Women's health

Significant perinatal distress and depression affects 14% of women, producing short and long term consequences for the family. This suggests that measures for early detection are important, and non-identification of these women may exacerbate difficulties. Screening provides an opportunity to access large numbers of women and facilitate pathways to best-practice care. A valid, reliable, ...

Anne E Buist MD, FRANZCP · Jeannette Milgrom PhD, FAPS · Bryanne E W Barnett MD, FRANZCP · Sherryl Pope PhD · John T Condon MD, FRANZCP · David A Ellwood MA, DPhil, FRACOG, FRANZCOG · Phillip M Boyce MD, FRANZCP · Marie-Paule V Austin MD, FRANZCP · Barbara A Hayes DNSc, FRCNA

Research papers should have a short section on how the results should be communicated to the public By all accounts, many of the half million Australian women who regularly take combined oestrogen and progestin hormone replacement therapy (HRT) were alarmed by the news on Wednesday, 10 July 2002, reporting that a United States study had shown HRT to increase the risk of breast cancer by 26%, as well as causing more vascular disease. Subsequently, numerous media reports, based on press releases from organisations such as the US National Institutes of Health (NIH)1 and the Cancer Council of New South Wales,2 continued to highlight the apparently large increases in risks caused by combined HRT and called for restrictions on the use of this treatment. General practitioners and cancer help-lines were inundated by enquiries from frightened women and reports of mass withdrawals from therapy soon followed. The source of this concern was the early termination of the NIH-funded Women's Health Initiative (WHI) trial comparing combined HRT and placebo among healthy postmenopausal women. The study was stopped after five years by an independent Safety and Data Monitoring Committee when a predetermined safety boundary for the risk of invasive breast cancer was crossed at an interim analysis. The report of the trial, published in JAMA,3 suggested that women allocated to combined HRT experienced increased risks of invasive breast cancer, coronary heart disease, stroke and venous thromboembolism, and decreased risks of colorectal cancer and hip fracture (Box 1). It was argued that, when all these outcomes were summed in a "global index", the adverse effects outweighed the benefits. However, treatment effects on only two of the outcomes — fractures and venous thromboembolism — met conventional criteria for statistical significance when appropriate (and prespecified) account was taken of the multiplicity of statistical tests performed. Even without adjustment for the dozens of statistical tests, the 95% confidence intervals for each of the other outcomes reportedly affected by combined HRT (including the global index) were consistent with a broad range of possible effects, including little or no effect. For example, any effect on the relative risk of invasive breast cancer appeared to lie somewhere in the range from no effect to an increase of about a half to two-thirds, whereas any effect on the absolute risk of the same outcome appeared to lie somewhere in the range from no excess cases to about 17 extra cases per 10 000 women per year. This very large degree of uncertainty about the true size (and arguably the existence) of most of the treatment effects reported is not reflected in any of the press releases we have seen, including that from JAMA,4 all of which report apparently precise estimates of the excess risks. However, the controversy that followed publicity about the results of the trial did not reflect concerns about the strength of the evidence, but rather dissatisfaction with the way in which the study outcomes were described. While the original report published in JAMA provided estimates of both relative-risk and absolute-risk differences, press releases from most sources focused on the relative increases in risk — in particular, the 26% increase in invasive breast cancer. That this increase in relative risk reflected a difference in incidence of eight cases per 10 000 women per year was much less emphasised. It was suggested by the economics editor of the Sydney Morning Herald that the reported 26% increase was likely to have been misinterpreted by many women as meaning that combined HRT conferred a one-in-four chance of developing invasive breast cancer.5 Others argued that the use of relative risks in press releases was a deliberate effort to dramatise results that would appear much less newsworthy if described in absolute terms. The same commentators suggested that press releases should focus instead on absolute treatment effects, as these are of most direct relevance to the advice provided by doctors and the decisions made by women. Are these criticisms justified? Certainly, there is little doubt that the way in which risk data are presented influences treatment preferences.6-9 In a recent randomised trial in which general practitioners were asked whether they would prescribe a preventive treatment that had negligible side effects, 91% of those given information about relative risks alone said they would do so, compared with 63% of those given information about absolute risks.6 Other studies suggest that the way in which risk information is presented to consumers can generate even greater divergence in preferences.7 Should we therefore abandon the use of relative risks entirely in interpreting the results of clinical trials? Almost certainly not — although a strong case can be made for not allowing relative risks to dominate press releases without appropriate reference to absolute risks. Arguably, each has a place in communications to doctors and patients, and neither should be relied upon exclusively, as both have strengths and weaknesses. For example, while relative risks are usually generalisable to a variety of different patient subgroups (since the proportional effects of treatments are often broadly similar in most major patient subgroups), absolute risks are not (since absolute effects are determined in large part by background disease risks, which can vary substantially). Conversely, relative-risk estimates do not provide sufficient information for assessing the ratio of benefit to harm, as this can only be calculated from estimates of absolute treatment effects. Given the obvious complexity of identifying and delivering the most appropriate message to consumers (whether doctors or patients), medical journals might well consider taking a more substantive role in overseeing the broader dissemination of information about the results of major randomised trials. At a recent seminar ("The HRT debate: how should the new evidence affect policy?") conducted by the Australian Health Policy Institute at the University of Sydney, it was suggested that research papers should have a short section on how the results should be communicated to the public (Sally Crossing, Chair, Breast Cancer Action Group NSW, personal communication). Journals could assume more responsibility in two ways. Firstly, by ensuring compliance with a checklist of essential statistical components to be included in press releases issued by journals (Box 2); and secondly, by publishing a section within the main journal article that summarises the key messages for consumers, with reference to the same checklist. Such a checklist should include requirements for information about absolute as well as relative treatment effects, and for information about the full range of possible effects consistent with the observed result. If journals were to adopt this policy, it would be less likely that consumers would be misled, unintentionally or otherwise, by information released through the press. One can only speculate as to whether providing such information after the termination of the WHI would have altered the subsequent 30% fall in sales of the most commonly prescribed HRT preparations in Australia.10 1: Main results of the Women's Health Initiative trial of oestrogen plus progestin in healthy postmenopausal women3 Outcome Hazard ratio* Adjusted 95% CI† Unadjusted 95% CI Cardiovascular disease 1.22 1.00–1.49 1.09–1.36 Coronary heart disease 1.29 0.85–1.97 1.02–1.63 Stroke 1.41 0.86–2.31 1.07–1.85 Venous thromboembolism 2.11 1.26–3.55 1.58–2.82 Cancer 1.03 0.86–1.22 0.90–1.17 Invasive breast 1.26 0.83–1.92 1.00–1.59 Endometrial 0.83 0.29–2.32 0.47–1.47 Colorectal 0.63 0.32–1.24 0.43–0.92 Fractures 0.76 0.63–0.92 0.69–0.85 Hip 0.66 0.33–1.33 0.45–0.98 Vertebral 0.66 0.32–1.34 0.44–0.98 Deaths from other causes 0.92 0.62–1.35 0.74–1.14 Total deaths 0.98 0.70–1.37 0.82–1.18 Global index‡ 1.15 0.95–1.39 1.03–1.28 * Hazard ratios from Cox regression analyses of outcome among 8506 women randomly allocated to oestrogen plus progestin and 8102 women allocated to placebo. † Adjusted using group sequential methods to correct for multiple analyses over time. ‡ First event for each participant from among the following: coronary heart disease, stroke, pulmonary embolism, breast cancer, endometrial cancer, colorectal cancer, hip fracture, and death from other causes. 2: Essential statistical components for medical journal press releases describing the results of randomised clinical trials A. Provide estimates of absolute treatment effect in addition to estimates of relative treatment effect Estimates of relative treatment effect should not be provided without accompanying information about absolute treatment effect (or, at least, absolute disease rates). If the rates observed in the trial are substantively different from absolute disease rates in major patient subgroups, the limited generalisability of the observed absolute treatment effects should be acknowledged. For example, among perimenopausal women beginning hormone replacement therapy (HRT), whose average age is 10–15 years younger than those recruited to the Women's Health Initiative (WHI), any absolute increase in invasive breast cancer incidence is likely to be less than that observed in WHI, as breast cancer rates are strongly age related. B. Describe the full range of possible effects consistent with the observed result Avoid inappropriate focus on point estimates of either relative or absolute effect when confidence intervals indicate a broad range of potential effects. For example, the WHI result for invasive breast cancer risk was reported in press releases as a 26% increase in relative risk (and, occasionally, as an absolute excess of 8 cases per 10 000 women per year). However, the observed result is consistent with no increase in risk, as well as with an increase in relative risk of half to two-thirds and an increase in absolute risk of up to about 17 cases per 10 000 women per year (based on unadjusted 95% confidence intervals).

Anushka Patel MB BS, MS, FRACP · Robyn Norton PhD, MPH · Stephen MacMahon PhD, FACC, FAHA

Objective: To determine whether hormone replacement therapy (HRT) after treatment for breast cancer is associated with increased risk of recurrence and mortality.Design: Retrospective observational study.Participants and setting: Postmenopausal women diagnosed with breast cancer and treated by five Sydney doctors between 1964 and 1999.Outcome measures: Times from diagnosis to cancer recurrence or new breast cancer, to death from all causes and to death from primary tumour were compared between women who used HRT for menopausal symptoms after diagnosis and those who did not. Relative risks (RRs) were determined from Cox regression analyses, adjusted for patient and tumour characteristics.Results: 1122 women were followed up for 0–36 years (median, 6.08 years); 154 were lost to follow-up. 286 women used HRT for menopausal symptoms for up to 26 years (median, 1.75 years). Compared with non-users, HRT users had reduced risk of cancer recurrence (adjusted relative risk [RR], 0.62; 95% CI, 0.43–0.87), all-cause mortality (RR, 0.34; 95% CI, 0.19–0.59) and death from primary tumour (RR, 0.40; 95% CI, 0.22–0.72). Continuous combined HRT was associated with a reduced risk of death from primary tumour (RR, 0.32; 95% CI, 0.12–0.88) and all-cause mortality (RR, 0.27; 95% CI, 0.10–0.73).Conclusion: HRT use for menopausal symptoms by women treated for primary invasive breast cancer is not associated with an increased risk of breast cancer recurrence or shortened life expectancy.

Eva M Durna MBioeth · Leo R Leader MD, FRANZCOG · Peter Sjoblom PhD · John A Eden MD, FRANZCOG · Barry G Wren MD, FRANZCOG · Gillian Z Heller PhD

Clinical question"What treatments are available for hot flushes in women receiving tamoxifen?" A 62-year-old woman asked her radiation oncologist this question. She was taking tamoxifen as adjuvant treatment for node-positive breast cancer, but was experiencing persistent and frequent hot flushes. Search questionThe search question was refined to "What treatments can be added to tamoxifen to reduce the frequency or severity of hot flushes? What are the benefits and risks?" The ideal study to answer these questions is a randomised controlled trial that compares various treatments in women taking adjuvant tamoxifen for breast cancer and prospectively assesses changes in flushing. SearchWe used a comprehensive strategy to search electronic databases, including MEDLINE, the Cochrane Library and SUMSearch <http://sumsearch.uthscsa.edu/searchform45.htm>. The search terms "hot flashes" / "hot flushes" and "tamoxifen" were combined to identify the relevant trials. Summary of findingsSeven agents have been tested in randomised, placebo-controlled trials. Appropriate randomisation procedures included stratification for tamoxifen use where applicable. Sample sizes ranged from 85 to 194 women, and the duration of baseline and evaluation periods ranged from 4 to 7 days and 28 to 84 days, respectively. Concurrent tamoxifen was an eligibility requirement in two studies, but otherwise between 59% and 81% of women were taking tamoxifen. Each study used frequency of hot flushes, as well as "activity scores" (which incorporate frequency and severity of flush episodes), to evaluate the medications. These were assessed using daily patient diaries, with a similar format in each study. Megestrol acetate (40 mg/day),1 venlafaxine (37.5–150 mg/day),2 transdermal clonidine (at a dose eqivalent to 0.1 mg/day orally)3 and oral clonidine (0.1 mg/day)4 were all significantly more effective than placebo at reducing the frequency of flushes after four weeks (P < 0.05). They resulted in reductions in the median number of flushes by 73%, 30%–58%, 44%, and 34% from baseline levels, respectively (ie, 4.5–2.7 fewer flushes daily from baselines of 6.1–8.0). The activity scores showed greater percentage reductions. Oral clonidine was also effective at eight weeks, but long-term effectiveness was not examined in any study. The three other agents examined — soy phytoestrogens,5 vitamin E6 and a "herbal remedy" black cohosh (Cimicifuga sp.)7 — were found not to be useful. Hormone replacement therapy is an established treatment for postmenopausal flushing. However, no randomised trials assessing its value in patients receiving tamoxifen for breast cancer were identified. Its safety in women with a history of breast cancer is controversial and it cannot be routinely recommended.8 Adverse reactions greater than those with placebo1-4 were, for megestrol acetate — withdrawal menstrual bleeding (31%); for venlafaxine — dry mouth, anorexia, nausea, and constipation; for oral clonidine — difficulty sleeping (41%); and for transdermal clonidine — itchiness under the patch, drowsiness, dry mouth and constipation. Each side effect may be dose-dependent. Each medication also has a number of recognised contraindications and precautions. OutcomeEach of the medications assessed in randomised trials is a reasonable option for treatment. However, venlafaxine's sole indication on the Pharmaceutical Benefits Scheme is major depression, while transdermal clonidine is not available in Australia. The radiation oncologist discussed the available choices with his patient. She declined venlafaxine on the basis of cost, and both megestrol acetate and clonidine on the basis of potential side effects, but continued to take tamoxifen.

Sean A Bydder MB ChB, FRANZCR · Nigel A Spry MB BS, FRANZCR

With our high standards of sanitation and healthcare, how important is breastfeeding? Any breastfeeding advocate can rattle off a list of the advantages of breastfeeding to infants, their mothers and society. The list of benefits ranges from better emotional attachment to a lower risk of childhood leukaemia or dental malocclusion. However, claims of benefit have been contentious, with many studies failing to demonstrate a clear advantage and some even showing increased risk of a negative health outcome with breastfeeding. The constituents of human milk suggest that it has evolved to promote infant health and human growth, particularly to protect children from infections and to support the rapid growth of the human brain. Despite advances in science and manufacturing, infant formula will always be a poor copy of human milk. It is improbable that a substitute will ever reproduce the full spectrum of human milk proteins, milk sugars (numbering over 100), live white cells and antibodies programmed by infections in the infant's environment, together with constant variations in milk content to meet the needs of the growing infant. But does this matter in a developed country such as Australia? Is there justification in the argument that women are being pushed too hard to breastfeed, or is there more to infant nutrition than the provision of clean water and biologically safe artificial feeds? Many studies reporting the effects of breastfeeding, both positive and negative, have major methodological flaws. Indeed, robust studies are difficult to carry out. Random allocation of study participants to either a "breastfeeding" or an "artificial feeding" group is unethical, especially if we accept the belief that "the epidemiologic evidence is now overwhelming that, even in developed countries, breastfeeding protects against gastrointestinal and (to a lesser extent) respiratory infection, and that the protective effect is enhanced with greater duration and exclusivity of breastfeeding".1 So evidence for the effects of breastfeeding must rely largely on observational cohort and case–control studies. Blinding to the intervention group is difficult, except at the analysis level. Moreover, mothers who elect to breastfeed differ from those who don't — the former group are generally better-educated women of higher socioeconomic status, who are more likely to have partners and less likely to smoke. All of these factors are likely to be independently associated with positive health outcomes, so failure to adequately adjust for these confounders generally favours positive breastfeeding outcomes. On the other hand, apparently poorer outcomes may result if mothers preferentially breastfeed more vulnerable infants. Difficulties with defining terms such as "breastfeeding" and "exclusively breastfed", and with defining endpoints such as "atopic disease", also make comparisons between studies difficult. So, have the roughly 2000 papers on breastfeeding and human milk listed in Medline since the year 2000 helped answer the question of whether or not it matters if a term infant born in a country like Australia is breastfed? I will confine my comments to the three most common health problems in Australian children: infection, obesity, and asthma. In Australia, there are almost 20 000 hospital admissions a year for acute gastroenteritis in children under five years old. Rotavirus accounts for about half of these episodes and is also one of the most important nosocomial infections in paediatrics. A Belarussian study2 (involving 17 000 healthy mother–infant pairs intending to breastfeed) showed that, in centres randomly assigned to deliver support for breastfeeding (as outlined by the Baby Friendly Hospital Initiative3), there were increases in exclusive and continued breastfeeding and reductions in episodes of gastrointestinal infection. In an Italian study4 of infants aged 1–18 months admitted to an infant ward, fewer breastfed infants contracted rotavirus infection (10.6% v 32.4%), and none of these became symptomatic. It has been shown that human milk lactadherin prevents symptoms in breastfed infants infected with rotavirus by binding to the virus and inhibiting its replication.5 Obesity is the commonest chronic health problem in Australian children. This has health implications both in and beyond childhood, as about half of obese children become obese adults. The effect of breastfeeding on later overweight/obesity remains contentious. A 2001 review of 18 studies6 concluded that most studies examining the effects of breastfeeding on later obesity had found an insignificant effect, although two of the studies actually found a positive association between breastfeeding and later body fatness. Since that review, four large studies7-10 (involving between 2000 and 14 000 children) have shown a lower prevalence of overweight in previously breastfed children, with several showing decreasing risk with longer duration of breastfeeding. The three studies of older children (aged 5–14 years)8-10 also found a negative association between breastfeeding and obesity (with adjusted odds ratios [ORs] ranging from 0.66 to 0.8). Similar results in these three studies, despite differences in method, suggest that the finding may be robust. The second most common chronic health problem in Australian children is asthma. A large Western Australian study showed a substantial reduction in risk of childhood asthma, as assessed at six years of age, if exclusive breastfeeding is continued for at least the first four months of life.11 This was included in a systematic review with meta-analysis of 12 prospective studies,12 which gave a summary OR of 0.70 (95% CI, 0.60–0.81) for asthma among children who had been breastfed, with a greater effect in children from families with a history of atopy (OR, 0.52; 95% CI, 0.35–0.79). The studies were mainly of younger children but included children up to 8.4 years. Another prospective study of more than 330 000 children followed to age 24 months supported these findings: breastfeeding of less than nine months' duration was associated with an increased risk of asthma or wheezing, and a dose–response effect was observed with breastfeeding duration.13 However, a recent report has suggested that atopic children with asthmatic mothers are more likely to develop asthma in later childhood if they have been exclusively breastfed.14 There may be interesting possibilities for intervening to further reduce atopy in at-risk families. Mothers of infants who develop atopic sensitisation have a higher intake of saturated fat,15 and their breast milk is much lower in some long-chain unsaturated fatty acids (which may have antiallergenic properties16). Perhaps improving maternal diets and the use of probiotics17 may reduce the prevalence of atopic disease in their children. I have selected three childhood conditions for which small changes in prevalence or disease severity would have a major impact on the health of the nation. The US Department of Agriculture, Food and Nutrition chose otitis media, gastroenteritis and necrotising enterocolitis, and estimated that the United States would save a minimum of US$3.6 billion dollars a year if breastfeeding rates increased by 10% at initiation and by 20% at the age of six months.18 While we should be careful not to convey to mothers that breastfeeding will make their child a trim, non-atopic, infection-free genius, the balance of the evidence is that breastfeeding is of benefit in many ways. Every healthcare professional in contact with young children and parents should be familiar with their responsibilities under the World Health Organization Code19 to encourage and promote breastfeeding — for the health of the nation.

