Experience of a systematic approach to care and prevention of fragility fractures in New Zealand.

This narrative review describes efforts to improve the care and prevention of fragility fractures in New Zealand from 2012 to 2022. This includes development of clinical standards and registries to benchmark provision of care, and public awareness campaigns to promote a life-course approach to bone health. PURPOSE: This review describes the development and implementation of a systematic approach to care and prevention for New Zealanders with fragility fractures, and those at high risk of first fracture. Progression of existing initiatives and introduction of new initiatives are proposed for the period 2022 to 2030. METHODS: In 2012, Osteoporosis New Zealand developed and published a strategy with objectives relating to people who sustain hip and other fragility fractures, those at high risk of first fragility fracture or falls and all older people. The strategy also advocated formation of a national fragility fracture alliance to expedite change. RESULTS: In 2017, a previously informal national alliance was formalised under the Live Stronger for Longer programme, which includes stakeholder organisations from relevant sectors, including government, healthcare professionals, charities and the health system. Outputs of this alliance include development of Australian and New Zealand clinical guidelines, clinical standards and quality indicators and a bi-national registry that underpins efforts to improve hip fracture care. All 22 hospitals in New Zealand that operate on hip fracture patients currently submit data to the registry. An analogous approach is ongoing to improve secondary fracture prevention for people who sustain fragility fractures at other sites through nationwide access to Fracture Liaison Services. CONCLUSION: Widespread participation in national registries is enabling benchmarking against clinical standards as a means to improve the care of hip and other fragility fractures in New Zealand. An ongoing quality improvement programme is focused on eliminating unwarranted variation in delivery of secondary fracture prevention.

Biological and Socio-Cultural Factors Have the Potential to Influence the Health and Performance of Elite Female Athletes: A Cross Sectional Survey of 219 Elite Female Athletes in Aotearoa New Zealand.

Health is a pre-requisite for optimal performance yet the parameters which govern health and performance of elite female athletes are little understood. The aim of this study was to quantify the health status of elite female athletes, and understand sociocultural factors influencing that status. The survey addressed demographic, health and athletic performance history, training load, contraceptive use, sport-specific appearance and performance pressures, and communication barriers. Three hundred and fifty-seven elite New Zealand female athletes were recruited to complete an on-line survey. Two hundred and nineteen athletes completed the survey. Oligomenorrhea/amenorrhea had been diagnosed in only 12% of athletes compared with 50% of athletes not on hormonal contraception who reported symptoms consistent with this diagnosis. Stress fractures and iron deficiency were common and associated with oligomenorrhoea/amenorrhea (P = 0.002), disordered eating (P = 0.009) or menorrhagia (P = 0.026). Athletes involved in individual sports (P = 0.047) and with higher training volumes (P < 0.001) were more likely to report a medical illness. Seventy-three percent of athletes felt pressured by their sport to alter their physical appearance to conform to gender ideals with 15% engaging in disordered eating practices. Barriers to communicating female health issues included male coaches and support staff, and lack of quality information pertaining to health. Elite female athletes may fail to reach peak performance due to specific health issues and undiagnosed pathology. Sociocultural factors influence the effectiveness of support of female's health and performance. Organizational and cultural change is required if elite female athletes are to combine optimal health with best performance.

An observational study of pregnancy and post-partum outcomes in women with prolactinoma treated with dopamine agonists.

BACKGROUND: In women with prolactinoma medical treatment with dopamine agonists (DA) can restore fertility. A number of studies have established the safety of DA during pregnancy and the impact of pregnancy and lactation on remission of prolactinoma. However, the total number of reported cases remains modest and further evidence is needed. AIMS: To evaluate the safety of DA during pregnancy and remission of prolactinoma after pregnancy and lactation. MATERIALS AND METHODS: Retrospective cohort study (2002-2014) of 57 pregnancies in 47 women with prolactinoma who received DA. Neonatal and pregnancy complications were recorded. Prolactin levels and treatment data were collected at the time of diagnosis, pre-conception, during pregnancy and lactation, and post-partum (up to 114 months). RESULTS: DA treatment was stopped a median of 4.5 weeks after conception in 49 pregnancies (86%). There were 49 live births (86% of pregnancies) and six miscarriages. Six pregnancies had an adverse neonatal outcome including two with congenital malformations. Following 26% of pregnancies women achieved remission after birth or lactation, and 25% of women were in remission at last follow-up. Remission was associated with older maternal age (P = 0.036), a lower prolactin level at diagnosis (P = 0.037), and a smaller adenoma at diagnosis (P = 0.045). CONCLUSIONS: Successful pregnancy and lactation is common after DA treatment for prolactinoma. Fetal exposure in the first four weeks of pregnancy appears to be generally safe. Encouragingly, post-partum and after lactation a quarter of women had a normal prolactin level without medical treatment.

Discordant Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome in identical twins - a case report and implications for reproduction in MRKH women.

