies for young adult women, with implications for subjectivity and relationships. While previous qualitative research has concentrated on the impacts of EM/POI on biography and sense of self, in this article, we examine the enmeshment of personal relationships with the formation of early menopausal subjectivities. Drawing on research exploring concepts of 'biographical disruption' and personal relationships, and theoretical work on social norms and subject formation, we present findings from a narrative thematic analysis of 25 interviews with women diagnosed with spontaneous or medically induced EM/POI. We identify three main narrative 'types' of subjective and relational experience in response to the 'disruption' of EM/POI: interlude and continuity; disruption and adaptation; and disruption and ambivalence. Women's accounts of their experience of EM/POI indicate that the formation of early menopausal selves is mediated by the extent to which women and those around them identify with gendered norms related to reproduction and age. Consistent with theoretical perspectives that consider the self as relationally produced, we argue that the subjective and relational dimensions of EM/POI are intertwined and must be understood in tandem.

Identifying and addressing osteoporosis knowledge gaps in women with premature ovarian insufficiency and early menopause: A mixed-methods study.

OBJECTIVE: Osteoporosis associated with premature ovarian insufficiency (POI) and early menopause (EM) is a major concern for women. We aimed to (a) identify information and knowledge gaps and behaviours regarding bone health in women with POI/EM and (b) co-design an osteoporosis fact sheet. DESIGN: Mixed-methods study: survey of women and online resource appraisals to develop and refine, using semi-structured interviews, an osteoporosis fact sheet. PATIENTS: Women with POI/EM (menopause before ages 40 and 45 years respectively). MEASUREMENTS: Demographics, comorbidities, information needs, calcium intake, exercise, osteoporosis knowledge (OKAT), beliefs and self-efficacy, DISCERN appraisal (validated scales). ANALYSIS: descriptive statistics, logistic regression and thematic analysis of interviews. RESULTS: Median age of survey respondents (n = 316) was 54(IQR47-63) years, median age of menopause was 40(IQR38-43) years, and osteoporosis diagnosis was reported in 19%. Most reported inadequate dietary calcium intake (99%) and exercise (65%). Median OKAT score 8 [IQR6-10]/19 indicated knowledge gaps regarding risk factors and treatment options. Adjusting for age and education, OKAT predicted calcium intake (OR 1.126 [CI 1.035-1.225]; P = 0.006) and screening (OR 1.186 [CI 1.077-1.305]; P = 0.001); beliefs predicted screening (OR 1.027 [CI 1.004-1.050]; P = 0.019); and self-efficacy predicted calcium intake (OR1.040 (CI 1.013-1.069); P = 0.003] and exercise (OR 1.117 [CI 1.077-1.160]; P < 0.001). Current online resources have deficiencies. Five themes identified from two interview rounds (n = 10/ round) were as follows: content, emotional response, design, perceived usefulness and clinical considerations. The final fact sheet was considered acceptable and useful in addressing knowledge gaps, promoting information-seeking, impacting behaviours and facilitating healthcare discussions. CONCLUSION: A co-designed fact sheet is acceptable and addresses identified osteoporosis knowledge gaps in women with POI/EM.

Using cumulative human-impact models to reveal global threat patterns for seahorses.

Understanding threats acting on marine organisms and their conservation status is vital but challenging given a paucity of data. We studied the cumulative human impact (CHI) on and conservation status of seahorses (Hippocampus spp.)-a genus of rare and data-poor marine fishes. With expert knowledge and relevant spatial data sets, we built linear-additive models to assess and map the CHI of 12 anthropogenic stressors on 42 seahorse species. We examined the utility of indices of estimated impact (impact of each stressor and CHI) in predicting conservation status for species with random forest (RF) models. The CHI values for threatened species were significantly higher than those for nonthreatened species (category based on International Union for Conservation of Nature Red List). We derived high-accuracy RF models (87% and 96%) that predicted that 5 of the 17 data-deficient species were threatened. Demersal fishing practices with high bycatch and pollution were the best predictors of threat category. Major threat epicenters were in China, Southeast Asia, and Europe. Our results and maps of CHI may help guide global seahorse conservation and indicate that modeling and mapping human impacts can reveal threat patterns and conservation status for data-poor species. We found that for exploring threat patterns of focal species, species-level CHI models are better than existing ecosystem-level CHI models.