Patricia McVeagh MB ChB FRACP

Improving health outcomes for women with this enigmatic disease Endometriosis remains an enigma despite having been extensively studied. Its aetiology remains unclear, although there is a positive correlation with retrograde menstruation, probably with a background genetic predisposition. Traditionally, the symptoms of endometriosis are said to be pelvic pain and infertility, but, while a causal link between these symptoms and the disease is sometimes clear, the link is not always established. Treatment aimed at eliminating endometriotic deposits is effective in controlling symptoms in a proportion of patients, but recurrence is common. The diagnostic dilemmaEndometriosis is considered difficult to diagnose because the extent of the disease (endometriotic deposits and scar tissue) does not correlate with symptoms. The only accepted diagnostic test is direct visualisation (usually laparoscopically) by an experienced surgeon.1 Arguably, as endometriosis can be diagnosed in up to 40% of menstruating women at laparoscopy,2 it may be detected in all women at some stage of their reproductive lives, only to regress spontaneously in some. In addition, some symptoms associated with endometriosis are common. For instance, dysmenorrhoea occurs in up to 60% of women with regular menses3 and infertility occurs in about 15% of the population (of whom 30% have endometriosis).4 Hence, common conditions (mild endometriosis) may be associated with common symptoms (eg, dysmenorrhoea) by chance, not causally. The enormous variation in symptomatic expression and lack of clear correlation with the extent of endometriosis suggest the need for epidemiological studies of each symptom and of women with either mild or severe disease. This would exclude the possibility that mild endometriosis may be a normal finding in women. Epidemiological studies of women with endometriosis associated with dysmenorrhoea may find a causal link only in women with progressive dysmenorrhoea. In addition, epidemiological studies confined to specific symptoms causally associated with endometriosis (eg, dyspareunia and endometriosis in the uterosacral ligaments, progressive dysmenorrhoea and American Fertility Society stage III and IV endometriosis5) may result in consistent findings of the role of genes in disease development. 6 Management issuesFrom observations that pregnancy resolves symptoms, particularly of dysmenorrhoea, "mimicking pregnancy" became a treatment option. Medications that resulted in amenorrhoea (such as GnRH analogues, danazol and high-dose progestogens) have been used. These work by antagonising the growth-promoting effect of oestrogens or reducing the oestrogenic stimulus for growth, as well as increasing apo-ptosis. Each of these medications has been shown in a recent Cochrane meta-analysis of randomised controlled trials to be equally effective in control of dysmenorrhoea, dyspareunia and pelvic pain, and in decreasing the bulk of endometriotic tissue.7 However, the follow-up period in these trials was usually only three to six months. Annual recurrence rates of endometriosis after treatment are generally accepted to be of the order of 10%.8 Hence, further trials with longer follow-up, and possibly comparisons with the oral contraceptive pill (which has a better side-effect profile than the other drugs), in three-monthly cycles, would be beneficial. That medical therapies are not effective for infertility associated with mild endometriosis has been well established in large-scale, randomised controlled trials.9 Another Cochrane review showed that laparoscopic ablation or excision of the endometriotic tissue is effective in treating endometriosis associated with pelvic pain. However, this conclusion was based on one randomised controlled trial10 and further trials are needed to confirm this finding. Similarly, further evidence to support the effectiveness of laparoscopic surgery for subfertility associated with endometriosis is needed to support the beneficial finding in one randomised controlled trial. This is the aim of a protocol developed by the Cochrane Library.11 While the above conclusions are based on Cochrane reviews of the best available evidence, doubt remains. All trials are subject to a chance of showing a real effect when there is a probability that there is no effect. Continued development of well conducted randomised trials will reduce the probability of an incorrect conclusion. In addition, expert opinion based on the current extensive body of literature, and taking into account the basic mechanisms of the disease process of endometriosis, will help distinguish the causal relationship between each symptom associated with endometriosis. In turn this would lead to improved clinical outcomes for patients with associated dysmenorrhoea, chronic pelvic pain, dyspareunia and infertility. It is argued that current evidence for effective treatment of each of the symptoms associated with endometriosis could be further improved by further randomised controlled trials with clearly defined patient groups (eg, chronic pelvic pain in association with mild endometriosis, in-vitro fertilisation for three to five years of infertility associated with mild endometriosis). In addition, if results of epidemiological studies show no probable causal link between endometriosis and dysmenorrhoea then therapeutic regimens targeted at both symptom relief and monitoring progression of the disease may be more efficacious than excision of endometriotic tissue alone. While many of our current treatment regimens are effective in some patients, continued improvement in long term health outcomes for women with endometriosis requires a mindset open to critical evaluation.

Kevin L Forbes MB BS, FRACOG

Clinical Record A 30-year-old woman in the 30th week of pregnancy was admitted with a two-day history of fever, malaise, dysuria, frequent micturition and mild lower abdominal pain. Slight lower abdominal tenderness was the only clinical abnormality. Results of urine microscopy were white blood cell (WBC) count, 33 × 106/L (normal range, 0–10); red blood cell count, 15 × 106/L (normal range, 0–12); epithelial cell count, 21 × 106/L (normal range, 0–5); and culture was sterile. Full blood count revealed haemoglobin, 113 g/L (normal range, 100–180); WBC count, 11.6 × 109/L (normal range, 5–18); platelet count, 215 × 109/L (normal range, 150–450); and lymphocyte count, 0.23 × 109/L (normal range, 2–8). Liver function tests were mildly abnormal at presentation (Table). The patient was treated with empirical ampicillin and gentamicin, with resolution of her symptoms. However, her liver function tests worsened. Leptospiral serology was negative and blood cultures were sterile. Hepatitis A, B and C, flavivirus, Ross River virus, cytomegalovirus, Epstein–Barr virus, HIV, parvovirus and toxoplasmosis were all excluded. Negative antinuclear, mitochondrial and smooth muscle antibodies and normal immunoglobulin levels indicated that autoimmune hepatitis was unlikely. From the fifth day after admission, her condition deteriorated, with marked upper abdominal pain and worsening liver function tests (Table). On admission to the intensive care unit she was confused, febrile (37.5°C) and tachycardic (112/min). Blood pressure was 105/70 mmHg and results of cardiorespiratory examination were normal. Right hypochondrial tenderness was present. There were no clinical stigmata of hepatic decompensation. Results of laboratory tests (Day 7) were international normalised ratio of prothrombin time, 1.7 (normal, < 1.2); lymphocyte count, 0.57 × 109/L; leukocyte count, 3.1 × 109/L; and liver function tests as shown in the Table. Renal function and platelet counts were normal. Delivery was deemed necessary to preserve the baby's life. A live baby was delivered by caesarean section (Day 10). There were no orogenital lesions on the mother. The baby was well, with no clinical abnormalities. After the caesarean section, the patient remained stable for 24 hours and then suffered progressive circulatory insufficiency. Despite escalating doses of vasopressors, she developed renal failure. Bilateral pneumonia and pleural effusions led to respiratory failure, and the patient was intubated for assisted mechanical ventilation. Results of liver function tests (Table) confirmed worsening of disordered hepatic synthesis, progressive hepatocellular injury and coagulopathy. An abdominal computed tomography scan revealed gross hepatomegaly, with diffuse low attenuation of the left lobe of the liver and mottling of the right lobe of the liver. Liver biopsy, precluded by coagulopathy during the caesarean section, was accomplished on Day 13. Histology revealed hepatic necrosis, with 40%–50% of the hepatic parenchyma showing haemorrhagic necrosis with a neutrophilic infiltrate (Box 1A). At the interface between necrotic areas and surviving parenchyma, many liver cells showed glazed amphophilic chromatin consistent with herpesvirus inclusions. Polyclonal herpes simplex virus immunoperoxidase stain showed strong nuclear staining in these cells (Box 1B). Polymerase chain reaction testing of her serum subsequently revealed herpes simplex virus (HSV) DNA and HSV 2 was cultured from a vaginal swab. The patient was treated with intravenous aciclovir (750 mg every 8 h), but remained critically ill, with persistent circulatory shock, anuric renal failure and fulminant hepatic failure. Enterococcus faecalis bacteraemia compounded her shock. On Day 25, she died of fulminant hepatitis and multiorgan failure. Autopsy revealed severe hepatic architectural distortion, with almost complete absence of portal tracts and central veins. The necrotic foci were more extensive than those seen at biopsy. HSV immunohistochemical stain showed cytoplasmic staining. Interstitial pneumonitis and autolysis of the kidneys were seen, with no evidence of glomerulonephritis. Viral inclusions were seen only in the liver. Her infant was treated empirically with aciclovir and is growing and developing normally. Days after admission Normal range 1 4 7 10 13 16 19 25 Serum aspartate transaminase (U/L) 7–56 66 919 1738 3814 2499 1592 144 103 Serum alanine transaminase (U/L) 7–56 62 558 522 700 443 335 77 25 Bilirubin (µmol/L) < 17 8 10 11 24 47 68 400 600 Albumin (g/L) 35–45 20 15 12 17 14 15 18 16 Serum alkaline phosphatase (U/L) 30–120 123 333 378 471 345 294 155 125 Serum γ-glutamyltransferase (U/L) 10–75 16 76 105 126 100 71 28 25 Many pregnancy-specific liver disorders occur in the third trimester; thus, an aetiological diagnosis of liver diseases can be difficult. Common liver disorders in pregnancy are intrahepatic cholestasis of pregnancy, HELLP syndrome (haemolysis, elevated liver enzymes and low platelets), and acute fatty liver of pregnancy. The commonest cause of jaundice in pregnancy is acute viral hepatitis, which can result from primary infections with hepatitis viruses A to E or as part of a systemic infection with viruses such as cytomegalovirus, Epstein–Barr virus, varicella zoster virus and herpes simplex virus (HSV).1 Except when caused by hepatitis E virus or HSV, viral hepatitis does not usually increase maternal or fetal mortality.2 Hepatitis due to HSV infection is a rare but frequently fulminant disease. Most reports have been in immunocompromised patients3 or newborns.4 Fulminant HSV hepatitis has been reported in immunocompetent adults,5-7 mostly pregnant women.8-10 Two per cent of susceptible women acquire HSV infection during pregnancy, and seroconversion can be asymptomatic.6 Most reported cases of HSV hepatitis followed a primary orogenital infection with HSV type 1 or 2.5,8-10 As in our patient, the reported cases included initially normal serum bilirubin levels, markedly elevated serum transaminase levels, and very high AST/ALT ratios. In our patient, liver histology and immunohistochemistry established the diagnosis. Serology, PCR and vaginal swab cultures were complementary. Early administration of aciclovir has been successful in treating HSV hepatitis.5,7 Liver transplantation is another treatment option,11 but the risk of recurrent HSV hepatitis with overwhelming viral dissemination and concurrent enterococcal sepsis were contraindications in our patient. A high index of suspicion for HSV infection is warranted, as hepatitis can occur without orogenital herpetic lesions. HSV serology, PCR testing for HSV DNA, and vaginal swab cultures are recommended in undifferentiated liver disorders. Liver biopsy should be considered in patients with hepatitis when a definitive aetiology is elusive. Empirical treatment with aciclovir should be considered. 1: Photomicrographs of liver biopsy A: H&E stain, showing significant necrosis of liver parenchyma (lower and lateral edges of micrograph); typical intranuclear herpesvirus inclusions are visible (arrow). Nuclear chromatin is completely effaced and is darkly amphophilic and glazed. Viable hepatocytes are seen uppermost in the photomicrograph. Magnification × 400. B: Immunohistochemical stain for herpes simplex virus, showing strong positive intranuclear staining. Magnification × 400. 2: Lessons from practice Herpes hepatitis can occur without preceding orogenital lesions. Diagnostic tests for herpes simplex infection should be performed in patients with fulminant hepatic failure. Detection of HSV DNA by the polymerase chain reaction, and histological examination of liver tissue, are diagnostic. Empirical treatment with aciclovir may be indicated in patients with liver failure where the aetiology is unclear.

Ramesh Nagappan MD, FRACP · Geoffrey Parkin MB BS, FFICANZCA · Ian Simpson MB BS, FRCPA · William Sievert MD, FRACP

To the Editor: The recent article by the Obstetric Medicine Group of Australasia alluded to the increasing relevance and importance of thrombophilia screening following adverse pregnancy outcomes, namely recurrent miscarriage, stillbirth, retarded intrauterine growth and pre-eclampsia.1 Formerly, these outcomes were generally attributed to "placental insufficiency", where a cause was not readily identified. Screening for disorders in the uteroplacental circulation after such adverse pregnancy outcomes was formerly confined to investigations for an autoimmune basis, such as antinuclear antibodies, anticentromere antibodies, anti-DNA antibodies and the lupus inhibitor. However, in recent years, it has become more apparent that inherited or acquired thrombophilias may play a significant role in certain adverse pregnancy outcomes.2-5 Reports from Israel2,3 and elsewhere have suggested that thrombophilias can be found in up to 65% of women with recurrent pregnancy loss of unknown cause, as well as in cases of intrauterine growth retardation, stillbirth, placental abruption and pre-eclampsia. It is also known that certain thrombophilic factors are more likely to produce thrombogenic changes and hence are possible deficiencies in the uteroplacental circulation. Preliminary work has shown that treating women who have had recurrent pregnancy loss complicated by thrombophilia with antithrombotic agents (low molecular weight heparins) is beneficial, with improved pregnancy outcomes in a significant number of these cases.3 With the growing understanding of the role of thrombophilias in pregnancy, it seems that thrombophilia screening will assume a more prominent role in investigating patients after recurrent miscarriage, stillbirth, intrauterine growth retardation and pre-eclampsia.

David Morgans

In 1991, the "organised approach to preventing cancer of the cervix" recommended Pap smears every two years for women aged 18–70 years who have ever been sexually active. The two-year interval was a compromise step towards the scientifically supported three-year interval, as many influential groups were strongly attached to annual screening. When other components of the organised approach were in place, the policy was to be reviewed. Since the safeguards in the "organised approach" have been proven effective, it is appropriate to change the policy to recommend a three-year interval. Increasing the interval would allow more resources to be allocated to enrolling women currently underscreened and to evaluating and improving the program. The age of commencing smears could also be reconsidered to reflect the balance of potential benefits and harm in young women, for whom cancer is very rare but follow-up investigation common. If consensus is not reached within the profession, an evidence-based decision may need to be made at the political level.

