DECEMBER 2012 VOLUME 2012:4

Changes

Now that it is COOL again to talk about HRT, 10 years on from WHI, this Congress will update you and provide inspiring speakers to talk about diagnosing menopause and all the latest in both hormonal and non hormonal treatments for vasomotor symptoms.

Psychological health and bones will also be a focus. Combine the excellent medicine with an extended break in Adelaide ...

Menopause...Cool AgainMenopause...Cool Again

IN THIS ISSUE

Adelaide Congress Program News

The celebration and the learning that was Melbourne

Sex steroid hormones throughout the female lifespan

Bone density scans – quality control in your practice

Prevention of falls and fractures as you age past the menopause

The AMS Congress is the annual Women’s Midlife Meeting you cannot miss!

2 December 2012 Volume 2012:4 www.menopause.org.au

ChangesINVITATION TO ADELAIDE and the 17th Congress of the AMS

Come to Adelaide from Friday 6 to Sunday 8 September 2013 for a special not-to-be-missed AMS Congress at the Hilton Hotel.

Menopause … Cool Again is the Congress theme. Professor Myra Hunter is to be our key invited speaker. Her first plenary presentation on ’Vasomotor symptoms: Hot and Bothered’ will be right on the theme.. She will also be giving another presentation on ‘Cognitive behavioural therapies for menopausal symptoms’.

Come to Adelaide from Friday 6 to Sunday 8 September 2013 for a special not-to-be-missed AMS Congress at the Hilton Hotel.

Menopause...Cool AgainMenopause...Cool Again

Editor’s Report

Melbourne Congress Report

CelebrationsTurning 25!

Sex steroid hormones throughout the female lifespan

Bone density scans – quality control in your practice

Prevention of falls and fractures

President’s Report

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CONTENTS

Myra Hunter is Professor of Clinical Health Psychology at the Institute of Psychiatry, King’s College London and Consultant Clinical Psychologist with the South London & Maudsley NHS Trust in London. She has combined clinical and academic roles in clinical health psychology for over 30 years and conducted clinically relevant research, primarily on understanding and developing interventions for people with physical and emotional problems related to women’s health (PMS and menopause), cardiology and oncology.

Her menopause research includes developing measures (the Women’s Health Questionnaire, Menopause Representations Questionnaire, Hot Flush Rating Scale, Hot Flush Beliefs Scale, and Hot Flush Behaviour Scale), developing a cognitive behavioural model of hot flushes and developing and refining cognitive behavioural interventions for menopausal symptoms. She has recently published two randomised controlled trials to evaluate psychological interventions for menopausal symptoms experienced by women who have had breast cancer (MENOS1) and for well women in the community (MENOS2).

Several other scientific sessions in the Congress program will cover wide-ranging topical issues including: • Diagnosing Menopause

• Psychological Health

• Bones of Contention

• Endometrial protection throughout reproductive life

and

• WHI-where are we now? A decade post WHI: what have we learned?

The Call for Abstracts for free communications will be published in March and we hope many of you will submit abstracts for this important, contemporaneous part of the congress.

The program will also include the ever-popular pre-Congress Update. For Adelaide the theme for this workshop will focus on “Menopause Essentials”.

So please lock the dates in your diary and as the weeks go by, take time to check the AMS website for updates on program developments. This Congress promises to be a fantastic meeting with a great mix of stimulating science, great collegiality and great fun!

Dr Amanda VincentChair 2013-2014 Scientific Program Committee

Myra Hunter

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www.menopause.org.auwww.menopause.org.auwww.menopause.org.au December 2012 Volume 2012:4December 2012 Volume 2012:4December 2012 Volume 2012:4 333

Dear AMS members,

We’ve come to the end of another year, and what a year it has been! Ten years has passed since the

initial publication of the Women’s Health Initiative study results, and hot on the tails of this milestone was the release of the preliminary results of KEEPS (Kronos Early Estrogen Prevention Study) and also DOPS

(Danish Osteoporosis Prevention Study).

The latter two studies investigated HRT use in women aged between 42 and 58 years and hence have provided some much needed data on the benefits and risks of HRT in peri- and recently postmenopausal women, rather than for mostly asymptomatic women up to many years postmenopause. Whilst the KEEPS and DOPS studies have their design flaws, especially the lack of a placebo group in the latter study, they do give some important and much-needed information for different HRT formulations, including oral and transdermal oestradiol and also micronised progesterone.