Infertility has previously been considered as an inevitable consequence of Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome. With modern assisted reproductive technology (ART) techniques becoming increasingly accessible, MRKH women have the opportunity for their own genetic offspring. The availability of such technology, however, increases the importance of understanding the aetiology of this complex condition. The literature debating the relevance of genetic versus post-zygotic events in the aetiology of MRKH syndrome is reviewed in the context of this report of monozygotic twins discordant for MRKH syndrome.

Polycystic ovary syndrome and depression in New Zealand adolescents.

OBJECTIVE: To determine whether adolescents with polycystic ovary syndrome (PCOS) are more depressed than adolescent girls in the community and to examine factors associated with depression. DESIGN: An observational study comparing clinical and community samples. SETTING: Two specialist reproductive endocrine clinics in Auckland, New Zealand. PARTICIPANTS: 102 girls aged 14-19 presenting for clinical assessment, fulfilling the Rotterdam consensus for PCOS. The comparison group was 1349 girls from a school-based survey of New Zealand youth. INTERVENTIONS: Clinically significant depression was identified by the long and short form Reynolds Adolescent Depression Scale. BMI, androgen levels, oral contraceptive use, objective symptom severity, age, ethnicity, and socioeconomic grouping were recorded. MAIN OUTCOME MEASURES: Clinically significant depression in the PCOS and community samples. Potential determinants of depression. RESULTS: Clinically significant depression in adolescent girls with PCOS was not increased compared with the community sample (OR 1.3; 95%CI 0.7-2.7, P = .42). Within the PCOS cohort, depression was correlated with increased BMI (P = .01) and possibly acne (P = .08). CONCLUSIONS: Lean adolescent girls with PCOS did not have more clinically significant depression than girls in the community. Within the PCOS cohort, however, there was a clear association between higher depression scores and elevated BMI. There is a potentially important interaction between obesity and depression in PCOS.

Does insufficient access to dual-energy X-ray absorptiometry (DXA) stifle the provision of quality osteoporosis care in New Zealand?

UNLABELLED: Access to dual-energy X-ray absorptiometry (DXA) scanning varies significantly throughout New Zealand with the majority of scans funded privately or through the health industry. Barriers to access need to be addressed if osteoporosis guidelines are to be implemented across the country equitably, to reduce the incidence and cost of fragility fractures in New Zealand. PURPOSE: This study aims (1) to estimate the number of dual-energy X-ray absorptiometry scans performed in New Zealand, (2) to determine funding sources of DXA scans and (3) to determine the level of regional variation in access. METHODS: DXA scan providers in New Zealand were accessed through a nationwide database and asked to provide data on DXA scans performed in 2007. The numbers of DXA scans performed in each District Health Board (DHB) region were calculated by using a funding source and compared with DHB population estimates provided by Statistics New Zealand for 2007. RESULTS: In New Zealand in 2007, 33,104 DXA scans were performed, with a population rate of 78.1 DXA scans per annum per 10,000 general population, significantly less than international guidelines. There were important regional differences in access to DXA scanning. Funding for scans was predominately by private and pharmaceutical industry funders. DHBs funded only 31 % of DXA scans during this time period. CONCLUSIONS: Access to DXA scan technology varies significantly throughout New Zealand, with the majority of DXA scans funded by the private sector or health industry. Barriers to access need to be addressed if osteoporosis guidelines are to be implemented across the country in an equitable fashion and so reduce the incidence and cost of fragility fractures to New Zealand.

Treatment of infertility with hypogonadotropic hypogonadism: 10-year experience in Auckland, New Zealand.

Infertility in idiopathic or acquired hypogonadotropic hypogonadism (HH) was managed with exogenous gonadotropins and artificial reproduction as needed, in Auckland, New Zealand, from 2000 to 2010. Of eight men seeking conception, 2/2 with acquired HH but only 2/6 with congenital HH achieved clinical pregnancy with exogenous gonadotropins, whereas 12/14 women (86%) achieved one or more live births. Current gonadotropin treatment does not seem to be optimal for men with congenital HH.

Delayed puberty from partial 17-alpha hydroxylase enzyme deficiency.

An 18-year-old woman with primary amenorrhoea and pubertal delay was investigated for mild labile hypertension and secondary hypogonadism. Low renin and normal aldosterone levels combined with evidence of primary adrenal insufficiency suggested partial 17-alpha hydroxylase enzyme deficiency. The diagnosis was confirmed by measurement of 24-hour urine steroid metabolites and whole gene sequencing of CYP17A1 that demonstrated c.160_162delTTC (p.Phe54del) homozygous mutation. Ultrasound showed bilateral small ovaries with multiple cysts. The serum anti-mullerian hormone concentration was unremarkable at 6.6 (normal <12.6 ng/ml) but the outlook for her future ovulatory potential is uncertain. Dexamethasone 0.25 mg pre-bed and hydrocortisone 5 mg on waking normalised her hormonal profile and her blood pressure without side-effects.

Anejaculation as the presenting feature of pituitary microadenoma.