James A Dickinson FRACGP, PhD

John St George was born in Malaya on 2 December 1924. His family returned to Ceylon in 1925, where he studied at St Patrick's College in Jaffna. In 1950, he graduated with Honours in medicine from the University of Ceylon in Colombo. Between 1957 and 1959, John worked with Professor T Jeffcoate at the University of Liverpool, UK, then with Dr P Myerscough at the Eastern General Hospital, Edinburgh. He was accepted as a Member of the Royal College of Obstetricians and Gynaecologists (1958) and a Fellow of the Royal College of Surgeons (1959), the International College of Surgeons (1968), and the Royal College of Obstetricians and Gynaecologists (1970). After working as a Consultant in Obstetrics and Gynaecology for the Government of Ceylon from 1959 to 1964, John spent a number of years (1964–1967 and 1972–1975) as Chief Consultant in Obstetrics and Gynaecology for the government of northern Nigeria. It was there that he perfected his technique of vesicovaginal fistula repair. These fistulae, which are relatively common among rural women, arise from obstructed labour or from application of potassium permanganate by "bush doctors" (local herbalists). While in Nigeria, John initiated the obstetric "flying squad" to enable women in remote areas to receive emergency medical treatment, and helped to invent a two-wheel collapsible trolley for bush track roads to help reduce maternal mortality. In 1974, the London School of Hygiene and Tropical Medicine awarded him the Langley Memorial Prize for this work. In 1975, John migrated to Australia and set up practice at Burwood and Lakemba, in Sydney, working as a gynaecologist at the Western Suburbs Hospital until 1993. He retired in 1998. John was passionately interested in sports and the Church. From his early years at St Patrick's College, where he was the captain of both the athletics and soccer teams, he took to heart the College's motto "fide et labore" (faith and work). He based his entire life on this simple yet profound philosophy, which saw him succeed in his career and adapt to many different cultures and countries with ease. John died peacefully (of hypostatic pneumonia) at Concord Hospital on 9 December 2001, at the age of 77.

Lourdes I St George LRCPS FRCOG FRACOG

A 34-year-old woman (gravida 5, para 2) presented to the Government Hospital in Katsina, northern Nigeria, in 1973. She was in labour and had had no antenatal care. She successfully delivered a live 3.2 kg infant. A 14 cm right adnexal pelvic mass was noted postnatally. An x-ray and hysterosalpingogram (see picture) performed four months after the birth showed the calcified remains of an extrauterine pregnancy. The woman stated that four years earlier she had missed her periods and had consulted a "bush doctor" (local herbalist) about abdominal swelling and pain. The herbs he prescribed to rub on her abdomen had eased the pain, and her periods had returned after seven months. The mass was easily removed from the omentum at subsequent laparotomy. Histology confirmed an advanced lithokelyphopaedion (ie, calcified fetus, membranes and placenta).

Lourdes I St George LRCPS, FRCOG, FRACOG · John St George FRCS, FRCOG, FRACOG

The latest triennial review of maternal deaths showed a rise in the maternal death ratio. Whether this represents a new trend or just a statistical fluctuation remains to be seen. The Report on maternal deaths in Australia, 1994–961 was released in September 2001. It is the eleventh in a series of triennial reports that detail maternal deaths in a case summary format. The principal aim of the Report is to improve the quality and safety of healthcare during pregnancy and the puerperium through the education of obstetric practitioners. The Report defines a "maternal death" as the death of a woman while pregnant or within 42 days of the pregnancy being delivered or terminated, and classifies maternal deaths occurring in Australia into three categories: Direct deaths, resulting from obstetric complications of the pregnant state; Indirect deaths, resulting from pre-existing disease or disease that developed during pregnancy and was not due to obstetric causes, but which may have been aggravated by the physiological effects of pregnancy; and Incidental deaths, due to condition(s) occurring in pregnancy, in cases where the pregnancy is unlikely to have contributed significantly to the death. The current Report documents the first rise in the maternal death ratio in Australia since the 1988–1990 triennium — a rise from 10.9 deaths per 100 000 confinements in 1991–1993 (total number of deaths, 84) to 13.0 deaths per 100 000 confinements in 1994–1996 (total number of deaths, 100). Of particular concern is the finding that the rise in the number of deaths was almost exclusively in the "direct deaths" category (see Box). However, as the rise was non-significant in a statistical sense, we will not know, until the next two triennial maternal death reviews are completed, whether this represents the beginning of a new trend or just a statistical fluctuation in very rare events. Although a high proportion of the direct deaths (22/46 [48%]) involved the presence of avoidable or preventable factors, the lack of uniform assessment of avoidable factors across all States and Territories, and the absence of any single factor that could account for the rise in deaths, suggests the apparent increase in avoidable factors should be interpreted with caution. The disparity between Indigenous and non-Indigenous maternal mortality rates has previously been observed2 and remains an issue of concern. The Indigenous maternal mortality rate did decline, from 41.4 to 34.8 deaths per 100 000 confinements, between the 1991–1993 and 1994–1996 reviews. However, changes in ascertainment of Indigenous status over the past nine triennia make it difficult to determine whether there has been a consistent decline, particularly among direct Indigenous maternal deaths. A number of factors may have contributed to the increase in deaths in the most recent triennium. In other countries,3 improved ascertainment of maternal deaths through the use of multiple data sources, including vital statistics and hospital morbidity collections, has resulted in the identification of more deaths. However, in the latest Australian Report, only three of the 12 deaths identified using additional data sources were direct deaths. The changing risk profile of women becoming pregnant may account for some of the increase in deaths. Many women are delaying child-bearing,4 leading to an older cohort of women being pregnant and at increased risk of maternal death.5 Furthermore, with advances in technology an increasing number of women who previously were unable to have children because of infertility or complex medical problems are now having children. Also to be considered is the largely unevaluated impact on maternal death rates of the implementation of multiple models of delivery of obstetric care as well as the larger structural changes in healthcare delivery. Both require further investigation. Despite recent publicity to the contrary, the rise in maternal deaths does not appear to be attributable to the increasing caesarean section rate. The proportion of maternal deaths associated with caesarean section has remained higher than the proportion of all caesarean births over the past four triennia. However, despite rising caesarean section rates (18.4% of all births in 1991–1993 and 19.4% in 1994–1996), maternal deaths associated with caesarean section, excluding those on recently dead or moribund women, fell from 29.8% of deaths in 1991–1993 to 24.0% in 1994–1996. There are no data causally relating the rising caesearan section rate with the increase in the number of maternal deaths. With a small number of deaths from a range of very different causes, it is difficult to draw meaningful conclusions about the impact of the many factors purported to relate to maternal death in Australia. Furthermore, without the availability of the 1997–1999 and probably the 2000–2002 results, it cannot be determined whether the increase in deaths represents a new trend or merely an aberration. Overall, the risk of maternal death during pregnancy and the puerperium remains small. Although differences in definition and collection procedures make international comparisons difficult, Australia appears to compare well with other developed countries, having a similar adjusted maternal mortality ratio to Canada, and a lower ratio than New Zealand, the United States and the United Kingdom.6 With improved general health status and family planning and increased access to general and specialised healthcare, maternal mortality declined considerably in the 20th century. Nevertheless, life-threatening complications still occur, often unpredictably and relatively more often among Indigenous women. It is therefore important that we closely monitor and review all maternal deaths and develop a surveillance system for severe maternal morbidity to ensure the health and safety of all women during pregnancy and the puerperium. The inclusion of pregnancy tick-boxes on Australian death certificates and the use of a standardised national maternal death reporting form should facilitate more accurate reporting of maternal deaths in the future. Summary of key findings from the Report on maternal deaths in Australia, 1994–961 The 1994–1996 Australian maternal mortality ratio was 13.0 per 100 000 confinements, compared with the 1991–1993 ratio of 10.9 per 100 000 confinements. In the 1994–1996 triennium, there were 100 maternal deaths, of which 46 (46%) were direct deaths, 20 (20%) were indirect deaths and 34 (34%) were incidental in nature. This represented an increase of 19% in the number of deaths compared with the 1991–1993 triennium. The increase in deaths occurred almost exclusively in the direct deaths category: 27 (32%) direct deaths were reported in the 1991–1993 triennium, compared with 46 (46%) direct deaths in 1994–1996. There was an increase in the proportion of direct maternal deaths in which avoidable factors were considered to be possibly or certainly present from 7 (26%) of 27 deaths in 1991–1993 to 22 (48%) of 46 deaths in 1994–1996. The principal causes of direct maternal deaths remained pulmonary embolism (8 deaths [17%]), amniotic fluid embolism (8 deaths [17%]) and pre-eclampsia (6 deaths [13%]). Cardiorespiratory disease was the most common cause of indirect maternal death, with 10 (50%) indirect deaths falling into this category, while the leading causes of incidental death were injuries (16 deaths [47%]), neoplasms (5 deaths [15%]) and cerebrovascular disease (4 deaths [12%]). The Indigenous maternal mortality ratio (34.8 deaths per 100 000 confinements) remains about three times that of the non-Indigenous maternal mortality ratio (10.1 deaths per 100 000 confinements).

William AW Walters FRCOG FRANZCOG PhD · Jane B Ford BA (Hons) PhD · Elizabeth A Sullivan MPH FAFPHM · James F King

Objectives: To assess the intentions of Australia's specialist obstetricians to cease practice and their reasons for abandoning this specialty.Design: A structured questionnaire posted to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), issued 11 July 2001 with a return date of 31 July 2001 (in practice, responses were accepted up to 31 August 2001).Participants: Australian specialists holding a Fellowship of the RANZCOG.Main outcome measures: Demographic data (eg, age, sex); type and location of practice; past, current and intended future obstetric practice; reasons for stopping practice; cost of indemnity premiums; experience of litigation and its influence on practice; and experience in giving medicolegal opinion.Results: The response rate was 74% (829/1116), with 826 responses fulfilling our selection criteria. The median number of years since admission as a Fellow was 17 (range, 1–47 years), and 19% (158/817) of respondents were women (9 people did not specify their sex). Of the 826 respondents, 596 (72%) were currently practising obstetrics, 548 (66%) intended to still be practising after one year, 365 (44%) intended to be practising after five years, and 196 (24%) intended to be practising after 10 years. The median indemnity premium in 2001–02 was $35 515 (range, nil to $156 000) for practising obstetricians. The main reasons given for ceasing obstetrics were intention to specialise in gynaecology, fear of litigation, high indemnity costs, family disruption, and long working hours. About two-thirds of respondents (557/818) had experienced the threat of litigation, and almost all (768/803) desired some type of "no-fault" indemnity scheme. Thirty-three of the 314 respondents who had given medicolegal opinions accounted for 71% of the total number of opinions. Many of these were non-practising obstetricians who were not accredited RANZCOG expert witnesses.Conclusion: There will soon be a shortage of experienced practising obstetricians in Australia.

Alastair H MacLennan MD, FRANZCOG · Michael K Spencer BSc(Hons), LLB(Hons)