Uso de Modelos de Impacto Humano Acumulativo para Revelar los Patrones de Amenaza Mundial para Hipocampos Resumen El entendimiento de las amenazas que actúan sobre los organismos marinos y su estado de conservación es de suma importancia pero a la vez un gran reto debido a la insuficiencia de datos. Estudiamos el estado de conservación y el impacto humano acumulativo (CHI, en inglés) que existe sobre los hipocampos (Hippocampus spp.)- un género de peces marinos raro y escaso de datos. Construimos modelos lineales aditivos con el conocimiento de expertos y conjuntos de datos espaciales relevantes para evaluar y mapear el CHI de los doce estresantes antropogénicos que afectan a las 42 especies de hipocampos. Examinamos la utilidad que tienen los índices de impacto estimado (el impacto de cada estresante y cada CHI) para la predicción del estado de conservación de las especies usando modelos de bosque azaroso (RF, en inglés). Los valores del CHI para las especies amenazadas fueron considerablemente más altos que aquellos obtenidos para las especies no amenazadas (categoría basada en la Lista Roja de la Unión Internacional para la Conservación de la Naturaleza). De esto derivamos modelos RF de alta certeza (87% y 96%), los cuales pronosticaron que cinco de las 17 especies deficientes de datos estaban amenazadas. Las prácticas de pesca demersal con una captura accesoria elevada y la contaminación fueron los mejores pronosticadores de la categoría de amenaza. Los principales epicentros de amenaza se ubicaron en China, el sureste asiático y en Europa. Nuestros resultados y mapas de CHI pueden ayudar a guiar la conservación mundial de hipocampos y también indican que el modelado y el mapeo de de los impactos humanos pueden revelar los patrones de amenaza y el estado de conservación de las especies deficientes de datos. Descubrimos que para explorar los patrones de amenaza de especies focales, son mejores los modelos de CHI a nivel de especie que los ya existentes modelos de CHI a nivel de ecosistema.

Assessment and management of bone health in women with oestrogen receptor-positive breast cancer receiving endocrine therapy: position statement summary.

INTRODUCTION: Representatives appointed by relevant Australian medical societies used a systematic approach for adaptation of guidelines (ADAPTE) to formulate clinical consensus recommendations on assessment and management of bone health in women with oestrogen receptor-positive early breast cancer receiving endocrine therapy. The current evidence suggests that women receiving adjuvant aromatase inhibitors and pre-menopausal woman treated with tamoxifen have accelerated bone loss and that women receiving adjuvant aromatase inhibitors have increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven anti-fracture benefit in post-menopausal women receiving aromatase inhibitors for hormone receptor-positive breast cancer. MAIN RECOMMENDATIONS: Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density measurement, with monitoring based on risk factors. Weight-bearing exercise and vitamin D and calcium sufficiency are recommended routinely. Anti-resorptive treatment is indicated in women with prevalent or incident clinical or morphometric fragility fractures, and should be considered in women with a T score (or Z score in women aged < 50 years) of < - 2.0 at any site, or if annual bone loss is ≥ 5%, considering baseline bone mineral density and other fracture risk factors. Duration of anti-resorptive treatment can be individualised based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with anti-resorptive treatments are low. CHANGES IN MANAGEMENT AS RESULT OF THE POSITION STATEMENT: Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimised by non-pharmacological intervention and, where indicated, anti-resorptive treatment, in an individualised, multidisciplinary approach.

Assessment and management of bone health in women with oestrogen receptor-positive breast cancer receiving endocrine therapy: Position statement of the Endocrine Society of Australia, the Australian and New Zealand Bone & Mineral Society, the Australasian Menopause Society and the Clinical Oncology Society of Australia.