I briefly reviewed these new studies in the 2012 Clinical Trial Update at our recent congress and Members who may wish to read more about the findings from these studies can refer to this update on our website at: www.menopause.org.au/health-professionals/ams-congress-2012/clinical-trial-update-2012

Our Congress was a really wonderful way to come together and be updated as to the recent evidence in managing women’s health at mid-life and beyond. Our speakers spoke on a diverse range of topics and we’re already busy planning for the AMS congress in Adelaide in September 2013. Congratulations to all of the presenters in our free communications sessions, and we highlight congress prize winners in this edition of Changes.

I wish all of our members a happy, healthy and safe festive and holiday season, and look forward to bringing you more Changes in 2013!

Yours sincerely,Sonia Davison

DISCLAIMERThis newsletter is published by the Australasian Menopause Society as a service to its members. All expressions of opinion are published on the basis that they are not to be regarded as expressing the official opinion of either the Australasian Menopause Society or the editor unless expressly stated. The Australasian Menopause Society and the editor accept no responsibility for the accuracy of any of the opinions or information contained in this newsletter or the consequences of any person relying upon such information. Unless specifically stated products and services advertised or otherwise appearing in this newsletter are not endorsed by the Australasian Menopause Society. Readers should rely upon their own enquiries and take appropriate professional advice in making decisions touching upon their own interests.

Editor’s Report

2013 Membership is now due at the same rate as last year and Member benefits will include a subscription to the 2013 Membership is now due at the same rate as last year and Member benefits will include a subscription to the new look AMS quarterly magazine, ‘Changes’, plus new look AMS quarterly magazine, ‘Changes’, plus

IT’S TIME TO RENEW YOUR AMS MEMBERSHIP for 2013

■ Regular news bulletins including links to useful resources■ Access to our secure Members’ Area on the AMS website – for you

to download more in-depth resources and information including media releases and abstracts together with immediate details on newly published research and topical issues

■ A streamlined new ‘Find a Doctor’ service listing member-only practices

■ Members will also be able to register at reduced rates for the annual AMS Congress from 6 to 8 September this year in Adelaide. An ALM program, free to members, will also be coordinated.

For more details and payment options, check your 2013 Membership Notice and Invoice which have been posted to you.

. . RENEW ONLINEThe easiest way for you to renew and pay your AMS Membership is to use the new secure credit card/debit card facility on the AMS website at: http://www.menopause.org.au/membersEFT payment facilities via the secure Online Form are also available. The online renewal form includes sections for you to confirm your current Find a Doctor listing including practice contact details. Shortly, with the new AMS website, you will also be able to update your details yourself at any time. Receipts for all membership payments are sent by e-mail. AMS looks forward to hearing from you and having your support in 2013

4 December 2012 Volume 2012:4 www.menopause.org.au

ChangesMelbourne Congress Report

Around 280 registrants attended the Congress and the pre-Congress Update over the three days and delegate feedback strongly echoed one participant’s summary, “Excellent meeting,

wide-ranging and clinically very relevant”. The Scientific Committee led by Dr Anna Fenton, is warmly thanked for organising such a stimulating program set around themes which included Sexual Health, Cognition/Parkinson’s Disease, Effective Health Screening, Sleep Disorders and also Musculoskeletal Health.

The focus of the Menopause Update Workshop on the Friday morning was Premature Menopause/ Premature Ovarian Insufficiency. More than 150 delegates attended. Their feedback underscored the value of maintaining this now well-established pre-Congress program with its up-to-date guides to managing menopausal issues.

AMS launched a structured online 2012 Active Learning Module (for RACGP Category 1 points) and nineteen members and one non-member signed on to the program. This started with a pre-disposing activity before the Congress and integral to the ALM, there was a requirement for ALM participants to attend and be involved with the Pre-Congress Update Workshop. Next steps followed with additional case studies, articles and finally a reinforcing activity.

In association with the main Congress, delegates were able to attend Meet the Expert and other breakfast sessions, and a lunchtime gathering for Allied Health Professionals was also well attended. These informal

sessions worked really productively with delegates able to directly ask questions of plenary speakers as well as meet others and link into their own networks.

Abstracts from the Congress program are being made available via the Members Section on the AMS website. Our invited speakers also kindly agreed to publication of their slides.