Preamble: the burden of osteoporosis in Australia The clinical manifestations of osteoporosis affect nearly two million Australians.1 In the absence of interventions, the prevalence of osteoporosis-related conditions is predicted to increase over the next two decades from 10% of the population currently to 13.2% by 2021.1 The incidence of osteoporotic fractures is also predicted to increase, from one every 8.1 minutes in 2001 to one every 3.7 minutes in 2021. Total costs relating to osteoporosis are currently estimated at $7.4 billion per annum, of which $1.9 billion are direct costs. Its disease burden can be expressed in terms of premature mortality and disability, which together represented over 25 000 healthy years of life lost to Australians in the financial year 2000–01.1 In Australia there are three ongoing prospective cohort studies of fracture epidemiology: The Dubbo Osteoporosis Epidemiology Study (DOES) of a cohort of about 1600 men and 2100 women aged over 60 years with pre-fracture assessments;2 The Geelong Osteoporosis Study (GOS) of about 109 900 men and women aged over 35 years;3 and The Tasmanian Older Adult Cohort (TASOAC) study of about 229 600 men and women of all ages.4 The participants in these studies were selected because their age and sex distribution were considered to reflect the Australian population. Importantly, each study used substantially the same method for capturing "events", namely x-ray reports containing the word "fracture" in radiology service records in each region. These studies provide different estimates of the number of fractures occurring in Australia. DOES reported 306 fractures in 3.25 years (1989–1992), giving an estimated residual lifetime fracture risk of 29% for men and 56% for women aged over 60.5 TASOAC reported 2140 fractures over two years (1997–1999), with an estimated residual lifetime fracture risk of 27% for men and 44% for women aged over 50.4 GOS reported 2184 fractures over two years (1994–1996), with an estimated lifetime risk of fracture of 42% in women aged over 503 (the estimate for men is not yet available). From these studies, the total number of fractures each year among Australians aged over 60 has been estimated at 73 000 (DOES), 57 000 (TASOAC) and 51 000 (GOS). Using a different methodology, Access Economics has estimated there were 65 000 osteoporotic fractures in Australia in 2001.1 Using the GOS estimates, it is calculated that the total number of hip fractures in Australia will increase from 15 000 in 1996 to 21 000 by 2006.6 In 1996, the Pharmaceutical Benefits Advisory Committee of the Commonwealth Department of Health and Family Services sponsored a Consensus Conference on Osteoporosis. Since then there have been advances in our understanding of the epidemiology, pathogenesis, diagnosis and treatment of osteoporosis. Accordingly, Osteoporosis Australia and the National Prescribing Service convened a Fracture Prevention Summit in September 2001. The aims were to estimate the size of the problem of osteoporosis and to formulate appropriate practice in primary care, with special emphasis, where possible, on evidence-based guidelines for the treatment of osteoporosis. The National Health and Medical Research Council (NHMRC) levels of evidence (see Box, this page) are a useful guide for defining the quality of available data on the treatment of osteoporosis. The most important criteria for a high-quality trial include randomisation, placebo controls, double-blinding, large sample sizes, prolonged observation, low dropout rates, preplanned intention-to-treat analyses, and replication. Replication and internal consistency are particularly important, as low event rates will often result in wide confidence intervals and type 2 errors (ie, failing to detect a difference when it is really present). Meta-analyses should be done to adequately define the point estimate of outcomes such as fracture risk reduction. Uncritical acceptance of reported "significant" results when a study is poorly designed and executed creates uncertainty and is not useful in decision-making in clinical practice. Lack of rigorous design in a drug trial does not mean a drug is necessarily ineffective, only that there is not good evidence to support the hypothesis that it is effective. Whether one drug has better antifracture efficacy than another can not currently be determined, as there have been no comparator trials using antifracture efficacy as an endpoint. Most trials compare a group treated with a single drug with a control group receiving a placebo (calcium). Rating of the evidence for recommendations Evidence is graded according to the level-of-evidence classifications endorsed by the National Health and Medical Research Council (NHMRC) in 1995.* E1 Level I: Evidence obtained from a systematic review of all relevant randomised controlled trials. E2 Level II: Evidence obtained from at least one properly designed randomised controlled trial. E3 Level III: Evidence obtained from all well designed controlled trials without randomisation; well designed cohort or case–control analytic studies, preferably from more than one centre or research group; or from multiple time series with or without intervention. E4 Level IV: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees. * A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: National Health and Medical Research Council, 1995. Summary of key recommendations Diagnosis Measurement of bone mineral density (BMD) of the hip and spine should be used to diagnose osteoporosis and for monitoring response to interventions. Wider availability of Medicare Benefits Schedule (MBS) rebates for bone densitometry items, particularly for older people and those with a family history of osteoporosis, is recommended. Biochemical markers of bone turnover provide additional information to assess fracture risk. The finding of an elevated bone resorption marker in addition to low BMD strengthens the case for treatment in an individual. In selected patients, biochemical markers may have a role in assessing therapeutic response and enhancing compliance. Initiation of treatment The presence of a spinal fracture is an indication that treatment should be given, provided that BMD is in the range for "osteoporosis" (T-score < –2.5) or "osteopenia" (T-score between –1 and –2.5) (see Box 1). If a non-spinal fracture is present, treatment should be considered if BMD is in the osteoporosis range (T-score < –2.5). However, prospective studies evaluating the antifracture efficacy of drugs in patients with osteoporosis and non-spinal fractures at baseline are not available. Women with osteoporosis (T-score < –2.5), with or without fractures, should be investigated and considered for treatment. Evidence in men is limited, and recommendations must await further research. First-line drug therapies for postmenopausal women with osteoporosis The potent bisphosphonates alendronate and risedronate are the first-line agents for treating postmenopausal osteoporosis. For women with osteoporosis and one or more baseline spinal fractures, treatment with these bisphosphonates reduces the relative risk of subsequent spinal fractures by approximately 50% (E1). It also reduces the risk of non-spinal fractures, including hip fractures. These potent bisphosphonates can reduce bed-day use and healthcare costs (E2). Treatment with raloxifene is an alternative first-line approach to prevent spinal fractures, but not non-spinal fractures. A dose of 60 mg daily is associated with a 36% reduction in the relative risk of spinal fractures (but not non-spinal fractures) over four years (E1). The anabolic agent parathyroid hormone (PTH) is associated with a 65% reduction in the relative risk of spinal fractures in women who have osteoporosis and one or more baseline spinal fractures (E2). It also reduces the relative risk of non-spinal fractures. Although not yet available in Australia or elsewhere, it is likely to become first-line therapy in patients with severe osteoporosis given its marked effect on bone structure. Other drug therapies for postmenopausal women with osteoporosis Other, less rigorously evaluated agents include etidronate, a less potent bisphosphonate, and hormone replacement therapy (HRT). Both agents are likely to reduce the risk of spinal fractures (E3). A reduction in non-spinal fractures is not well established. There is weak evidence for the efficacy of calcitriol in reducing fracture risk in women with postmenopausal osteoporosis (E3). There are no randomised controlled trial (RCT) data to support a role for anabolic steroids such as nandrolone in reducing the risk of fractures. 1: Explanation of T- and Z-scores, with World Health Organization thresholds Relationship between hip bone mineral density (BMD) and age in women, showing the difference between: (i) Z-score (number of SDs from population mean for age). Z = –2.0 to +2.0 is the reference range; and (ii) T-score (number of SDs from mean for a young, healthy population). A T-score of –2.5 is defined as the threshold for osteoporosis. • Indicates a woman aged 70 years with a BMD Z-score of –1, which is within the reference range for age. However, this Z-score means the woman has double the risk of fracture compared with a 70-year-old woman with mean BMD for age. Further, her T-score is –2.5, indicating her BMD is at the threshold for osteoporosis (adapted from Prince7). Calcium and vitamin D Dairy products are the largest source of calcium in the diet. Increased calcium intake, from dietary sources or supplementation, should always be adjunctive therapy in the treatment of postmenopausal osteoporosis (E4). Studies suggest that calcium monotherapy has a modest effect in reducing fracture incidence. Vitamin D, alone or in combination with calcium, reduces the risk of non-spinal fractures in institutionalised elderly people (E2), among whom there is generally a high prevalence of vitamin D deficiency. A calcium–vitamin D combination is recommended for such people. Exercise Engaging in regular exercise, to maximise peak bone mass and prevent age-related and menopause-related bone loss, is a potentially important approach to reducing fracture risk (E4). However, there is currently no RCT evidence supporting the efficacy of exercise in preventing fractures at any specific site. Exercise increases muscle strength and may improve coordination and balance and reduce the risk of falls. Evidence that the reduction in falls leads to fewer fractures is not currently available. Fall-prevention strategies and hip protectors Fall-prevention programs that involve balance training and environmental modifications reduce the risk of falls (E2). Hip protectors prevent hip fractures in people at high risk of falls, but compliance remains an issue (E1). Therapies for osteoporosis in men Alendronate or etidronate are the drugs of choice for men with primary osteoporosis (E2). Testosterone replacement therapy is indicated in men with hypogonadism (E3). There is no evidence to support the use of calcitriol for osteoporosis in men. Men with osteoporosis should be considered for investigation and treatment. Therapies for glucocorticoid-induced osteoporosis Postmenopausal women and older men receiving glucocorticoids are at the greatest risk of spinal fracture and should be considered for prophylaxis, usually with a bisphosphonate plus calcium as the first choice (E1). Adjunctive therapy with some form of vitamin D should also be considered. Other strategies to reduce the fracture burden As the risk of fracture increases after the first fracture and the initial osteoporotic fracture often goes undiagnosed and untreated, education and awareness programs are one key strategy to increase rates of treatment in people who have already sustained an osteoporotic fracture. Liaison with orthopaedic units to ensure patients with fractures are adequately investigated and treated is recommended. Secondary prevention by special clinics in teaching hospitals or initiatives in primary care are another strategy that may increase treatment rates in people who have sustained their first osteoporotic fracture. Specific programs are needed to address the high prevalence of vitamin D deficiency in elderly people in both residential care and the general community. Public health prevention strategies, including increasing dietary calcium intake from dairy sources and promoting exercise for people of all ages, are recommended. Wider availability of drugs under the Pharmaceutical Benefits Scheme (PBS) for subgroups at high risk of fracture, such as people with very low BMD or those using glucocorticoids, is recommended. Diagnosis Use of densitometry Dual-energy x-ray absorptiometry (DEXA) is the current "gold standard" for the diagnosis of osteoporosis. BMD predicts fracture risk. Each standard deviation reduction in femoral-neck BMD increases the age-adjusted risk of hip fracture by a factor of about two (range, 2.0–3.5) and the risk of any atraumatic fracture by almost the same amount (range, 1.7–2.4).8 Similarly, each SD reduction in lumbar spine BMD increases the risk of spinal fracture by a factor of about 2.3 (range, 1.9–2.8). Proximal femur BMD appears to be the best overall predictor of fracture risk, particularly as it is unaffected by osteoarthritis, which can spuriously elevate spine BMD values. DEXA is reliable, with a reported precision of about 1%. However, these precision data are obtained under idealised conditions — in clinical practice such values are rarely achieved. At a realistic clinical precision of 2%, a change of at least 5.6% between measurements is necessary to be 90% confident the change is real. In postmenopausal women, the rate of bone loss is generally 1%–2% per annum, and hence, in most patients, an interval of two years between scans is satisfactory, unless there is an accelerated rate of bone loss (eg, as a result of glucocorticoid medication), in which case yearly measurements may be warranted. BMD is expressed in terms of a "T-score", representing the number of SDs from the young normal mean BMD. Diagnosis based on bone densitometry, measured by DEXA and the T-score, provides a normal distribution of values as defined by a working group for the World Health Organization (see Box 1): 9 Normal bone density: T-score greater than –1; Osteopenia (low bone mass): T-score between –1 and –2.5; Osteoporosis: T-score less than –2.5. Population screening is inappropriatePopulation screening is a seemingly simple solution to the problem of fractures. Screening may appear to be justifiable: fractures are a public health problem, densitometry is a safe screening tool, BMD measurements identify high-risk individuals, and drugs are available that reduce fracture rates. So why not screen, and treat those at high risk? A BMD measurement should only be done if the decision to treat (or not to treat) is influenced by the result of the test. Thus, it is a valid and essential investigation in patients at high risk of osteoporotic fracture who seek medical advice, but not justified for screening a population of healthy people. At present, the decision to measure BMD in patients is supported by a Medicare rebate for certain high-risk categories only.10 The usefulness of population screening also depends on the prevalence of the disease and cost of the screening test. Screening of unselected populations (eg, using ultrasound in pharmacies) is not recommended by any authoritative group in the field of bone biology. Moreover, the definition of osteoporosis is not without problems. The BMD cut-off of –2.5 SD below the young normal mean used to define osteoporosis was developed to apply to DEXA measurements of BMD at the spine or hip. This cut-off value, when applied to other techniques such as ultrasound, quantitative computed tomography or forearm measurements, does not identify the same number or the same proportion of individuals.11,12 Moreover, reference ranges may differ between people of different ethnic origin. In summary, measurement of BMD by DEXA of hip and spine is the current gold standard for diagnosing osteoporosis and monitoring response to lifestyle interventions or pharmacological treatments. It should be used as part of patient care rather than screening. Biochemical markers of bone remodelling Several biochemical markers of bone turnover can be measured in serum and urine. Although measuring the levels of biochemical bone markers can not quantify total skeletal bone mass, it can provide additional information to assess fracture risk and may have a clinical role in measuring a patient's compliance and response to therapy. Serum and urine levels of several biochemical markers of bone resorption and formation have been used as surrogate endpoints for gauging drug efficacy. In women aged 75 years or older, urine C-telopeptide and free deoxypyridinoline crosslinks of type I collagen have been shown to be independent predictors of an increased risk of hip fracture, and their combination with low BMD is an even stronger predictor.13 Two other prospective studies, one of hip fractures in elderly women and the other of spinal and peripheral fractures in women closer to the menopause, have confirmed these observations.14,15 An elevated bone resorption marker in addition to low BMD strengthens the case for treatment in an individual. In clinical trials of HRT or bisphosphonates, the percentage decrease in bone turnover markers correlates with the change in BMD at two years.16,17 There is no good evidence that reduced levels of bone-turnover markers in response to therapy predict fracture-risk reduction. Treatment of osteoporosis in postmenopausal women The purpose of treatment is to reduce morbidity and mortality associated with the first fracture and all subsequent fractures. Treatment of osteoporosis is needed because (i) fractures are associated with significant morbidity and mortality; (ii) bone loss and fracture risk accelerate with advancing age; and (iii) treatments are available to prevent accelerated bone loss, slow the deterioration of microarchitecture and reduce the risk of fractures. Who to treat and when 1. Women with osteoporosis or osteopenia and fractures — treat Perhaps the single most easily recognised risk factor for osteoporotic fracture is the presence of any spinal18 or non-spinal fragility fracture. The risk for further spinal fractures increases 3–5-fold as the number or severity of prevalent deformities increases, rising to an 11-fold increase if three or more fractures are present. The risk of hip fracture increases after one or more spinal fractures. The risk of forearm fracture is higher if there has been a previous forearm fracture: of patients who had had a distal forearm fracture, 46% of women and 30% of men suffered further fractures over the following seven years.19 Moreover, in people having an incident fracture (with or without a prevalent [pre-existing] fracture at baseline), the risk of a further fracture is increased by 30%–40% within three years. Thus, if a spinal fracture is present, treatment should be given, provided that BMD is in the "osteoporosis" range (T-score < –2.5) or should be strongly considered if BMD is in the "osteopenia" range (T-score between –1 and –2.5). Values in the osteopenia range should not deter the clinician from proceeding with assessment and treatment — the lower the BMD, the greater the imperative to treat. If the T-score is above –1, assessment and investigation should proceed with a high index of suspicion that the fracture may be due to trauma or local pathology rather than bone fragility. Although there have been no RCTs of prevention of fracture in patients with non-spinal fractures and osteoporosis, it is likely that treatment would reduce future fracture rates. This is an area in need of further research, and studies designed to examine this are under way. 2. Women with osteoporosis without fractures — treat The aim of treatment is to prevent the first and all subsequent fractures safely and cost-effectively, reducing total morbidity and mortality. Women aged over 50 years with a T-score below –2.5 are already at increased risk for fracture. Even though the absolute risk of fracture in the ensuing five years may be low, menopause-related oestrogen deficiency will increase bone remodelling, prolong osteoclast life span, reduce osteoblast life span and increase the negative bone balance, thus accelerating bone loss and further increasing the risk. There is evidence that existing treatments can reduce the risk of fracture in these women. Trials of alendronate and raloxifene have been carried out in women who have osteoporosis but no prevalent fracture. Treatment reduces spinal fracture rates and, at least with bisphosphonates, the reduction in fracture rate is seen within 12–18 months.20,21 Data from alendronate studies indicate that a BMD T-score below –2.5 indicates a level of fracture risk comparable to that associated with a pre-existing low-trauma fracture. 21,22 The number needed to treat (NNT) to prevent a spinal fracture was 15 in women with a prior spinal fracture and 35 in women with low BMD without a prior fracture; for hip fracture, the NNTs were 81 and 90, respectively. Women with osteoporosis, even if they have no fractures, should be treated. 3. Women with osteopenia or normal BMD — defer treatment Should women with BMD T-scores between –1 and –2.5 but no prevalent fracture be treated? The issue in this group is that it comprises such a large proportion of women in the general population (estimated to be about 50% of all women over 50 years). In the Geelong Osteoporosis Study, 80% of the fractures occurred in women over 60 years; of the women under 60 years who had fractures, about 40% had osteoporosis and about 60% had normal BMD or BMD in the osteopenic range.3 As the majority of fractures occur after 60 years of age, it is difficult to justify treating large numbers of 50–60-year-old women with osteopenia, as the modest deficit in BMD and younger age confer only a low absolute risk of fracture over the following five years. When absolute risk is low, the NNT to prevent one fracture is large. Thus, large numbers of people would be exposed to the inconvenience of treatment, side effects and costs without likelihood of benefit. Early treatment may maintain or increase BMD, but most 50–60-year-old women are at low risk of an event, even if they have not received therapy. Few data are available on the antifracture efficacy of drugs in women with osteopenia, as most trials have been carried out in women with osteoporosis. For this reason alone, making recommendations for treatment of women with osteopenia is difficult and not evidence-based, and making recommendations about universal treatment of large sectors of the population at modest risk for fracture is inappropriate. In RCTs, bisphosphonates have been shown to reduce by about 50% the risk of spinal fractures in women with BMD T-scores between –1 and –2.5, but this was not statistically significant, as event rates were low.20 Although antiresorptive drugs (oestrogen, bisphosphonates, raloxifene) prevent bone loss, lifelong treatment of women from the age of 50 onwards can not be recommended except for those with osteoporosis. Drugs have not been shown to reduce fracture rates in women with normal BMD or in women with osteopenia but no fracture. 4. Women with other clinical risk factors for bone loss and falls — more data needed Risk factors are used in the clinical decision-making process, but there is limited evidence that women selected solely on the basis of risk factors for osteoporotic fractures or falls benefit from drug treatment. Risk factors that are common and have a large effect may be important for both the individual and the population. For example, suboptimal dietary calcium intake and vitamin D deficiency are important public health problems in Australia. Surveys of dietary calcium intake in Sydney, Dubbo and Geelong suggest that 75%–87% of premenopausal and postmenopausal women receive less than the recommended daily calcium intake of 800 mg/day (premenopausally) and 1000 mg/day (postmenopausally).23-25 Among older people and those with low exposure to sunlight, there is a high prevalence of vitamin D deficiency. For example, vitamin D deficiency has been found to be remarkably high among residents of hostels and nursing homes in Sydney and Melbourne. Whether calcium intake or vitamin D status can be altered in the whole population, and whether this would reduce the population burden of fractures, is unknown. However, on the basis of current evidence,26 calcium and vitamin D supplementation is recommended for nursing-home residents in Australia. How long should treatment continue? In principle, drug therapy should be continued indefinitely, because stopping treatment results in increased remodelling, bone loss, progression of structural damage and increased fracture risk. Most of the increase in BMD that is observed occurs within the first two years of treatment, although continued increases have been reported with alendronate beyond that time. The longest study of bisphosphonates has been for seven years.27 If BMD increases into the normal range, it may be reasonable to consider stopping treatment and monitoring bone turnover markers and rates of bone loss. However, further research is needed to address the optimal duration of therapy. Barriers to identification and treatment and case-finding strategies Although there are deficiencies in our knowledge of the barriers to identification and treatment of osteoporosis in primary care, some areas that have been identified include a doctor's knowledge, perception and interpretation of diagnostic methods. In a study on diagnosis and treatment of osteoporosis by primary care physicians compared with specialists, the records of 1743 patients who had undergone bone densitometry scans were reviewed. The study revealed that primary care physicians were less likely to recognise and treat osteoporosis than specialist endocrinologists or rheumatologists, as they had had less exposure to specific education about osteoporosis.28 Despite evidence that the incidence of further fracture increases markedly after the first fracture, most people (over 80% in Australia) who present with their first osteoporotic fracture fail to be investigated or treated.29 Initiatives to increase rates of treatment, such as specialised multidisciplinary hospital-based first-fracture clinics, in cooperation with Divisions of General Practice, are one approach to this problem. Orthopaedic surgeons should heighten their awareness of the need for secondary prevention after a fracture in people aged over 50 years. Barriers to identification, treatment and prevention of osteoporosis include inaccessibility of bone densitometry testing facilities and limited availability of subsidised medication. Patients and their treating practitioners require physical and financial access to bone densitometry testing facilities for effective clinical management. Current indications for bone densitometry under Medicare restrict access to densitometry,10 and PBS guidelines restrict the use of some agents to patients who have already had an osteoporotic fracture. Densitometry testing has been subsidised by the MBS for selected indications since 1994. This followed a comprehensive evaluation by the National Health Technology Advisory Panel, with input from the medical profession, mainly the Australian and New Zealand Bone and Mineral Society and the Australian Medical Association. In the year 2000, Medicare funded 110 737 densitometry services in Australia at a cost of $7.6 million. There is a case for expanded indications for densitometry that might include patients at high risk of fracture, such as older patients, or people with a family history of spinal or hip fracture in a first-degree relative.30 For over 50 years, Australia has had in operation a subsidised scheme for pharmaceuticals as part of a comprehensive national health cover for all residents. Of all pharmaceutical expenditure in Australia (including prescription and over-the-counter products), the PBS system pays about 50%. The cost-effectiveness of medications is relevant to whether they are PBS-listed. The relative risk reduction in the incidence of new spinal fractures associated with most anti-osteoporotic medications is fairly consistent at around 50%, regardless of baseline risk or history of fracture. The NNT to prevent a fracture varies with the absolute difference in fracture rates between treatment and control groups and is higher in groups whose baseline fracture risk is lower. However, RCT data suggest that the cost-effectiveness is comparable between people with bone density T-scores less than –2.5 and those with a pre-existing osteoporotic fracture. As over 90% of hip fractures result from a fall, people found to be at high risk of falls are a group worthy of further investigation. Simple assessments for falls risk have been developed that discriminate (with sensitivities and specificities of 75%) between "faller" and "non-faller" groups living in the community and in institutions.31,32 Evidence for specific therapies in postmenopausal women with osteoporosis Bisphosphonates Three bisphosphonates are available in Australia for the treatment of osteoporosis: alendronate, risedronate and etidronate. Alendronate has been reported to reduce the risk of single and multiple spinal fractures, asymptomatic (morphometric) and symptomatic spinal fractures in women with osteoporosis and one or more baseline spinal fractures (E1).22,33 Risedronate has also been reported to reduce the risk of single and multiple spinal fractures and morphometric spinal fractures in women with osteoporosis and one or more baseline spinal fractures (E1) (see Box 2).34,35 Alendronate halves the risk of spinal fractures in women who have osteoporosis without a pre-existing spinal fracture.20 No studies with risedronate in this population are available. Although the BMD response and the suppression of bone remodelling with alendronate 70 mg once weekly is no different from alendronate 10 mg daily,38 there are no fracture studies with the latter formulation. Etidronate may also prevent spinal fractures (E2), but problems in design, execution, and analysis make the results of existing studies difficult to interpret.39,40 2: Major fracture-prevention randomised controlled trials with bisphosphonates in postmenopausal women with osteoporosis The risk reduction with potent bisphosphonates is seen early, usually within 12 months. There is evidence that the reduction in spinal fracture risk with alendronate reduces bed-days, days of sickness and pain and healthcare costs.36 Non-spinal fracture rates are also reduced with alendronate and risedronate in patients with a prevalent spinal fracture (E1).33-35 Data for anti-hip-fracture efficacy are also available. In the alendronate trials there was consistency in hip-fracture risk reduction, but event rates were low and hip fracture was not a primary endpoint.20,22 In one risedronate trial,37 in which hip fractures were the primary endpoint and there were many events (232 hip fractures), there was a 40% reduction in hip-fracture risk among women aged 70–79 with a baseline femoral-neck T-score below –4 (or below –3 together with one non-skeletal risk factor for hip fracture) (E2). In women aged over 80 years and selected primarily on the basis of non-skeletal risk factors (such as poor gait or propensity to fall) but not low BMD, there was no significant reduction in hip-fracture risk overall. However, a recent analysis suggests that there was a reduction in intertrochanteric fractures in this group.41 Selective oestrogen-receptor modulators Selective oestrogen-receptor modulators (eg, raloxifene) are compounds that have oestrogen agonist activity at some sites and antagonist activity at others. RCTs of the effects of raloxifene have shown increases in bone density,42 but less than those reported with bisphosphonates or oestrogen. Despite this, in postmenopausal women with osteoporosis, raloxifene treatment has been found to be associated with a 36% reduction in the risk of one or more spinal fractures using a 60 mg daily dose for four years.21 Non-spinal fractures were not reduced, for reasons that are unclear. Raloxifene treatment is also associated with a 60%–70% reduction in risk of breast cancer43 and with reduced low-density- lipoprotein