To formulate clinical consensus recommendations on bone health assessment and management of women with oestrogen receptor-positive early breast cancer receiving endocrine therapy, representatives appointed by relevant Australian Medical Societies used a systematic approach for adaptation of guidelines (ADAPTE) to derive an evidence-informed position statement addressing 5 key questions. Women receiving adjuvant aromatase inhibitors and the subset of premenopausal woman treated with tamoxifen have accelerated bone loss and increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven antifracture benefit. Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density (BMD) measurement, with monitoring based on risk factors. Weight-bearing exercise, vitamin D and calcium sufficiency are recommended routinely. Antiresorptive treatment should be considered in women with prevalent or incident clinical or morphometric fractures, a T-score (or Z-scores in women <50 years) of <-2.0 at any site, or if annual bone loss is ≥5%, considering baseline BMD and other fracture risk factors. Duration of antiresorptive treatment can be individualized based on absolute fracture risk. Relative to their skeletal benefits, risks of adverse events with antiresorptive treatments are low. Skeletal health should be considered in the decision-making process regarding choice and duration of endocrine therapy. Before and during endocrine therapy, skeletal health should be assessed regularly, optimized by nonpharmacological intervention and where indicated antiresorptive treatment, in an individualized, multidisciplinary approach. Clinical trials are needed to better delineate long-term fracture risks of adjuvant endocrine therapy and to determine the efficacy of interventions designed to minimize these risks.

A holistic investigation of the ecological correlates of abundance and body size for the endangered White's seahorse Hippocampus whitei.

Analysing the associations between the endangered White's seahorse Hippocampus whitei and characteristics of its environment (including habitat, prey and predator variables) in an estuary in New South Wales, Australia, revealed that seahorses had a greater number of significant associations with environmental correlates within a single seagrass bed than among seagrass beds. Predator abundance was negatively correlated with H. whitei abundances among seven seagrass beds (200-6,000 m apart) and no ecological correlate was associated with H. whitei body size distributions. Within the seagrass bed with the greatest number of H. whitei, individuals preferentially selected locations that were deeper, had denser seagrass, more epiphytic prey types and fewer predators. Smaller H. whitei were associated with greater depths within the bed. In this study, each class of ecological correlate (habitat, prey, predators) was found to have at least one significant relationship with H. whitei, depending on the scale, demonstrating that all three are important to H. whitei populations. As such, future studies that evaluate animal populations may benefit from holistic approaches that consider each of these together. For animals that are experiencing dramatic population declines due to habitat destruction, as H. whitei has over the last decade, a better understanding of its relationship to its environment is important to inform conservation action.

Cardiometabolic Risks in Polycystic Ovary Syndrome: Non-Traditional Risk Factors and the Impact of Obesity.

Polycystic ovary syndrome (PCOS) is a common and complex endocrinopathy with reproductive, metabolic, and psychological features and significantly increased cardiometabolic risks. PCOS is underpinned by inherent insulin resistance and hyperandrogenism. Obesity, more common in PCOS, plays an important role in the pathophysiology, exacerbating hyperinsulinaemia and hyperandrogenism, leading to recommended first-line lifestyle intervention. Significant traditional and non-traditional risk factors are implicated in PCOS in addition to obesity-exacerbated cardiometabolic risks and are explored in this review to promote the understanding of this common metabolic and reproductive condition.

Premature ovarian insufficiency in general practice: Meeting the needs of women.

BACKGROUND: Premature ovarian insufficiency (POI), defined as amenorrhoea due to the loss of ovarian function before 40 years of age, can occur spontaneously or be secondary to medical therapies. POI is associated with cardiovascular morbidity, osteoporosis and premature mortality. Women with POI present in primary care with menstrual disturbance, menopausal symptoms, infertility and, often, significant psychosocial issues. General practitioners play an important role in the evaluation and long-term management of women with POI. OBJECTIVE: This article examines the diagnostic and management issues when providing care for women with POI in the primary care setting. DISCUSSION: Diagnosis of POI requires follicle-stimulating hormone (FSH) levels in the menopausal range on two occasions, at least four to six weeks apart in a woman aged.

parkin-induced defects in neurophysiology and locomotion are generated by metabolic dysfunction and not oxidative stress.