Thank you to all who contributed ideas and feedback through their interest and involvement with the local planning committee. There were also several important supporters especially our major sponsors, the Bayer Group and Pfizer Australia, also Novo Nordisk and MSD as well as the Exhibitors, who together helped make it happen for AMS and we thank them all.

During the last morning of the program, Dr Ann Olsson, Congress Chair for the Adelaide Congress from 6 to 8 September 2013, officially invited everyone to a ‘new look’ event with the theme “Menopause … Cool Again”. This will be at the Hilton Hotel in Victoria Square. The Scientific Program is almost complete and the Pre-Congress workshop will pick up the biennial “Menopause Essentials” theme for this program. Online from the AMS website, there will be regular updates on program developments and everyone is invited to attend. Supporting AMS, the organisers for the Adelaide Congress will be sapro. Best Wishes to All.

Beverley VollenhovenCongress Chair Melbourne

The 16th Australasian Menopause Society Congress held at the Crown Promenade Hotel in Melbourne from 12 to 14 October, generated a highly enthusiastic ‘best congress ever’ response.

This award is presented for the best overall free communication or poster by any delegate.

ASSOCIATE PROFESSOR CASSANDRA SZOEKE

DEPRESSION IN THE POSTMENOPAUSAL YEARS: THE SECOND DECADE OF FOLLOW-UP IN THE WOMEN’S HEALTHY AGEING PROJECT

Campbell, Katherine1,2, Szoeke, Cassandra1,3, Dennerstein, Lorraine1, Ames, David1,3

1 Department of Psychiatry, University of Melbourne, Melbourne, Victoria, Australia2 Mental Health Research Institute, Melbourne, Victoria, Australia3 National Ageing Research Institute, Melbourne, Victoria, Australia

AWARDS ANNOUNCED AT THE 16TH AMS CONGRESS MELBOURNE 2012

Background: Transition from the late reproductive years to postmenopause has been demonstrated as a time of increased risk for depression (Bromberger et al., 2004). However whilst studies of the menopausal transition and ageing population (over 65) exist the postmenopausal years are neglected in the literature despite this time being a crucial period of change in partnerships, household, family and employment status for women.

Methods: The Women’s Healthy Ageing Project (WHAP) is an ongoing longitudinal prospective study involving a cohort of 438 women which began recruitment in 1991 as the MWMLHP. This latest round of biennial follow-up will also include neuropsychological testing, and brain imaging in addition to previous measures.

Results: The first 80 participants show that mild to moderate rates of depressive symptoms are present in 11.5%, (CESD), 13.6% (HADS) and 4.1% (GDS) of the population. The association between midlife factors and mood is discussed.

Conclusion: Preliminary findings show prevalence rates of depressive symptoms are consistent with published norms in this age range. There was an increase in depressive symptoms in the post menopausal years from late transition/post menopause to early ageing. CES-D scores > 10 have increased from 24% in 11th year of follow up to 33% in the 20th year of follow up, the factors associated with this are discussed. Variability in scores found between depression measures has been demonstrated previously (Blank et al., 2004) and our study provides opportunity to determine the role of these different tools.

BARBARA GROSS AWARD

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Background: The relationships between endogenous sex hormone levels and cardiovascular disease (CVD) risk profile in women is contentious.

Objective: To systematically investigate the relationships between endogenous androgen and estrogen levels and lipids in postmenopausal women, taking into account, sex hormone binding globulin (SHBG), insulin resistance and body mass index (BMI).

Design: A cross-sectional study of naturally and surgically menopausal women.

Setting and Participants: 624 postmenopausal women not using any systemic hormones lipid-lowering therapy, mean age 53.9 + 5.8 years, recruited in the US, Canada, Australia, UK, and Sweden between July 2004 and February 2005.

Main outcome measures: The relationships between total testosterone, dihydrotestosterone (DHT), estrone, estradiol and sex hormone binding

globulin (SHBG), the homeostasis model assessment of insulin resistance (HOMA-IR) and each lipid variable were explored using linear regression.

Results: None of the sex steroids measured made an independent contribution to the multivariable models for total cholesterol, HDL-cholesterol, LDL-cholesterol or triglycerides. The best model for total cholesterol included race and age, and that for LDL-cholesterol, race and blood pressure, with each model only explaining 4.8% and 3.3% of the variation in each of these lipid variables respectively. HOMA-IR, SHBG, age and surgical menopause explained 22.8% of the variation in HDL-cholesterol, whereas HOMA-IR, SHBG, race and surgical menopause explained 25.4% of the variation in triglycerides.