cholesterol and total cholesterol (the latter being surrogate endpoints for cardioprotection).42 An increased risk of venous thrombosis has been reported with raloxifene, similar to that seen with oestrogen. Raloxifene should be stopped if patients are immobilised for any prolonged period. Unlike oestrogen, raloxifene is not useful for control of menopausal symptoms, and indeed may worsen them. Raloxifene has also been shown to be effective in preventing postmenopausal bone loss,44 and can be considered as an alternative in women unable to take oestrogen for this indication. Currently, there are no RCTs with preplanned endpoints supporting the use of selective oestrogen-receptor modulators for the prevention of non-spinal fractures. Hormone replacement therapy Numerous RCTs have shown that oestrogen therapy can prevent bone loss in postmenopausal women (E1). Oestrogen is not only effective in preventing bone loss when given at or near menopause, but also continues to reduce bone loss for 10–15 years after menopause, with increases in bone density averaging 5% over three years.45,46 However, the paucity of trials demonstrating antifracture efficacy of HRT has led to questions about its value in the treatment of osteoporosis. Two recent meta-analyses of the effects of HRT on spinal and non-spinal fractures have reviewed 22 controlled trials of at least one year's duration in which HRT was compared with either placebo, no treatment, calcium, or vitamin D.47,48 In the pooled analysis, the relative risk of non-spinal fracture in women randomly assigned to receive HRT was 0.73 (95% CI, 0.56–0.94; P = 0.02). For hip and wrist fractures alone, the relative risk was 0.60 (95% CI, 0.40–0.91; P = 0.02). Significant effects were seen only in women under the age of 60.47 The finding that risk reduction was not significant in women over 60 was dependent on the inclusion of the HERS study,49 which involved relatively obese older women with cardiovascular disease who may not have had osteoporosis. For spinal fractures, the relative risk in women randomised to receive HRT was 0.67 (95% CI, 0.45–0.98; P = 0.04) and the effect was not confined to women under 60 years.48 Thus, although some positive data exist, there is a need for RCTs of the effect of HRT on spinal and non-spinal fractures. Ideally, oestrogen therapy should be continuous, not cyclical, and long-term. Women with a uterus should take oestrogen in combination with progestogens to protect against endometrial cancer. Progestogens may be given cyclically for 10–14 days each month in perimenopausal women or as continuous therapy combined with oestrogen in postmenopausal women. The latter treatment is more suitable for women who are more than two years postmenopausal, to prevent the initial irregular bleeding (normally seen with this regimen) being unduly prolonged. Tibolone, a synthetic steroid reported to have activity through oestrogenic, progestogenic and androgenic receptors, can also improve bone density.50 Moreover, it can be taken without unwanted progestogen-induced withdrawal bleeding. However, there are no data evaluating its antifracture efficacy. CalciumIt is important to realise that most RCTs discussed so far have used calcium as adjunctive therapy and compared a single treatment (plus calcium) with a calcium control group. Dairy products or calcium-enriched soy drinks represent the best source of calcium in the diet. Although there are other dietary sources, dairy products are the primary dietary source for most people. Three or more servings of dairy products per day, combined with a normal diet, should allow most individuals to achieve their recommended daily intake. Controlled trials of calcium as a monotherapy have found small but consistent effects of calcium on BMD (E1), averaging 1%–2% over two to three years and showing accumulation over time.51,52 Several studies have reported a significant beneficial effect of calcium monotherapy on fracture incidence.51,53-55 However, these findings should be interpreted with caution, as the studies were small and not powered to assess the effects of calcium supplementation on fractures. They may represent selective reporting of fracture results in that fracture data were probably recorded in other RCTs but not reported because no significant effect was found. The effect of this bias towards the reporting of positive results will only be addressed when adequately powered studies with fracture rate as the primary endpoint are undertaken. Vitamin D Vitamin D is better regarded as an endogenously produced pro-hormone than as an essential dietary constituent. It is produced in the skin as a result of sunlight exposure. With increasing age and frailty, vitamin D levels tend to decline, resulting in malabsorption of calcium and increased secretion of PTH, which in turn leads to accelerated bone loss. Physiological supplements of calciferol (eg, 400 IU/day) reduce PTH concentrations and lead to increases in BMD. Similar changes in biochemical endpoints can be achieved with regular sunlight exposure for 15–30 minutes daily. Two large studies have assessed the effect on fracture rates of calciferol supplementation alone. Lips et al56 reported no change in fracture incidence among 2578 community-dwelling men and women aged over 70 years who were randomised to receive calciferol 400 IU/day or placebo, whereas Heikinheimo et al57 reported that 150 000 IU/year of vitamin D reduced symptomatic fracture rates by 25% in a cohort of 800 elderly subjects in Finland. Two other studies have reported the effects of calcium plus calciferol given to elderly people. Chapuy et al26 reported a reduction of more than 25% in non-spinal and hip fracture rates in a cohort of 3000 elderly institutionalised women studied over three years. Dawson-Hughes et al58 reported a reduction of more than 50% in non-spinal fracture rates among 400 older men and women randomised to receive calcium 500 mg/day plus 700 IU vitamin D per day, or placebo. It is not possible to determine whether the calcium, the vitamin D or the combination were the essential components in the success of these two studies. However, the studies point to the possibility that a safe and inexpensive intervention with calcium and vitamin D may reduce morbidity among institutionalised elderly patients. Calcitriol Evidence is less straightforward for the vitamin D metabolite calcitriol. There are a number of studies demonstrating both small beneficial and small detrimental effects on BMD and reports of both increased and decreased numbers of fractures. A recent study of 489 postmenopausal women compared the effects of HRT and calcitriol over three years.59 HRT increased BMD by 3% at the femoral neck (P < 0.0001) and by 4.4% at the spine compared with placebo (P < 0.0001). By comparison, calcitriol had no significant effect on BMD at the femoral neck (0.1% increase; P = 0.57), but significantly increased BMD at the spine (1.7% increase; P = 0.01). An open-label trial of 622 women found a threefold reduction in new spinal fractures among women with postmenopausal osteoporosis treated with calcitriol compared with women receiving supplemental calcium60 — fracture rates remained stable in calcitriol-treated patients but increased in the calcium-treated patients. This study suffered from several design flaws, making the results difficult to interpret (E3). In summary, the paucity of available data from well-designed, large-scale RCTs provides only weak evidence for the efficacy of calcitriol as a treatment for postmenopausal osteoporosis. Parathyroid hormone The possibility that PTH might have an anabolic effect on bone has been explored over many decades. Recently, RCTs have confirmed that PTH substantially increases bone density and reduces the incidence of spinal and non-spinal fractures (E2). It is well tolerated in human studies, but there remains some concern based on long-term animal toxicology results. The largest study, involving 1637 postmenopausal women with prior spinal fractures, assigned participants randomly to receive placebo or one or two doses of subcutaneous recombinant human PTH over a median period of 19 months.61 New spinal fractures occurred in 14% of placebo-treated women versus 5% of women treated with 20 µg PTH. A 20 µg dose of PTH increased BMD by 9% (spine) and 3% (femoral neck) over and above the control group. Fracture-risk reduction with 20 µg PTH was 65% for spinal fractures and 55% for non-spinal fractures. Other drugs Androgenic steroids such as nandrolone have been widely used in Australia for management of osteoporosis. While there is some evidence of beneficial effects on bone density (E3),62 their antifracture efficacy is untested and there are no adequate safety data. Recently, anabolic effects of statins on bone have been reported in vitro and in animal experiments. However, observational epidemiological studies of bone density and fracture rates among statin users are conflicting and may be confounded by the metabolic abnormalities that led to statin use in the first place. Two RCTs of statin use in non-osteoporotic populations have failed to demonstrate an effect of statins on fracture risk.63,64 Plant constituents with a phenol structure similar to oestrogen are known as phyto-oestrogens. Epidemiological studies, primarily comparing Asian and Western populations, have been interpreted to indicate that a phyto-oestrogen-rich diet ameliorates oestrogen-deficiency symptoms in postmenopausal women and may protect against breast cancer, bone loss and cardiovascular disease. However, the interindividual diversity and complexity of dietary phyto-oestrogen absorption and metabolism make the bioactivity of these compounds unpredictable, and results of in vitro and in vivo studies are inconsistent. There is a paucity of data on the effects of phytooestrogens on bone65,66 and no evidence that phyto-oestrogen supplements prevent bone loss. In one prospective, randomised, placebo-controlled study of 474 women treated with ipriflavone, no significant differences in BMD, biochemical bone markers or spinal fracture rates were observed after 36 months.67 Fall-prevention strategies and hip protectors Risk factors for falls include impairments of vision, sensation, strength and balance, and patient thinness and frailty. In the Dubbo Osteoporosis Epidemiology Study, quadriceps strength and postural sway were of similar importance to BMD in predicting fractures in both men and women.2 Most fractures occur after falls, but not all falls result in fractures. Nevertheless, interventions that reduce falls risk may prevent fractures. Several studies have examined single and multiple risk factors and the use of hip protectors. Of the single risk factor interventions, programs that involve balance training, such as home-based physiotherapy and tai chi, reduce the risk of falls (pooled relative risk [RR], 0.80; 95% CI, 0.66–0.98; and RR, 0.51; 95% CI, 0.36–0.75, respectively).68,69 Environmental modifications by occupational therapists (eg, removing mats, improving lighting) may reduce falls.70 One study has reported that a reduction in psychoactive medications reduces the risk of falls (RR, 0.34; 95% CI, 0.16– 0.74), but adoption and compliance rates in the study were low.71 Studies in nursing homes in Denmark and Sweden of the effect of hip protectors have reported reductions in hip fracture rates of 56% and 67%, respectively (E2).72,73 However, hip fractures did occur in the intervention subjects when not wearing their hip protectors, so that compliance remains an issue (one reason for non-compliance is that women believe it makes them look "fat" around the hips). Systematic reviews74 suggest that hip protectors reduce the risk of hip fracture in high-risk populations (E1). Exercise Evidence that exercise reduces fractures is derived from retrospective and prospective observational cohort studies and case–control studies (E3). Maximising the attainment of peak bone mass and preventing age- and menopause-related bone loss by exercise, as well as attending to related risk factors (such as loss of muscle mass, poor gait and balance and depression), are potentially important approaches to reducing fracture risk in older people. However, no RCTs have examined the efficacy of exercise in preventing fractures at specific sites and this remains a gap in our knowledge. Vigorous exercise undertaken by athletes during growth is well documented as increasing peak bone mass by biologically worthwhile amounts.75-77 The difference in bone density between athletes and sedentary controls ranges from 5% to 25%, depending on the sport and duration of participation. After retirement from intensive training, the effects appear to persist for many years, but whether the benefits are maintained into old age, when fractures and falls become common, is uncertain. The sparse data on 70–80- year-old retired athletes suggest that the effects may be eroded in people who have substantially reduced training volumes. The same pattern is seen for other physiological adaptations to exercise, such as muscle hypertrophy, increased aerobic capacity, and increased insulin sensitivity. Whether moderate exercise during growth produces benefits in terms of BMD and bone structure is less well established. There have been several exercise studies in school children in which loading (such as jumping and other sporting activity) is incorporated into the physical education program for 20–30 minutes three times weekly. The results are generally positive, with variable evidence of increased bone size, increased BMD and thickening of cortices.78-80 However, there are few data on whether the modest improvements in bone mass and structure are maintained after these exercise programs are stopped. There have been no long-term (> two years) exercise intervention studies using moderate exercise programs in normally active children. Moderate- to high-intensity weight-bearing aerobic exercise, high-intensity progressive resistance training and high-impact loading (such as jumping) increase BMD by 1%–4% in pre- and postmenopausal women (E1).81-85 Excessive exercise carries some risk, especially in premenopausal women, in whom it may induce amenorrhoea. In studies of generally one year's duration, with sample sizes ranging from 30 to 150, exercise has been found to slow the rate of bone loss in older women by about 1.5% per year compared with sedentary controls (E1).86 More robust exercise interventions appear to produce greater effects, but optimal prescriptive elements await further RCTs. Inclusion of weight-lifting and balance-training exercises should provide the widest range of benefits relevant to fracture protection, as well as reducing muscle weakness, falls risk and depression, and increasing muscle mass and mobility. Whether these benefits translate into fracture-risk reduction is currently unknown. Pain management and rehabilitation after osteoporotic fracture There is little evidence available regarding pain management after osteoporotic spinal fracture. The general principles of management of acute, subacute and chronic pain include use of non-pharmacological modalities and recognition of the potential for comorbid mood disorders, particularly in elderly people. Non-pharmacological, non-evidence-based modalities include physiotherapy and other physical modalities, transcutaneous electrical nerve stimulation, cognitive behaviour therapy, and procedures such as vertebroplasty, kyphoplasty and nerve blockade. Pharmacotherapy should employ a stepwise approach in the use of analgesics and other pain-modifying agents. Subcutaneous calcitonin has been reported to reduce the pain of acute spinal fractures in two small placebo-controlled trials (E2).87,88 Rehabilitation to independent living is the primary goal after any fracture. Rehabilitation after hip fracture has been the most investigated. Systematic reviews of randomised and non-randomised trials89,90 have concluded that coordinated geriatric hip-fracture programs and early discharge (with support) for selected patients can significantly increase rates of returning home and reduce length of hospital stay and costs (E1). No controlled trials are available to guide recommendations specifically for spinal fractures. Given the absence of evidence for this condition, strategies that encourage independence and limitation of disability, together with interventions directed at secondary prevention of fractures, should be applied in clinical practice. Evidence for treatment of other populations While there are multiple published RCTs assessing the benefits of different therapies for osteoporosis in postmenopausal women, studies of osteoporosis in other populations (such as men, glucocorticoid-treated patients, and frail older people) are relatively few. Here we attempt to summarise the evidence for treatments in these "neglected" populations, using the same NHMRC levels of evidence. Evidence and recommendations regarding children with osteoporosis and athletes with stress fractures can be found at the Osteoporosis Australia website (<http://www.osteoporosis.org.au>). Treatment of osteoporosis in men Osteoporotic fractures occur in about 28% of men aged over 60 years.5 While fractures tend to occur in elderly men with multiple comorbid disorders, secondary underlying causes of osteoporosis are common and need to be rigorously excluded. Up to 16% of men with spinal fractures have evidence of hypogonadism. Chronic smoking, excessive alcohol use, glucocorticoid therapy, malabsorption and underlying bone-marrow malignancies are some of the important risk factors for osteoporosis that need to be identified. Osteoporosis remains a neglected area in men's health, with less than 10% of men with osteoporotic fractures currently receiving antifracture therapy. RCTs of men with osteoporosis are generally of smaller sample size and lesser quality than in those involving postmenopausal women (see Box 3). The limited RCTs that have been conducted suggest that alendronate, followed by cyclical etidronate, are the drugs of choice for men with primary osteoporosis. 91,92,94 The effects of risedronate have not yet been reported, except in men receiving corticosteroids, but its efficacy should be similar to that of alendronate and etidronate. Preliminary studies also suggest that subcutaneous PTH may be as effective in reducing fracture rates in men as it is in postmenopausal women. Adequate supplementation with calcium and vitamin D (if required) is recommended for all men with osteoporosis. There are no RCTs assessing the role of calcium or vitamin D3 alone in men. In a single small RCT (20 treated subjects and 19 controls) in osteoporotic men with pre-existing fractures conducted over two years,95 calcitriol was no better than calcium in reducing spinal fracture (E3). Testosterone replacement therapy is indicated for men with hypogonadism (serum total testosterone concentration < 8 nmol/L), but there are no data to assess the antifracture efficacy of testosterone in men with osteoporosis. Testosterone therapy and its effect on BMD are largely dependent on the gonadal and growth status of the individual, the duration of pre-existing hypogonadism, the degree of osteopenia and the duration of testosterone therapy. Two RCTs (E2) have demonstrated the positive effects of testosterone therapy on both cortical and trabecular bone, with maximal responses occurring in men before epiphyseal closure.96,97 The results of studies of testosterone therapy in hypogonadal, osteoporotic eugonadal and normal elderly men are summarised in Box 3.96-100 Large, well designed RCTs with adequate power to demonstrate spinal and hip fracture prevention in men with osteoporosis are needed. 3: Summary of randomised trials in male osteoporosis Glucocorticoid-induced osteoporosis A number of RCTs of bisphosphonates, in which the primary efficacy endpoint was BMD, have shown a consistent reduction in spinal fracture risk in postmenopausal women taking glucocorticoids (E1).101-105 In these studies, the risk of spinal fracture in control-group women taking glucocorticoids ranged from 13% to 22% over 12 months. For etidronate, alendronate and residronate, the number of postmenopausal women taking glucocorticoids who would need to be treated to prevent one fracture over 12 months was low. Treating these women would be more cost-effective than treating postmenopausal women with osteoporosis unrelated to glucocorticoid use. A number of RCTs of active vitamin-D metabolites, such as calcitriol and alfacalcidol, have reported prevention of spinal bone loss in patients starting glucocorticoids.106,107 None of these studies were powered for fracture as an endpoint, and mild hypercalcaemia occurred in about 10%–20% of patients. In trials in which calcium alone was used as the control therapy for patients starting glucocorticoids, calcium did not prevent rapid spinal bone loss.106,108 However, in patients receiving chronic low-dose glucocorticoids, treatment with calcium and simple vitamin D resulted in small increases in spine BMD.109 Although none of these studies were powered for fracture as an endpoint, meta-analyses have concluded that adjunctive therapy with some form of vitamin D should be considered.110 There is limited evidence for the effects of HRT (either oestrogen or testosterone) on bone density (E2), and there are no data on the effectiveness of HRT in reducing fractures among people with glucocorticoid-induced osteoporosis. Nevertheless, HRT should probably be considered if hypogonadism is present.111,112 Fracture risk with glucocorticoids is a function of multiple factors, including the severity of reduction in bone density and the duration of exposure to glucocorticoids. The available evidence suggests that postmenopausal women and older men receiving glucocorticoids are at the greatest risk of spinal fracture and should be considered for prophylaxis, usually with a bisphosphonate as the first choice. Adjunctive therapy with some form of vitamin D should be considered. If an active vitamin D metabolite is used, calcium supplementation should be avoided, unless dietary calcium intake is low. In premenopausal women and young men who are taking glucocorticoids, the risk of spinal fracture is less clear but appears to be lower, so the decision to use antiosteoporosis prophylaxis is less straightforward. Osteoporosis in frail older people About a third of older Australians with profound and severe disability are resident in nursing homes and hostels (which provide a total of around 150 000 beds), and there is evidence of undertreatment for osteoporosis in this group. In one study, 26% of hostel residents and 36% of nursing home residents were known to have previous osteoporotic fractures, but anti-osteoporosis therapy was prescribed for only 17% and 11% of residents, respectively (Leon Flicker, Professor of Geriatric Medicine, Royal Perth Hospital, personal communication). Older people are more likely to have several risk factors for fracture, including previous fractures. NNT analyses suggest that older people are more likely to derive greater benefit per year of anti-osteoporotic treatment than younger people.113 However, in frail older subjects, osteoporosis treatments must take account of the likelihood of comorbidity and the use of multiple other therapies. Calcium and vitamin D supplementation may have a special role in treating older frail people, particularly those in residential care. In Australia, 22% of women in low-level care and 45% of women in high-level care have frank vitamin D deficiency, and virtually all the remainder have a 25-hydroxy-vitamin-D level in the lower half of the reference range.114 Other factors that need special consideration in frail older people are the use of hip protectors and interventions to prevent falls. Summary and recommendations Osteoporosis represents a substantial health burden on the Australian community. In the financial year 2000–01, it led to an estimated 65 000 fractures. Total financial costs in 2001 were estimated at $7.4 billion per annum, of which $1.9 billion were direct healthcare system costs. If nothing is done, it is estimated that the number of Australians sustaining a fracture will increase from one every 8.1 minutes in 2001 to one every 3.7 minutes in 2021. Relative to other diseases, management of osteoporosis is expensive — more costly in absolute terms than either diabetes or asthma, both of which are National Health Priority Areas. In terms of disease burden, more years of healthy life are lost in Australia due to osteoporosis than to Parkinson's disease, HIV/AIDs, rheumatoid arthritis or cervical cancer. New strategies to reduce the fracture burden Increased education and awareness programs Education and awareness programs are a key strategy for reducing the fracture epidemic. Because the risk of fracture increases after the first fracture and the initial osteoporotic fracture often goes undiagnosed and untreated, increasing the rate of treatment in people who have already sustained an osteoporotic fracture is important. Despite the evidence, most people do not realise they are at risk of osteoporosis. The role of lifestyle changes (including specific exercise regimens, changes in diet and quitting smoking) has not been evaluated adequately. Regardless of whether or not such strategies can reduce fracture risk, they are likely to have other major public health benefits. Wider use of effective treatments The most rigorously investigated drugs in the field of osteoporosis are the potent bisphosphonates alendronate and risedronate, and the selective oestrogen-receptor modulator raloxifene (see Box 4). Calcium, in combination with vitamin D, has been reported to reduce fracture risk in nursing-home residents and ambulant individuals. Lower levels of evidence exist for the effectiveness of HRT and etidronate. Still weaker and contradictory evidence for anabolic steroids and calcitriol makes these drugs difficult to recommend. Introduction of fall-prevention programs Fall-prevention strategies and hip protectors are potentially effective in preventing fractures, particularly in elderly people, for whom treatment of vitamin D insufficiency is also vital. 4: Algorithm for treatment of osteoporosis in postmenopausal women A national strategy The international Bone and Joint Decade (2001–2010), endorsed by the World Health Organization, provides an opportunity to launch a strategic plan against osteoporosis. In light of the enormous and growing prevalence, costs and disease burden of osteoporotic fractures in Australia, we make two recommendations: Osteoporosis should be adopted by the Federal Government as a National Health Priority Area, with commensurate funding; and The Federal Government should support a National Strategic Plan for urgent implementation during the international Bone and Joint Decade (see Box 5). 5: Components of a National Strategic Plan (a) Awareness programs implemented through State-based osteoporosis organisations with national coordination, including programs targeted at general practitioners. (b) Public health prevention strategies such as school-based programs to increase dietary calcium intake and exercise in young people. (c) Specific programs to address the high prevalence of vitamin D deficiency in elderly people, as well as fall-prevention programs and provision of hip protectors for older people in residential care and in the general community. (d) Secondary prevention strategies, such as special clinics in teaching hospitals or initiatives in general practice, to increase treatment rates in people who have sustained their first osteoporotic fracture. (e) Wider availability of Medicare Benefits Schedule rebates on bone densitometry items for elderly people and those with a family history of osteoporosis. (f) Wider availability of drugs under the Pharmaceutical Benefits Scheme to treat subgroups of people at high risk of suffering fractures (eg, people with very low bone mineral density [BMD] and glucocorticoid users). There is a need to identify a BMD level at which the cost-effectiveness of treatment is similar to that for a pre-existing fragility fracture. (g) Research initiatives in cooperation with the National Health and Medical Research Council and other funding agencies. (h) Monitoring and evaluation of fracture rates, the cost-effectiveness of treatments and the prevalence and burden of osteoporosis in Australia at specific time points over the next decade (eg, 2005 and 2010). (i) Liaison with orthopaedic units to ensure that patients with fractures are adequately investigated and treated. Abbreviations BMD bone mineral density DEXA dual energy x-ray absorptiometry DOES Dubbo Osteoporosis Epidemiology Study GOS Geelong Osteoporosis Study HRT hormone replacement therapy MBS Medicare Benefits Schedule NHMRC National Health and Medical Research Council NNT number needed to treat PBS Pharmaceutical Benefits Scheme PTH parathyroid hormone RCT randomised controlled trial RR relative risk TASOAC Tasmanian Older Adult Cohort Writing Group Philip N Sambrook, MD, LLB, FRACP Professor of Rheumatology, Institute of Bone and Joint Research, University of Sydney Ego Seeman, MD, FRACP Associate Professor of Medicine, Department of Endocrinology, Austin and Repatriation Medical Centre, Melbourne Stephen R Phillips, MB BS, FAMA Chairman, National Prescribing Service, Surry Hills, Sydney Peter R Ebeling, MD, FRACP Associate Professor of Medicine, Departments of Diabetes and Endocrinology, Royal Melbourne Hospital, and Department of Medicine, University of Melbourne Working Group Shona L Bass, PhD, MSc Senior Lecturer, School of Health Sciences, Deakin University, Victoria Kim L Bennell, BAppSc, PhD Associate Professor, and Director, Centre for Sports Medicine Research and Education, School of Physiotherapy, University of Melbourne Ian D Cameron, MB BS, PhD Associate Professor of Rehabilitation Medicine, Motor Accidents Authority of NSW, and Department of Medicine, University of Sydney Chris T Cowell, MB BS, FRACP Clinical Associate Professor, Institute of Endocrinology, The Children's Hospital at Westmead Susan R Davis, MB BS, FRACP, PhD Associate Professor, Department of Epidemiology and Preventive Medicine, Monash University, and Director of Research, Jean Hailes Research Unit, Clayton, Victoria Terry Diamond, MB BCh, FRACP Associate Professor of Medicine, Department of Endocrinology, St George Hospital, and University of NSW, Sydney John A Eisman, AO, PhD, FRACP Professor of Medicine, and Head, Bone and Mineral Research Division, Garvan Institute of Medical Research, Sydney Leon Flicker, MB BS, PhD Professor of Geriatric Medicine, Royal Perth Hospital, University of Western Australia Linda R Ferris, MB BS, BSc(Med), FRACS(Orth) Head, Orthopaedic Unit, Modbury Hospital, Adelaide Maria A Fiatarone Singh, MD, FRACP Professor of Medicine, John Sutton Chair of Exercise and Sport Science, University of Sydney Paul P Glasziou, MB BS, PhD Professor of Evidence-Based Practice, School of Population Health, University of Queensland, Herston, Queensland Michael J Hooper, MB BS, FRACP Clinical Associate Professor, Department of Medicine, Concord Hospital, Sydney Graeme Jones, MD, FRACP Associate Professor, and Head, Musculoskeletal Unit, Menzies Research Institute, Hobart Stephen R Lord, PhD Associate Professor, and Principal Research Fellow, Prince of Wales Medical Research Institute, Sydney Lyn M March, PhD, FRACP Associate Professor, Departments of Rheumatology and Public Health, Royal North Shore Hospital, Sydney Sheila M O'Neill, MB BCh, BAO, MICGP Clinical Director of Research, Betty Byrne Henderson Centre, Royal Women's Hospital, Brisbane Nick A Pocock, MD, FRACP Associate Professor of Medicine, and Senior Staff Specialist in Nuclear Medicine, Department of Nuclear Medicine, St Vincent's Hospital, Sydney Richard L Prince, MD, FRACP Associate Professor of Medicine, Department of Medicine, University of Western Australia, and Department of Endocrinology and Diabetes, Sir Charles Gairdner Hospital, Perth Ian R Reid, MD, FRACP Professor of Medicine and Endocrinology, Department of Medicine, University of Auckland, New Zealand Kerrie M Sanders, MHN, PhD Research Fellow, Department of Clinical and Biomedical Sciences, University of Melbourne, Barwon Health, Geelong John D Wark, PhD, FRACP Professor of Medicine, Department of Medicine, University of Melbourne, and Royal Melbourne Hospital