OBJECTIVE: To describe the resolution of anejaculation associated with PRL excess by dopamine agonist treatment. DESIGN: Case report. SETTING: Fertility clinic. PATIENT(S): Two men with anejaculation, in one case with associated infertility. INTERVENTION(S): Dopamine agonist treatment. MAIN OUTCOME MEASURE(S): Resolution of anejaculation and infertility. RESULT(S): Endocrine investigations in both men revealed low serum T, elevated PRL, and a pituitary microadenoma. Treatment with a dopamine agonist normalized serum hormone profiles and restored sexual function, with subsequent involution of the adenoma. CONCLUSION(S): Prolactinoma manifesting as anejaculation is rare but responds readily to treatment with a dopamine agonist. Serum PRL should be measured in any man presenting with anejaculation.

Temporal changes in insulin-like growth factors I and II and in insulin-like growth factor binding proteins 1, 2, and 3 in human milk.

AIM: To evaluate the postpartum time course of changes in insulin-like growth factors (IGFs) and their binding proteins (IGFBPs). METHODS: Breast milk IGF-I and IGF-II and IGFBP-1, IGFBP-2, and IGFBP-3 levels were determined in 23 women with babies born at term, from day 4 until up to 9 months after birth. RESULTS: The IGFBP-3 levels were highest from day 4 to day 6 and then decreased by days 10-12. In contrast, IGF-I and IGF-II and IGFBP-1 and IGFBP-2 showed little change over the first 2 weeks after birth. Subsequently, all the IGF components showed a moderate decline over approximately the first 1-3 months and then stable levels up to 9 months after birth. CONCLUSION: Although the possibility cannot be excluded that these changes in levels of IGFs and their binding proteins in human milk represent passive loss from the mammary gland, we speculate that higher early levels of the human milk IGF system contribute to maturation of the infant gut.

LH levels in women with polycystic ovarian syndrome: have modern assays made them irrelevant?

OBJECTIVE: To determine whether using newer monoclonal rather than polyclonal assays for measuring luteinising hormone (LH) alters the predictive value of LH and LH/follicle-stimulating hormone (FSH) ratios for polycystic ovarian syndrome. DESIGN: Prospective cohort study. SETTING: Fertility and Reproductive Endocrinology Clinic within a New Zealand Teaching hospital. POPULATION: Seventy-eight women presenting with oligomenorrhoea or hirsutism and polycystic ovaries on pelvic ultrasound and 59 volunteer controls with ultrasonically normal ovaries and a regular menstrual cycle. METHODS: Serum LH concentrations were measured using a polyclonal radio-immunoassay (Amerlex-M, Johnson & Johnson) and two monoclonal immunometric assays (Immulite, DPC; Cobas Core, Hoffman La Roche). The proportion of women with an elevated serum LH concentration in each group was calculated using both current local laboratory reference intervals and a new reference range derived from our control group. The LH/FSH ratios for women in both groups were also calculated using the three different LH assays. MAIN OUTCOME MEASURES: LH concentrations and LH:FSH ratios measured using polyclonal and monoclonal immunoassays. RESULTS: Using the local laboratory normal range, a significantly higher proportion of women had an elevated LH when measured with a polyclonal assay (23.1%) than when measured with a monoclonal assay (12.8% Core, 6.4% Immulite) (P < 0.05). LH/FSH ratios were significantly lower when monoclonal assay was used and receiver-operator characteristic curves suggest that LH/FSH ratios of 1 or lower provide the most reliable separation of women with polycystic ovarian syndrome from controls when these assays are used. CONCLUSIONS: Clinicians should be aware that the use of monoclonal LH assays will result in significantly lower measured LH levels and LH/FSH ratios in women with polycystic ovarian syndrome than previously used polyclonal assays. Account should be taken of the assay type used, when using endocrinological parameters in the diagnosis of polycystic ovarian syndrome, or the identification of women who have LH hypersecretion.

Factors associated with pregnancy or miscarriage after clomiphene therapy in WHO group II anovulatory women.

OBJECTIVES: The present study was designed to determine whether clinical and endocrine characteristics assessed on initial screening of normogonadotropic oligo/amenorrhoeic infertile patients could predict ovulation and then conception and successful live birth or miscarriage. STUDY DESIGN: Retrospective cohort study SETTING: Outpatient clinic. POPULATION: Eighty-two consecutive women receiving clomiphene citrate (CC) therapy from 1993 to 1998. RESULTS: A cumulative conception rate of 67% was reached after six or more CC-induced cycles. Patients with failure of ovulation after a full course of CC had more severe oligomenorrhoea (p < 0.001) and greater BMI (p < 0.05) at initial screening. There was no relationship with levels of LH or androgens. In contrast, among women who ovulated in response to CC, conception was associated with less frequent periods, and higher basal levels of LH, free testosterone and androstenedione. Conceptions with subsequent miscarriage were associated with intermediate levels of LH and numbers of spontaneous periods between non-conception and live births. CONCLUSIONS: These observations are consistent with the hypothesis that failure of ovulation after CC is related to different factors (overweight and severe oligomenorrhoea) from those that predispose to non-conception (low basal LH and androgen levels and mild oligomenorrhoea).