Conclusions: Endogenous estrogen and androgen levels are not independent predictors of lipid levels in postmenopausal women. HOMA-IR and SHBG were inversely related to HDL-cholesterol and positively related to TG. These factors made little contribution to total and LDL-cholesterol.

The prize is presented to conference delegates working in any area of medicine to submit a poster for inclusion in the Congress program. The inaugural award of the Vivien Wallace Poster Prize went to Ms Katharine Burn in recognition of her poster presentation.

THE ROLE OF GRANDPARENTING IN POST-MENOPAUSAL WOMEN’S HEALTH: RESULTS FROM THE WOMEN’S HEALTHY AGEING PROJECT (WHAP)

Burn, Katherine1,2, Ames, David1, Dennerstein, Lorraine1, Szoeke, Cassandra1,2

1 National Aging Research Institute, VIC2 University of Melbourne, Australia

Background: While declining executive function and episodic memory are normal in healthy ageing, early Alzheimer’s disease (AD) usually involves impairment in these functions. Preserving these functions improves quality of life and delays the onset of AD. Cognitive maintenance can be influenced by environmental variation. Previous studies have shown that social factors can affect cognitive ageing; however, none have examined the effect of grandparenting, an important role in post-menopausal women.

Aim: To investigate the effects of grandmothering on cognition in post-menopausal women.

Hypothesis: Time spent minding grandchildren would be associated with cognitive performance.

Method: Participants were 204 women (mean age = 60) from the longitudinal prospective Women’s Healthy Ageing Project (WHAP). Participants completed the 2004 core questionnaire assessing

grandparenting and self-rated memory. A subset of 186 participants completed the California Verbal Learning Test (CVLT), East Boston Memory Test (EBMT), Symbol-Digit Modalities Test (SDMT), and Tower of London (TOL) in 2002 and 2004.

Results: ANOVA revealed an association between time spent minding grandchildren and SDMT performance (p<0.05). Further analysis showed that participants who spent one day a week minding grandchildren performed better on the CVLT immediate recall, SDMT, and TOL (p<0.05) than those who spent more than one day a week in 2004. This was not seen in CVLT or TOL scores in 2002.

Conclusion: The data illustrates optimum cognitive performance in women who spend one day per week minding grandchildren. The results suggest a relationship between cognitive performance and caring for grandchildren, highlighting the importance of late-life social interaction for cognition.

This prize is presented to the best free communication or poster presentation by a current AMS member who is still within 10 years of completing their tertiary degree.

DR ROISIN WORSELY

SEX HORMONES AND LIPIDS IN POSTMENOPAUSAL WOMENWorsley, Roisin1, Robinson, Penelope1, Bell, Robin1, Moufarege, Alain2, Davis, Susan1

1 Womens Health Research Program, Monash University, Melbourne, VIC, Australia2 Private Practice Endocrinologist, 36 Rue de Picpus, 75012 Paris, France

JEAN HAILES MEMORIAL PRIZE

VIV WALLACE POSTER PRIZE

6 December 2012 Volume 2012:4 www.menopause.org.au

ChangesChangesChangesChangesChanges

CELEBRATIONS

TURNING 25!Leading the 25th Birthday celebrations at the Congress Party,

Jane Elliott, AMS President called on Past Presidents of AMS and current Council members to join with her in cutting the cake and

singing Happy Birthday to the AMS.

“AMS had gone from a fledgling organisation initiated in 1988 by a small group of inspired leaders in menopause, many of whom are present here tonight.

Initially the secretariat operated from the private offices of successive presidents until in 2001, active growth in membership resulted in Viv Wallace as Executive Officer taking charge of an official secretariat in 2001. We have now seen further modernisation of the organisation with the relocation of the secretariat to Melbourne in the past 12 months with Lee Tregloan as Executive Director.

AMS Council has overseen the development of a fabulously informative website. The success of this has been recognised not just within this region, but with our AMS information sheets being used by the International Menopause Society, we are truly punching above our weight on the world’s scene.

We have been through a fairly extraordinary time in the past decade due to the fallout from the WHI when HRT had been painted by the media in a very negative light. Thankfully we are now back on a more rational and balanced footing with our information and prescribing. This has been a welcome change at the coalface.