Philip N Sambrook MD, LLB, FRACP · Ego Seeman MD, FRACP · Stephen R Phillips MB BS, FAMA · Peter R Ebeling MD, FRACP

The widespread application of public iodine supplementation programs, which cover about 3–4 billion people worldwide,1,2 is a response to the paucity of iodine in the natural diet in many regions of the world and the severe public health consequences of iodine deficiency.3 However, in some countries, the tendency to low iodine intake has mostly been corrected by haphazard increases in the iodine content of certain parts of the diet.4 In the United Kingdom, dairy products may contain extra iodine as a result of adding iodine to cow feed to increase the animals' reproductive performance or of using iodine-containing cleansing agents in the dairy industry. As reviewed by Phillips,5 this unplanned increase in iodine intake has eliminated endemic goitre in Britain during the last 30–40 years. In the United States, London and colleagues encountered cases of unexplained very high iodine intakes (1100–1300 µg per day) in 1964. Subsequently, they discovered that bakers used iodine-containing conditioners in bread and that this caused high levels of iodine intake.6 Obviously, such unplanned variation in dietary iodine is a hazardous way of providing a population with an adequate intake of iodine, as mechanisms unrelated to disease prevention can profoundly alter iodine intake. To some extent, Australia may be a country where factors other than disease prevention have modulated the intake of iodine, and iodine intake may now be in an unplanned phase of decrease.7 A report by McElduff et al8 (page 317) in this issue of the Journal seems to support this proposition. McElduff and colleagues looked at the frequency distribution of whole-blood thyroid-stimulating hormone (TSH) concentrations in newborns in the northern Sydney area. TSH is measured as part of screening for congenital hypothyroidism. In 5%–10% of infants around 72 hours after birth, TSH values were above 5 mIU/L. The World Health Organization (WHO) recommends assessment of TSH concentrations in newborns to detect population iodine deficiency, and specifies that less than 3% of newborns should have a whole-blood TSH concentration over 5 mIU/L. In a subsample of neonates, McElduff et al found that, during pregnancy, their mothers had a median urinary iodine concentration of 109 µg/L, indicating borderline mild iodine deficiency. WHO specifies that the median urinary iodine concentration in adults should be over 100 µg/L, and an extra iodine intake of 50 µg/day in pregnant and lactating women.1 Thus, the corresponding median urinary iodine concentration of pregnant women would be around 130 µg/L. McElduff et al warn that Sydney may be an area of iodine deficiency, and suggest that iodine intake and risk of disease should be investigated in more detail. Their concern is well founded. Even if there is no documentation that these borderline iodine values are harmful to a mother and child, the margin of safety is small. Furthermore, in Australia, there is apparently no regular surveillance of population iodine status, or of the variable iodine content of dairy products and other foods. The iodine intake may well be even lower in other sections of the Australian population. Severe iodine deficiency may cause brain damage and other developmental disorders,3 and goitre and its complications may affect a significant proportion of the population at all levels of iodine deficiency.9 Any public healthcare system should evaluate iodine intake and prevent disorders caused by iodine deficiency. Several factors need to be taken into account in such an evaluation and prevention program: The relationship between iodine intake and the risk of thyroid disease is not a simple one. Even if iodine supplementation may decrease the risk of some thyroid disorders, the risk of other disturbances at a younger age, such as hypothyroidism and Graves' disease, may increase.4 Severe iodine deficiency, with a median urinary iodine excretion of less than 25 µg/24 h, is an instance where giving any type of iodine supplementation is better than doing nothing. However, at higher levels of intake, careful planning and surveillance are needed. The methods often used for evaluating iodine intake and the risk of disease are not perfect. Neonatal screening showing more than 3% of TSH values over 5 mIU/L is not, by itself, enough to indicate insufficient maternal iodine intake. Detection of neonatal hypothyroidism requires identification of relatively high TSH levels (20–25 mIU/L), and many TSH assays and screening programs are not designed to identify TSH values around 5 mIU/L with reasonable confidence. Technical aberrations can easily give an increased frequency of elevated blood TSH concentrations. One such aberration occurs with sampling of blood before TSH has fully returned to baseline levels after the early postnatal surge. As discussed by McElduff et al,8 early sampling may have contributed to their findings. Iodine deficiency is not the only pathogenetic mechanism leading to an increase in blood TSH levels in neonates. Iodine has an autoregulatory inhibitory effect on the thyroid gland, with a fall in both thyroid hormone synthesis and secretion. Possibly, this mechanism has been developed to protect against hyperthyroidism induced by a sudden iodine load. In a variety of abnormal states the thyroid gland overreacts, producing hypothyroidism. The thyroid of the fetus and infant is considerably more sensitive to iodine inhibition than the maternal thyroid. Excess iodine intake, rather than iodine deficiency, in mother or infant has been a more common cause of transient neonatal hypothyroidism in countries with a relatively low iodine intake, such as Germany, Italy and Belgium.4 In severe iodine deficiency, iodine supplementation to the mother decreases the abnormally high serum TSH in both the mother and the newborn.10 On the other hand, in pregnant women with urinary iodine concentrations around 50 µg/L, iodine supplementation decreases TSH levels in mothers, but not in cord blood. TSH levels in the newborn may even be higher after iodine supplementation.11 The finding of McElduff et al of a positive correlation between maternal urinary iodine concentrations during pregnancy and whole-blood TSH levels in neonates needs further elaboration,8 but it may be an example of iodine autoregulation of the fetal thyroid. Should pregnant women living in mild and moderately iodine-deficient areas receive iodine supplements, and does supplementation involve any risk? An increase in iodine intake will improve thyroid function in pregnant women, which is important for early brain development in their infants.12 There are still things to be learned about the influence of small amounts of iodine on neonatal thyroid function in mild iodine deficiency, and about pituitary/thyroid feedback regulation in the fetus and small infant. A tendency to a slight increase in neonatal TSH level after iodine supplementation may be of little importance, as, in these infants, the serum concentration of T4 (which may be the major thyroid hormone influencing brain development12) does not show a concomitant reduction.11 Finally, iodine supplementation imposes no risk of worsening of postpartum thyroid dysfunction in the mother.13 In conclusion, pregnant women should not be iodine deficient. To strictly follow WHO guidelines on iodine intake, pregnant women with similar urinary iodine levels to those found by McElduff et al could alter their diet towards more iodine-rich foods, or they could take a small iodine supplement as part of the vitamin and mineral supplements recommended for pregnant women in most countries. However, there is at present no evidence that a supplement will have beneficial effects. Ideally, iodine intake should be evaluated and kept optimal in the entire population, taking into account that unnecessary high iodine intakes may be associated with more hypothyroidism.4 The studies by McElduff et al8 and other researchers7 demonstrate the need for national monitoring and adjustment of iodine intake as part of a program of prevention of thyroid disorders and their complications. Such initiatives normally involve government nutrition or public health agencies in collaboration with experts in thyroid diseases, nutrition and epidemiology and prevention.1,2 It would be an added bonus if the program elucidated some of the unresolved issues in the field of population iodine supplementation in developed countries. This would continue the considerable contribution of Australian scientists to the understanding and correction of iodine-deficiency disorders.3,14