Parkinson's disease (PD) is characterized by movement disorders, including bradykinesia. Analysis of inherited, juvenile PD, identified several genes linked via a common pathway to mitochondrial dysfunction. In this study, we demonstrate that the larva of the Drosophila parkin mutant faithfully models the locomotory and metabolic defects of PD and is an excellent system for investigating their inter-relationship. parkin larvae displayed a marked bradykinesia that was caused by a reduction in both the frequency of peristalsis and speed of muscle contractions. Rescue experiments confirmed that this phenotype was due to a defect in the nervous system and not in the muscle. Furthermore, recordings of motoneuron activity in parkin larvae revealed reduced bursting and a striking reduction in evoked and miniature excitatory junction potentials, suggesting a neuronal deficit. This was supported by our observations in parkin larvae that the resting potential was depolarized, oxygen consumption and ATP concentration were drastically reduced while lactate was increased. These findings suggest that neuronal mitochondrial respiration is severely compromised and there is a compensatory switch to glycolysis for energy production. parkin mutants also possessed overgrown neuromuscular synapses, indicative of oxidative stress, which could be rescued by overexpression of parkin or scavengers of reactive oxygen species (ROS). Surprisingly, scavengers of ROS did not rescue the resting membrane potential and locomotory phenotypes. We therefore propose that mitochondrial dysfunction in parkin mutants induces Parkinsonian bradykinesia via a neuronal energy deficit and resulting synaptic failure, rather than as a consequence of downstream oxidative stress.

Femora of women with premature ovarian insufficiency exhibit reduced strength and misalignment with the transmitted vertical forces from the upper body.

BACKGROUND: Women with premature ovarian insufficiency (POI) lack oestrogen, which is a key determinant of bone growth, epiphyseal closure, and bone tissue organisation. Although dual-energy X-ray absorptiometry (DXA)-derived areal bone mineral density (BMD) remains the gold standard for fracture risk evaluation, it does not fully characterise the skeletal abnormalities present in these women. Hence, we aimed to assess hip/femur anatomy, strength, and geometry and femoral alignment using advanced hip analysis (AHA). METHODS: We conducted a cross-sectional, case-control study including 89 women with spontaneous normal karyotype POI (s-POI) or iatrogenic POI (i-POI), aged 20-50 years compared with 89 age- and body mass index (BMI)-matched population-based female controls. Hip anatomy, strength, geometrical parameters, and femur alignment were measured using hip DXA images and Lunar AHA software. Femoral orientation angle (FOA) was quantified as the overall orientation of the femur with respect to the axis of the forces transmitted from the upper body. RESULTS: The median age of POI diagnosis was 35 (18-40) years; the mean POI duration at the time of DXA was 2.07 (range 0-13) years, and 84% of POI women received oestrogen therapy. Areal BMD at all sites was significantly lower in the POI group (all P < .05). Indices of compressive and bending strength were lower in women with POI compared with controls, specifically the cross-sectional area (CSA, mm2) and section modulus (SM, mm3) (139.30 ± 29.08 vs 157.29 ± 22.26, P < .001 and 665.21 ± 129.54 vs 575.53 ± 150.88, P < .001, respectively). The FOA was smaller (124.99 ± 3.18) in women with POI as compared with controls (128.04 ± 3.80; P < .001) at baseline and after adjusting for height and femoral neck BMD. CONCLUSION: Alongside lower BMD at multiple sites, the femora of women with POI demonstrate reduced strength and a misalignment with forces transmitted from the upper body. Further research is needed to establish the role of these newly identified features and their role in fracture risk prediction in this population.

A qualitative study of work and early menopause: 'On-the job' experiences and career trajectories.