On this eve of our 25th birthday I’d like to wish AMS going forward to a great future. As we all know we are not just about menopause or

HRT but very much the organisation for all aspects of women’s midlife health. So while half the population are still reaching this time of life we have,a job to do!

I’ll end with a quote from Henry Ford: “ Coming together is a beginning; keeping together is progress; working together is success”.

Let’s all raise our glasses “To AMS – Happy Birthday”

Dr. Jane Elliott President, Australasian Menopause Society

L to R: Michael Webster, Liz Farrell, Barry Wren, Jane Elliott and Henry BurgerL to R: Michael Webster, Liz Farrell, Barry Wren,

Jane Elliott, AMS President called on Past Presidents of AMS and

L to R: Michael Webster, Liz Farrell, Barry Wren, L to R: Michael Webster, Liz Farrell, Barry Wren,

Changes

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Changes

Women have a unique biology with regard to sex steroid hormone secretion, characterised by distinct phases of life in terms of ovarian function and reproductive capacity.

A recent revision of the STRAW (Stages of Reproductive Aging Workshop) criteria has highlighted that ovarian aging in women is associated with key hormonal and clinical manifestations from menarche until late postmenopausal years. The STRAW +10 criteria are; menstrual cycle length and frequency, hormonal changes, antral follicle count and the symptoms of oestradiol deficiency. This criterion can be a useful tool in assessing where a woman is within her reproductive life.

The key sex steroid hormones are derived from cholesterol, and early steps in the pathway involve production of progesterone and DHEA (dehydroepiandrosterone). In turn androstenedione and testosterone are produced, followed by oestrone and oestradiol, which are further metabolised and inter-converted. As the main biologically active oestrogen in premenopausal women is oestradiol, menopause treatment focuses on symptoms resulting from its reduced levels.

For normal sex steroid hormone production an intact hypothalamic-pituitary-ovarian axis is required, and throughout life many factors can interrupt this, including exercise and weight extremes. At between 6 and 9 months of foetal life a female’s pool of primordial follicles develop which are the reproductive units of the ovary, from which the dominant follicle will develop in each ovulatory menstrual cycle. The number of primordial follicles decreases from several million in gestation to several hundred thousand at birth, and of these approximately 400 will undergo selection to dominance if not interrupted by OCP use, pregnancy, breastfeeding etc.

The pathway to normal sex steroid hormone production in women relies on normal secretion of the hypothalamic hormone GnRH (gonadotropin releasing hormone), which stimulates anterior pituitary production of FSH and LH. GnRH levels can be detected in early infancy and FSH and LH levels can be elevated even up to 12-48 months of age, and oestradiol secretion may be evident. During childhood, maturation of hypothalamic-pituitary-ovarian feedback occurs after approximately 6 months of age, with a decline in FSH and LH with lowest levels at about 4 years. Ovarian activity begins to increase after age 6, when diurnal rhythms of FSH, LH and sex steroid hormones can be detected. During late pre-puberty GnRH is secreted in increasing amounts. The nocturnal pulsatile release of GnRH, leading to FSH and LH secretion and coupled with growth hormone brings about pubertal development, primarily via increased oestradiol

levels, which in the majority of girls is first evidenced by breast development. The sequence of normal pubertal development in girls varies widely, but a useful summary diagram of this has been produced, focusing on the normal timecourse in terms of development of height, menarche, breasts and pubic hair, including Tanner stages for the latter two.

The median age at menarche in Australian girls is 13 years. Once menarche has occurred cyclical production of the inhibins and oestradiol from dominant follicles, and progesterone and inhibin A from the corpus luteum will result, with the eventual development of regular ovulatory and potentially fertile cycles, once the hypothalamic-pituitary-ovarian feedback is fine-tuned. Normal cycles can vary between 21-35 days in a given individual. Testosterone has a mid-cycle peak resulting from the surge in LH at this time. This reproductive phase lasts until the onset of the menopause transition, typically in the mid to late 40s. During the menopause transition hormone secretion and cycles can become erratic, and women may start to experience vasomotor and other symptoms. Over this time the levels of ovarian inhibins decline, resulting in a rise in FSH, with a later decline in oestradiol, starting about 2 years before the final menstrual period. The median age at menopause (the final period) is 51 years in Australian women. Following menopause oestradiol levels remain low and FSH levels high, yet menopause is not thought to have an independent effect on testosterone or other androgen levels which decline with age in women, beginning from the late teenage years .