Peter Laurberg MD, DMedSci · Susanne B Nøhr

Objective: To determine whether thyroid-stimulating hormone (TSH) concentrations in a large sample of neonates meet World Health Organization criteria for an iodine-replete population (< 3% of neonates with whole-blood TSH concentrations > 5 mIU/L), and, in a small subset of neonates, to examine the correlation between maternal urinary iodine and neonatal TSH concentrations.Design: Cross-sectional study of neonatal whole-blood TSH values obtained as part of a routine newborn screening program.Setting: Royal North Shore Hospital (RNSH) in northern Sydney.Participants: Two anonymous samples of neonates born at RNSH (1316 infants born between August 1998 and April 1999 and 1457 infants born between 1 March and 31 December 2000); and 84 infants whose mothers had attended RNSH between September 1998 and August 1999 and supplied a urine sample for iodine measurement.Main outcome measures: Iodine status of neonates (proportion with whole-blood TSH values > 5 mIU/L), and urine iodine concentrations of pregnant women.Results: In the two large population samples of neonates, 8.1% (95% CI, 6.6%–9.5%) and 5.4% (95% CI, 4.3%–6.6%), respectively, had whole-blood TSH values > 5 mIU/L (prevalence range for mild thyroid deficiency, 3%–19%). Comparing the TSH values of the 1316 anonymous infants and the 84 identified infants showed no difference between the proportions with TSH values > 5 mIU/L (8.1% v 10.7%, respectively; P = 0.39). Urine iodine concentrations in the 84 pregnant women indicated borderline mild iodine deficiency. TSH values in their 84 infants were positively correlated with maternal urine iodine concentrations.Conclusions: Our results suggest that the population of northern Sydney may have mild iodine deficiency. However, the expected relationship between maternal urine iodine levels and neonatal TSH concentrations was not found.

Aidan McElduff PhD, FRACP · Patrick McElduff BMath, PhD · Jenny E Gunton MB BS, FRACP · Graham Hams MAppSc · Veronica Wiley PhD · Bridget M Wilcken MB ChB, FRACP

Screening by high-quality programs successfully detects cancers at an earlier stage In 2002, the 10th anniversary of Australia's national program of mammographic screening for breast cancer, it is perhaps timely to reflect and review. The need for reassessment is highlighted by the recent furore in the breast-screening world1-4 precipitated by a Cochrane review by Olsen and Gøtzsche.1 In this issue of the Journal, the article by Barratt et al5 (page 266) also encourages us to review breast-screening policies — in this case for women 70 years and over who are no longer in the target group for free mammographic screening (50–69 years). Barratt et al5 estimated the benefit of screening women 70–79 years to be about one-third to three-quarters that achieved in women aged 50–69 years. As women age, the benefit of screening — reduced risk of death from breast cancer — is increasingly offset by the other causes of death. Furthermore, while the benefit is delayed, the hazards of screening — tests for false-positive films, discomfort and anxiety — are immediate. Thus, with increasing age, the data show a further decline in benefit, which is exaggerated when adjustment is made for qualit-of-life factors.5 Barrett et al also provide a rough estimate of the cost-effectiveness of screening older women. The wide range of cost estimates (per quality-adjusted life-year saved) underlines their imprecise nature, but suggests that mammographic screening of women aged 70–79 years is as cost-effective as screening the other outlier group — women 40–49 years. However, Barratt et al remind us that the estimation of benefits, harms and costs would be improved with data from randomised trials in the appropriate age group — which unfortunately are still lacking. In 1999, 63.7% of women in the target age group for mammographic screening in Victoria (50–69 years) were screened.6 In view of Barratt and colleagues' estimates of benefits and costs per quality-adjusted life-year saved, it could be argued that money for screening older — or younger — women could be better spent on recruiting more women in the target group to achieve the desired 70% participation. Trials of mammographic screening commenced in the 1960s and seven have been completed and reported. On the basis of these trials, which showed a reduction in mortality from breast cancer in screened women, mammographic screening recommendations have been drawn up (eg, in the United States), and in several countries political decisions were made to institute national programs (eg, in the United Kingdom, Australia and New Zealand). In 2000, Gøtzsche and Olsen, publishing a "Cochrane review" of the seven trials in the Lancet,7 reported that they found no reliable evidence that screening for breast cancer reduced mortality. However, this report did not fulfil the Cochrane Group protocol for such a review. Since then Gøtzsche and Olsen have worked with the Cochrane Breast Cancer Editorial Group, and in October 2001 part of their review was accepted and included in the Cochrane Library.1 Almost simultaneously, the Lancet published Gøtzsche and Olsen's review in full on its website, and a research letter in its printed journal2 with an editorial commentary3 criticising the Cochrane Breast Cancer Editorial Group for interference. The whole episode has drawn a flurry of criticism and countercriticism.4. After all this, what should women believe, especially as the systematic review of Barratt et al5 suggests that screening for women over 70 years may be of some benefit (and as cost-effective as it is for those under 50 years), on the basis that screening is beneficial in women aged 50–69 years? Although clinical-trial methodology has improved in four decades, population-health intervention studies remain notoriously difficult to perform because of problems associated with large cohort numbers, the randomisation process and guaranteeing reliable stratification. It is not surprising that the seven, now old, trials can be criticised. However, not all would suggest ditching them and their conclusions on these grounds. The Cochrane Breast Cancer Editorial Group has not accepted the other conclusion of Olsen and Gøtzsche — that screening leads to more aggressive treatments8 — and has not included that section of their review in the Cochrane Library. Others4 reject Olsen and Gøtzsche's conclusions because they are based on all-cause mortality, which may be inappropriate in population studies. Do we have other surrogate measures to guide us? Cancer registry data from Victoria9 suggest a "slight downward trend since 1994" in breast cancer mortality, but it cannot be assumed that any of this trend is due to screening. However, from 1982 to 1996, there was no change in breast cancer mortality in Australia.10 The impact of breast screening may be seen more readily in the stages at which breast cancer is detected. In 1997, when the national program was six years old and well established, 30% of new breast cancers were detected through screening. Data suggest that screen-detected invasive cancers were smaller, less likely to involve nodes, and, if node positive, more likely to involve fewer nodes (Box).11 Tumour size, nodal involvement and number of nodes involved — the basis of the tumour–node–metastases (TNM) staging system — are all known to be of prognostic significance. Hence, it is likely that the cohort of women with screen-detected invasive cancer will have a better prognosis and live longer, provided lead-time bias does not negate the prognostic effect of lower staging by detecting cancer earlier while not influencing the natural history of the disease. The prognostic significance of non-invasive cancer (ductal carcinoma in situ), its treatment and the appropriateness of various local and systemic treatments for any breast cancer can be debated and argued. However, the histopathological prognostic (TNM) data would suggest that mammographic screening by high-quality programs successfully detects cancers at an earlier stage, giving a better prognosis and probably improved survival. Women should be made aware of these facts, along with any doubts raised by reviewers of somewhat out-of-date trials. Impact of breast screening on stage at which cancer is detected11 Tumour size/node involvement Screen detected All cancers < 15 mm 60.3% 42.7% Node positive 22.5% 30.0% 1–3 nodes positive 18.7% 23.4% > 3 nodes positive 8.4% 14.2%

Alan Rodger

Comprehensive management of pregnancy loss is enhanced by psychological support and follow-up counselling It is generally accepted that 12%–15% of confirmed pregnancies do not progress to term, with the risk of pregnancy loss increasing with maternal age. In particular, early pregnancy loss (< 20 weeks' gestation) is experienced by one in four women. In about half these women, a medical explanation can be found,1 although, in clinical practice, investigations to identify the cause are rarely pursued. Most women go on to have successful subsequent pregnancies, although there is a slightly increased risk of a second miscarriage that increases incrementally with each subsequent loss.1 Although early-pregnancy loss is relatively straightforward medically, the psychological outcome is more problematic and the grieving process is complicated.2 First, there is no tangible life or memory to grieve. Instead, the woman has to come to terms with grieving for a potential life with all its hopes and aspirations. Second, the grieving is often complicated by feelings of self-blame, particularly when there is no medical explanation for the loss or the woman has engaged in potentially hazardous behaviour (eg, alcohol consumption or smoking). Her partner may also harbour feelings of responsibility for the loss. Other factors which may influence the grieving process and the emotional outcome include miscarrying later in gestation (especially if the woman has felt the fetus move and formed an emotional attachment to it);2,3 the importance and meaning of the pregnancy (eg, a first, wanted pregnancy lost near the end of the reproductive lifespan); and the difficulty experienced in conceiving the pregnancy (eg, an assisted conception). Finally, psychosocial factors, such as a woman's support network (especially her intimate relationship) and her personality style and culture, will affect how she appraises her loss and her level of distress. The psychological sequelae after a late pregnancy loss and stillbirth are well described;3 those after an early pregnancy loss are similar but may not be as severe. There can be high levels of psychological distress characterised by anxiety, depression and somatisation, which can persist for at least six months4 and are only partly accounted for by grieving for the loss of a potential child. There is an increased risk of developing a depressive or anxiety disorder in the six months after a pregnancy loss, and any pre-existing psychotic disorders can be precipitated. The risk of developing depression is high, with studies reporting rates between 10%5 and 48%,6 depending on the study methods.7 One of the more rigorous controlled studies5 reported that 10.9% of women developed major depression after a miscarriage, compared with 4.3% of women (controls) from the same community who had not been pregnant in the previous year. Depression is more likely in women with a history of depression or past psychopathology, and in women who have had a previous pregnancy loss or have no other children. Other factors precipitating depression, such as poor social support or having a vulnerable personality style, are well recognised. The rates of anxiety disorder are lower than those for depression. Recently, exacerbation of obsessive–compulsive disorder after miscarriage has been reported.8 Finally, if the pregnancy loss has been traumatic (eg, an ectopic pregnancy or the woman's life was at risk), post-traumatic stress disorder can arise.9 The comprehensive management of pregnancy loss will be enhanced by psychological support and follow-up counselling.7,10 This can be provided by the woman's obstetrician, general practitioner or another health professional involved in her care, who can address medical as well as psychological issues.11 The purpose is to allow open discussion about the loss, monitor progress and counsel the woman about future pregnancies. In the initial stages, she will benefit from the opportunity to talk about her loss and have her grieving acknowledged. Providing information about the normal grief process may help a woman who is masking her grief or does not believe it is legitimate. The grief process will be facilitated by the opportunity to talk about feelings of guilt and self-blame, particularly when there is no medical explanation.12,13 In our opinion, there should also be an opportunity to discuss dissatisfaction with medical care, as the woman may feel angry and blame her medical practitioner for the loss. An open discussion about this will help her, and may reduce the possibility of litigation. Medical practitioners, particularly when the issue is pregnancy loss or stillbirth, are often reluctant to use the phrase "I'm sorry" because of fears that this equates with an acknowledgement of guilt and may have legal implications. Bereaved parents are often highly aware of this omission, angered by it, and may actually retaliate through litigation. Both obstetricians and insurance companies need to seriously look at the distinction between empathic expression of "sorrow" for the distress experienced as opposed to an apology for negligent action. Regular follow-up is recommended for the first six months. Distinguishing between feelings of grief (which may require grief counselling) and the onset of a depressive illness (which may require specific treatment) can be difficult. Depression is suggested by persistence of depressed mood, lack of enjoyment in pleasurable activities, low self-esteem or excessive guilt, and sleep or appetite disturbance or fatigue.14,15 A pathological grief reaction, characterised by excessive distress, guilt feelings or a preoccupation with the loss, may require more specific counselling. Sometimes a woman may have her depressed feelings dismissed as "grieving" and miss out on appropriate and effective treatment for a depressive disorder. Other family members may also need psychological support. The woman's partner may experience similar feelings of loss.16 In such situations, the father is often neglected ("men aren't expected to talk about their feelings"). He will also benefit from an opportunity to talk about his feelings of loss, as will other children in the family, especially as they may feel responsible if they had feelings of jealousy about the new sibling. The sense of loss may dissipate when the woman becomes pregnant again, and some studies suggest that the shorter the time between a pregnancy loss and a subsequent pregnancy the better the outcome for the woman.13 Such women usually feel anxious during the stage of pregnancy at which the previous loss occurred. Finally, women may benefit from the opportunity to talk to other women who have experienced a pregnancy loss through support groups such as SANDS <http://www.sands.org.au/>.