OBJECTIVES: Early menopause or premature ovarian insufficiency (POI), menopause occurring before age 45 and 40 years respectively, occur at the age when most women are establishing or consolidating their careers. Studies of older postmenopausal women indicate an adverse bidirectional relationship between menopause and work. However, data are lacking regarding the work experiences of women with early menopause or POI. We explored the experiences of women with early menopause or POI in relation to work. STUDY DESIGN: Using maximum variation sampling, 30 women (median age 44 years and 38 years at menopause diagnosis) of diverse backgrounds and menopause causes (16/30 iatrogenic) participated in qualitative interviews to explore experiences of early menopause/POI in the context of their overall lives, work and career. Dual thematic (themes identified across interviews) and thematic narrative (themes identified within individual interviews) analysis was done using NVivo 12 software. MAIN OUTCOME MEASURES: Themes related to work experiences and influencing factors. RESULTS: Two major themes were identified: 'on-the-job' experiences (work performance, bodily presentation and disclosure) and career trajectories (intact and altered). Factors impacting the interaction between work and early menopause/POI included: career (type of work, environment, working conditions), personal (age, socio-economic background, family arrangements, migration history) and menopause experience (spontaneous versus iatrogenic, treatment complexity). CONCLUSIONS: Early menopause/POI has multiple impacts on women's work experiences and career trajectories. As with older postmenopausal women, career and personal factors influence younger women's work experience. However, this research highlights differences associated with menopause occurring at an earlier, often unexpected age compared with menopause at the usual age.

Recommended measurement instruments for genitourinary symptoms associated with menopause: the COMMA (Core outcomes in menopause) consortium.

OBJECTIVE: The aim of the study is to identify appropriate definitions and patient-reported outcome measures (PROMs) for each of the eight core outcomes previously selected for genitourinary symptoms associated with menopause: pain with sex, vulvovaginal dryness, vulvovaginal discomfort or irritation, discomfort or pain when urinating, change in most bothersome symptom, distress, bother or interference of genitourinary symptoms, satisfaction with treatment, and side effects. METHODS: We conducted a systematic review to identify possible definitions and PROMs, including their measurement properties. Identified definitions and relevant PROMs with acceptable measurement properties were entered into an international consensus process involving 28 participants from 10 countries to achieve final recommendations for each core outcome. RESULTS: A total of 87 publications reporting on 34 PROMs were identified from 21,207 publications screened. Of these 34 PROMs, 29 were not considered to sufficiently map onto the core outcomes, and 26 of these also had insufficient measurement properties. Therefore, only five PROMs corresponding to two core outcomes were considered for recommendation. We recommend the PROMIS Scale v2.0 - Sexual Function and Satisfaction: Vaginal Discomfort with Sexual Activity to measure the outcome of "pain with sexual activity" and the Day-to-Day Impact of Vaginal Aging (DIVA) Questionnaire to measure "distress, bother or interference" from genitourinary symptoms. Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events in study participants, which is a requirement of Good Clinical Practice. CONCLUSIONS: Suitable PROMs and definitions were identified to measure three of eight core outcomes. Because of the lack of existing measures, which align with the core outcomes and have evidence of high-quality measurement properties, future work will focus on developing or validating PROMs for the remaining five core outcomes.

Recommended measurement instruments for menopausal vasomotor symptoms: the COMMA (Core Outcomes in Menopause) consortium.

OBJECTIVE: The aim of the study is to identify suitable definitions and patient-reported outcome measures (PROMs) to assess each of the six core outcomes previously identified through the COMMA (Core Outcomes in Menopause) global consensus process relating to vasomotor symptoms: frequency, severity, distress/bother/interference, impact on sleep, satisfaction with treatment, and side effects. METHODS: A systematic review was conducted to identify relevant definitions for the outcome of side-effects and PROMs with acceptable measurement properties for the remaining five core outcomes. The consensus process, involving 36 participants from 16 countries, was conducted to review definitions and PROMs and make final recommendations for the measurement of each core outcome. RESULTS: A total of 21,207 publications were screened from which 119 reporting on 40 PROMs were identified. Of these 40 PROMs, 36 either did not adequately map onto the core outcomes or lacked sufficient measurement properties. Therefore, only four PROMs corresponding to two of the six core outcomes were considered for recommendation. We recommend the Hot Flash Related Daily Interference Scale to measure the domain of distress, bother, or interference of vasomotor symptoms and to capture impact on sleep (one item in the Hot Flash Related Daily Interference Scale captures interference with sleep). Six definitions of "side effects" were identified and considered. We recommend that all trials report adverse events, which is a requirement of Good Clinical Practice. CONCLUSIONS: We identified suitable definitions and PROMs for only three of the six core outcomes. No suitable PROMs were found for the remaining three outcomes (frequency and severity of vasomotor symptoms and satisfaction with treatment). Future studies should develop and validate PROMs for these outcomes.