80% of women have some symptoms at menopause with 20% having severe symptoms. The use of exogenous sex steroid hormones to alleviate these symptoms has caused considerable debate. However, since the release of the WHI study in 2002, reporting an increased risk of breast Ca with long-term combined HRT use, a recent evaluation of the risks and benefits of HRT has been published. The consensus view is that in healthy, symptomatic, early menopausal women administration of exogenous sex steroids in the form of HRT is a safe, efficacious and cost effective short-term management strategy.

Reprinted with permission of Medical Observer:http://www.medicalobserver.com.au/news/sex-steroid-hormones-throughout-the-female-lifespan1 Dr Sonia Davison MBBS FRACP PhDSenior Postdoctoral Research FellowWomen’s Health Research ProgramSchool of Public Health and Preventive Medicine Monash UniversityEndocrinologist, Jean Hailes for Women’s Health

Sex steroid hormones throughout the female lifespanSonia Davison1

refer STRAW+10 figure over page

8 December 2012 Volume 2012:4 www.menopause.org.au

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Stage -5 -4 -3b -3a -2 -1 +1a +1b +1c +2Terminology REPRODUCTIVE MENOPAUSAL POSTMENOPAUSE TRANSITION

Early Peak Late Early Late Early Late

Perimenopause

Duration variable variable 1-3 years 2 years (1+1) 3-6 years Remaing lifespan

PRINCIPAL CRITERIAMenstrual Variable Regular Regular Subtle Variable Length Interval ofCycle to regular changes in Persistent ≥7-day amenorrhea Flow/ difference in of >=60 Length length of days consecutive cycles

SUPPORTIVE CRITERIAEndocrine FSH Low Variable* Variable* >25 IU/L** Variable* Stabilizes AMH Low Low Low Low Low Very Low Inhibin B Low Low Low Low Verv Low

Antral Follicle Low Low Low Low Very Low Very LowCount

DESCRIPTIVE CHARACTERISTICSSymptoms Vasomotor Vasomotor Increasing symptoms symptoms symptoms of Likely Very Likely urogenital atrophy

* Blood draw on cycle days 2-5 = elevated **Approximate expected level based on assays using current international pituitary standard67-69

Menarche FMP (0)

The STRAW+10 figure and article were published in the journals: Climacteric, Menopause, Journal of Clinical Endocrinology and Metabolism and Fertility and Sterility. The figure is reproduced here with permission of the lead author Professor Harlow and the journal Climacteric.

Sex steroid hormones throughout the female lifespanSonia Davison1

www.menopause.org.au December 2012 Volume 2012:4 9

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In a busy practice we often trust the providers of pathology and radiology reports to be accurate. However, when it comes to bone density, it is worthwhile taking the time to check the quality control of the bone density

scan you have in front of you, rather than just the report. This is especially the case if the report states there is a significant change which would change your treatment. Sometimes the comment on the report is generated by the machine, not by the person who signs it.

Here are some questions you should ask yourself.

1 Is the scan done on the same densitometry machineLook for the serial number of the machine on the scanning image report.

Bone density providers will sometimes change their machines, even the brand of machine or the patient may go to the same provider at a different location. A change of method such as this makes the minimum significant reportable difference larger and a reported percentage change may not be significant.Practice point – check the brand and serial number of the machine used on successive scans

2 How is the proximal femur positioned?The proper positioning of the proximal femur is crucial for the accurate

interpretation of femoral neck bone density and, in particular, for any change in femoral neck bone density. The femur is rotated by internally rotating the foot to bring the femoral neck parallel to the scan table. Proper positioning should allow you to see the lesser the trochanter as a small smooth rounded bump on the medial side of the femur. With insufficient rotation the lesser trochanter will appear as a larger pointed protrusion and with excessive rotation it will disappear altogether. Practice point - check the appearance of the lesser trochanter on the proximal femur scan and especially on successive scans

3 Should total hip or femoral neck be used for estimating change in peripheral bone density?

Because positioning is crucial for accurate femoral neck bone density, bone density readings at this site can vary on the same patient on the same day. Total hip bone density is much less variable and is preferable for judging whether femoral bone density has changed over time. Although many densitometry providers will print out the serial data using the femoral neck, you should look for the serial data on the total hip and judge changes on that.Practice point – use the total hip for monitoring changes in proximal femur bone density