Philip M Boyce MD, FRANZCP · John T Condon MD, FRANZCP · David A Ellwood DPhil(Oxon), FRANZCOG

Current practices should be re-examined in light of current evidence Antenatal care includes screening asymptomatic pregnant women, with the aim of detecting, and thereby preventing, both maternal and neonatal adverse events. The introduction of antenatal care in 1913 has been widely attributed to the efforts of Ballantyne at the University of Edinburgh. He suggested that the high maternal and perinatal mortality rates observed at the beginning of the 20th century reflected inadequate maternity care during pregnancy and lack of supervision of the progress of labour. Ballantyne's flow diagram, an antecedent of guidelines, defined interactions of many disciplines in antenatal care. During the 1930s, there was increased emphasis on educating healthcare professionals who provided maternity care. Women were encouraged to present during pregnancy, and were advised to give birth in hospital. The subsequent fall in perinatal mortality rates was attributed to antenatal care, without consideration of the contribution from social and other medical improvements.1 The falling mortality rates corresponded with a gradual increase in the number of antenatal visits recommended. By the 1950s, a schedule of monthly visits to 28 weeks, fortnightly visits to 36 weeks, and then weekly visits until birth had become standard.1 Although programs with fewer visits have been proposed, this schedule is widely accepted in clinical practice. This has remained largely unchallenged, as noted by Archie Cochrane, who stated "by some curious chance, antenatal care has escaped the critical assessment to which most screening procedures have been subjected".2 Traditional antenatal care was critically appraised in a retrospective review of 1907 pregnant women who gave birth at the Aberdeen Maternity Hospital in 1975.1 Antenatal and birth records were reviewed to determine the rates at which complications were diagnosed, misdiagnosed and overdiagnosed, in addition to the rate at which complications occurred despite routine antenatal care. Breech presentation and pre-eclampsia were the only complications reliably detected in the antenatal period, and the benefit in the detection of pre-eclampsia was confined to primigravid women beyond 34 weeks' gestation. Most antenatal admissions, apart from admissions for labour and birth, were for conditions that had arisen despite routine antenatal care — conditions that had not been prevented or detected by it. More recently, randomised controlled trials have assessed the optimal frequency of antenatal visits in preventing maternal and fetal complications. The main hypothesis tested in these trials is that models of care with fewer antenatal visits are as effective as the traditional model in terms of clinical outcomes and maternal satisfaction.3 A systematic review of seven randomised controlled trials involving 57 418 women found no differences in the detection of pre-eclampsia (odds ratio [OR], 0.91; 95% CI, 0.66–1.26), urinary tract infection (OR, 0.93; 95% CI, 0.79–1.10), low birthweight (OR, 1.04; 95% CI, 0.93–1.17) or maternal mortality (OR, 0.91; 95% CI, 0.55–1.51) when a schedule of reduced antenatal visits was compared with more traditional regimens of antenatal visits.4 However, women were more dissatisfied with fewer visits. Whether increased maternal satisfaction is of measurable benefit in terms of pregnancy and birth outcomes remains less certain. Clinical practice guidelines should define best practice, limit variations in the provision of care, recommend care that is cost-effective, and provide care in a way that meets the needs of all patients. In this issue of the Journal (page 255), Hunt and Lumley have reviewed guidelines used in Australian maternity units.5 They found that recommendations for the content of antenatal visits and screening procedures vary considerably across Australia. The value of certain tests or interventions can be readily appreciated in terms of a low cost treatment capable of disease modification (eg, provision of anti-D to rhesus-negative women); however, evidence of benefit is lacking in other circumstances (eg, routine screening for carbohydrate intolerance), although current clinical trials will address some of these issues. Routine antenatal screening for syphilis, although low cost and with effective therapy available for patients testing positive, could be questioned given the low prevalence of the disease among pregnant white Australians. However, selective testing and treatment has not been supported.6 Hunt and Lumley also demonstrate the other end of the clinical spectrum, where good-quality evidence exists to support a treatment or policy but institutions have no relevant guidelines. Good-quality evidence exists to support the cessation of smoking during pregnancy,7 and yet remarkably few institutions had a guideline providing practical information for caregivers to support women in smoking cessation. This also highlights the difficulty of implementing changes in policy, despite evidence of an important clinical effect, and reflects the wider challenges of translating research findings into clinical practice. The article by Hunt and Lumley describes the broad range of accepted antenatal care in Australia. Where to from here? The purpose of antenatal care needs to be redefined. The aims may differ for consumers and caregivers, and both should be incorporated into the "ideal" model of care. In addition, current practices (including timing and frequency of visits, and "routine" screening investigations) should be questioned in light of predetermined outcome measures and best available evidence. The principles of antenatal care were adopted over half a century ago; their maintenance can only be supported when rigorously tested against the best currently available evidence, which can then be incorporated into national guidelines for best practice.

Jodie M Dodd · Caroline A Crowther · Jeffrey S Robinson

Objective: To describe the variability and evidence base of recommendations in Australian protocols and national policies about six aspects of routine antenatal care.Design: Comparison of recommendations from local protocols, national guidelines and research about number of visits, screening for gestational diabetes (GDM), syphilis, hepatitis C (HCV), and HIV, and advice on smoking cessation.Setting: Australian public hospitals with more than 200 births/year, some smaller hospitals in each State and Territory, and all Divisions of General Practice were contacted in 1999 and 2000. We reviewed 107 protocols, which included 80% of those requested from hospitals and 92% of those requested from Divisions.Main outcome measures: Frequency and consistency of recommendations.Results: Recommendations about syphilis testing were notable in demonstrating consistency between local protocols, national policies and research evidence. Most protocols recommended screening for GDM, despite lack of good evidence of its effectiveness in improving outcomes. Specific approaches to screening for GDM varied widely. Coverage and specific recommendations about testing for HIV and HCV were also highly variable. Smoking-cessation information and advice was rarely included, despite good evidence of the effectiveness of interventions in improving outcomes. No national policies about the number of routine visits and smoking cessation could be identified. There were inconsistent national policies for both HIV and GDM screening.Conclusions: Antenatal care recommended in protocols used in Australia varies, and is not always consistent with national policies or research evidence. Producing and disseminating systematic reviews of research evidence and national guidelines might reduce this variability and improve the quality of Australian antenatal care.

Jennifer M Hunt MPH, FAFPHM · Judith Lumley PhD, FFPHM(UK)

Some infections are more serious in pregnant than non-pregnant women because of the potential for vertical transmission to the fetus or infant (eg, varicella, rubella, cytomegalovirus infection, toxoplasmosis and listeriosis). Pre-pregnancy or routine antenatal screening for presence of, or susceptibility to, some of these infections and appropriate management can prevent adverse fetal or perinatal outcomes; screening should include rubella IgG, hepatitis B surface antigen, serological tests for syphilis and HIV antibody. If certain other vertically transmissible infections are suspected because of a positive antenatal test result, confirmatory tests for maternal and, if indicated, fetal infection are essential before intervention is considered (eg, cytomegalovirus infection). For some vertically transmissible infections that are not readily preventable, appropriate management of maternal infection can reduce fetal damage (eg, toxoplasmosis).

Series Editors:

Should Australia follow the US decision to base prophylaxis on results of maternal screening? Ever since group B streptococcus (GBS) emerged as the commonest cause of perinatal sepsis in the late 1970s, there has been controversy about prevention strategies. A few hospitals in Australia were among the first in the world to introduce routine antenatal screening for GBS carriage and intrapartum antibiotic prophylaxis for carriers.1 This approach was later vindicated by randomised controlled trials in selected carriers2 and the demonstration of lower rates of sepsis after intrapartum prophylaxis compared with historical rates.3 However, problems remain. Group B streptococcus is a normal vaginal commensal in healthy women, but colonisation is often intermittent, and rates of colonisation can vary from 18% to 27%, depending on the detection method.4 Moreover, vaginal carriage is a very crude predictor of perinatal sepsis, with fewer than 1% of the infants of carriers affected (1–2/1000 overall) without intervention.1,5 In 1996, the Centers for Disease Control and Prevention (CDC) in the United States published consensus guidelines for selecting women for intrapartum antibiotic prophylaxis using either of two alternative strategies. One strategy was based on maternal GBS carriage, and the other on clinical risk factors — preterm labour (< 37 weeks' gestation), prolonged rupture of membranes (> 18 hours) or intrapartum fever (> 38oC).6 The rationale for the latter strategy was that, before widespread use of intrapartum antibiotics, one or more of these risk factors was found in up to 80% of mothers of infants with GBS sepsis.1,7 Gradual implementation of these consensus guidelines in the US was associated with a fall in the incidence of perinatal GBS sepsis from 1.7/1000 in 1992 to 0.5/1000 in 1999.8 In Australia, there was also a decrease in the incidence of perinatal GBS sepsis, from 1.2/1000 in 1991–1993, when three of nine neonatal units surveyed had prevention strategies in place, to 0.5/1000 in 1995–1997, when all 11 units surveyed had prevention strategies.5 A recent review concluded that there is evidence, albeit from relatively poor-quality trials, that intrapartum prophylaxis reduces the incidence of neonatal sepsis, but not deaths.9 Despite this evidence, concern continues about excessive use of intrapartum antibiotics. There have been several reports that their increasing use is associated with an increased proportion of cases of neonatal sepsis caused by penicillin-resistant bacteria.10,11 Although it is sometimes difficult to prove, there is considerable empirical evidence that increased antibiotic use generally leads to increasing bacterial resistance. It is plausible that exposure to antibiotics in utero might delay colonisation of the infant gut with penicillin-sensitive anaerobes and allow penicillin-resistant facultative bacteria — many of which are potential pathogens — to become established. Recently, the CDC published revised guidelines, recommending a single strategy for prevention based on universal prenatal screening for vaginal or rectal GBS colonisation.12 The recommendation was based on a retrospective cohort study, which showed that perinatal GBS sepsis was significantly less frequent in infants of women given intrapartum antibiotics on the basis of documented GBS screening results (0.33/1000 births) than in infants of women managed on the basis of risk factors (0.59/1000 births; relative risk, 0.48; 95% CI, 0.37–0.63).13 This result is not surprising. A risk factor-based protocol cannot, by definition, prevent sepsis in infants whose mothers have no risk factors. On the other hand, the proportion of cases prevented by a protocol based on GBS colonisation depends on the sensitivity of the screening method, effectiveness of prophylaxis and compliance with the protocol.4,14 What was surprising in the CDC study was that the anticipated overall rate of intrapartum antibiotic use was similar for both prevention strategies (31% and 29%).13 In contrast, we showed that in Australia a strategy based on risk factors would lead to significantly less use of intrapartum antibiotics (18%–20% of women) than a strategy based on antenatal screening at 35–37 weeks' gestation (35%).4 This difference is apparently due to a higher incidence of risk factors in the US compared with Australia, and failure to account for women given intrapartum antibiotics during preterm labour before results of screening are available. They suggest that obstetricians in Australia should not immediately discard the option of a risk-based strategy. Neither strategy is ideal, but either, if properly implemented, can reduce the incidence of perinatal GBS sepsis. The GBS screening strategy results in at least a third of healthy young women (and their infants) being given intravenous antibiotics during labour, at significant cost and with some risks, but can achieve a lower rate of perinatal GBS sepsis.13 In Australia, with a risk-based strategy, significantly fewer women and infants would receive intravenous antibiotics. Whichever strategy is chosen, the most important determinant of its effectiveness will be compliance.

Gwendolyn L Gilbert MD, FRACP, FRCPA

Objective: To review the clinical management of young women with intellectual disabilities with menstrual and contraceptive concerns.Design: Prospective cohort study of all girls and young women with a significant intellectual disability and moderate to high support needs who presented at my gynaecology clinic for management of menstrual and contraception-related issues in the period 1990–1999.Setting: Gynaecology clinic at the Centre for Adolescent Health, Royal Children's Hospital, Melbourne, and my private consulting rooms.Outcome measures: The clinical management options considered most appropriate for these women, including advice, reassurance, medication (oral contraceptive pill, non-steroidal anti-inflammatory drugs, depo-medroxyprogesterone acetate, hormone replacement therapy) and surgical options.Results: For 2 of 107 young women, surgical approaches were required to manage their menstrual problems or contraception-related issues. For the remainder of the women, information, advice or medical management were sufficient.Conclusions: Management of the menstrual and contraceptive needs of young women with an intellectual disability is similar in most cases to the management of non-disabled women. Surgical management is required infrequently.

Sonia R Grover MD BS, FRANZCOG

To the Editor: The 50 g glucose challenge test (GCT) is widely recommended as a screening test for gestational diabetes (GD).1 The test consists of a 50 g oral glucose load given at any time of the day, followed one hour later by the measurement of the plasma glucose concentration.2 This test is recognised as imperfect for screening, as sensitivity and specificity are not 100%.2,3 It is known that glucose tolerance deteriorates in the afternoon,4 which raises the question of whether time of day influences the response to the 50 g GCT. At Royal North Shore Hospital, screening for GD is performed at the 26–28-week visit by means of the 50 g GCT. In 2000, screening for GD was introduced into a morning midwives antenatal clinic, whereas previously it had only been performed in the afternoon. The population attending the clinic at the 26–28-week visit includes many women receiving shared care, and is regarded as being at low obstetric risk. The Table shows the results of screening at the morning clinic compared with screening in the afternoon over the same time period. The two groups were identical in terms of age, weight, ethnicity, and family history of diabetes or past history of GD. The percentage of women with a positive screening test result during the morning clinic (17.0%) was significantly lower than that during the afternoon clinic (31.1%). Positive screening results were followed up with a diagnostic 75 g glucose tolerance test, and GD was diagnosed according to the Australian Diabetes in Pregnancy Society criteria.5 Women with a positive screening test result confirmed with a 75 g glucose tolerance test in the afternoon were less likely to have GD than those with a positive test in the morning (31.5% v 40.0%). Despite the fact that a smaller percentage of women who screened positive in the afternoon had GD, a greater percentage of the total number screened in the afternoon had GD than in the morning group. In this cohort, the difference (9.8% v 6.8%) was not significant (Table; P = 0.15). These results are consistent with the hypothesis that a 50 g GCT test performed in the afternoon results in a greater number of positive results, a greater number of women undergoing diagnostic testing and a greater number of women identified with GD. The morning GCT appears to increase specificity, with an associated decrease in sensitivity. These results need to be taken into consideration when designing or implementing a screening program. Screening for gestational diabetes (GD): the effect of screening time Time Morning (0930–1200) Afternoon (1205–1710) Number screened 176 470 Age in years (mean ± SD) 31.2 ± 4.7 31.7 ± 5.0 Weight (mean ± SD) 59.4 kg ± 10.5 kg 60.8 kg ± 12.9 kg Family history of diabetes 27 24 Past history of gestational diabetes 1 3 % White/Asian/Middle Eastern 62.6/28.0/9.0 67.5/25.9/5.8 Positive result, 50 g glucose challenge test 30 (17.0%) 146* (31.1%) Abnormal result, 75 g glucose tolerance test 12 (6.8%)† 46‡ (9.8%)† *P < 0.001, χ2. † % Of number screened. ‡ P = 0.15, χ2.

Aidan McElduff · Rosemary Hitchman

To the Editor: We have recently noticed changes in the incidence of invasive cervical carcinoma in the Gippsland Health Region and would like to know whether other regions have noticed similar demographic changes. During 24 months in 1999–2000, 19 women (median age, 59 years; range, 33–88 years) with squamous carcinoma were registered in our pathology practice. Based on information from the Victorian Cervical Cytology Register, almost half (10 women) had no previous cervical smear history whatsoever, while three had had smears, but at irregular intervals up to 14 years apart. The remaining six women had had regular Pap smears, with 1–3 negative smears preceding the diagnosis of cancer. Sixteen of the women had consulted their general practitioner for some other ailment before the cervical cancer was discovered (median interval, 14 months), but no cervical smear had been obtained. Of particular interest is the fact that six of the 19 patients are in their seventh decade or older, with a median age of 80 years (range, 79–88 years). The Victorian Department of Human Services reports that the cervical-smear participation rate for eligible women in the Gippsland region is 68%, a rate not much different from the other regions.1 The two-yearly participation rate for the 60–69-years age group is 56%, and, although no official figure is available for women in their seventh or eighth decades, it is likely to be considerably lower. The Cancer Epidemiology Centre has recorded that, over a 16-year period, the incidence of cervical carcinoma in Victorian women aged over 70 years fell by 50%, and simultaneously there has been a shift in the peak incidence from the 70–74-years age group to one a decade older (Vicky Thursfield, Information Manager, personal communication). Accordingly, we suspect that women over 70 years of age still have a significant incidence of invasive cervical carcinoma, but are not being offered cervical smears, even when the National Health and Medical Research Council guidelines indicate the necessity.

Nicholas J Mulvany · Norman R Sonenberg