4Have the same vertebrae been measured on each scan?On a good scanning image you should be able to just see the ribs on T12

and the sacral ala coming up beside L5. Sometimes it is difficult to see these

landmarks or there may be small ribs on L1 or there may be six lumbar vertebrae. In general, densitometry technicians start with looking for L4, which should look like a capital H on the image, and then count up to L1. If there is pathology at L4 which alters the appearance they might then start with L1 as the first vertebra without ribs. Look to see if you agree if the vertebral assignment. If the patient has six lumbar vertebrae make sure that the technician has used the same vertebral assignment on successive scans.Practice point – Check the vertebral assignment – L1 to L4 – on successive scans

5 Is the density of one or more vertebra artefactually altered?Lumps of calcium anywhere in the field of the region of the scanning

image will falsely elevate bone density. The most common reason for this is osteoarthritis and ostesclerosis or calcification of the intervertebral discs. However, Paget’s disease in a vertebra or even calcification of the abdominal aorta can contribute to false elevation of bone density. The bone density reporter should exclude anatomically abnormal vertebrae where there is more than a 1.0 T-score difference between the vertebra in question and adjacent vertebrae. However this is not always done and this can be missed if one relies purely on the report. Conversely, but less frequently, sometimes spina bifida occulta will make the lower lumbar vertebra BMD lower.Practice point – check for anatomical abnormalities which will alter bone density artefactually

6 Has the patient lost weight?Studies have shown that a significant weight loss can lead to a decrease

in measured bone density but not in bone mineral content in successive scans. This apparent density loss appears to be artefactual.Practice point – check the patient’s weight between successive scans and read bone mineral content (BMC) if there has been a significant weight loss

7 Have you found or identified a possible problem with scan quality?

If you suspect an error on the scan, don’t be afraid to talk to the bone densitometry provider to clarify your question or provide feedback.Practice point – learn how to be an informed bone density reporter for your own patients

1 Professor Bronwyn StuckeyMedical Director / EndocrinologistKeogh Institute for Medical Research,QE2 Medical Centre, Nedlands, WA

Bone density scans – quality control in your practiceBronwyn Stuckey 1

10 December 2012 Volume 2012:4 www.menopause.org.au

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Falls are the main cause of fractures or broken bones at any age.

Risk of falling is increased with age, number of medical conditions (3 or more), number of medications (4 or more), small or large body size, vision or hearing decline, vestibular problems (middle ear balance organ problems), poor balance, stroke, diabetes, Parkinson’s disease and dementia. With every additional medical condition diagnosed before the age of 60, the risk of falling increases by 8%. After the age of 60, this increases to 35% with every additional medical condition such as high blood pressure, asthma or arthritis1.

Risk of fracture is increased with a history of a fall, and/or low bone density (osteopenia or osteoporosis)2.

Balance and bone density decline significantly between the age of 40 and 60 and this age usually coincides with menopause. Some sobering statistics are that:

• 1 in 5 women will fall each year before they reach 60

• After 65 years 1 in 3 will fall each year

• Women over 80, 1 in 2 will fall each year

• 1 in 2 women 50 and over will suffer a broken bone (fracture) due to a fall in their remaining life-time.

BALANCE SCREENING TEST• Inability to retain balance when standing on two feet on a firm foam cushion for 30 seconds with eyes closed is highly predictive of falls 2,3 and indicates need for full assessment of balance by a physiotherapist and referral for management.

NB. Safety issue: Anyone of any age might lose balance on this test and so stand very close and be prepared to catch the person being assessed during the test.

BONE DENSITY TEST• DXA scan of proximal femur [hip] and lumbar spine are the most

effective in diagnosing low bone density. (Heel [calcaneus] bone scans sometimes available at pharmacies are not reliable in diagnosing osteoporosis).

Recommendations for reducing fall risk• Change in lifestyle to ensure diet is supportive of good health and

will reduce likelihood of acquiring diabetes, heart disease and other nutrition related disorders.

• Increase level of physical activity and reduce sedentary time as this has been linked to prevention of chronic diseases such as diabetes and heart disease.

• Take up an exercise program that focuses on balance e.g. Tai Chi, Pilates or a specific balance strategy training program. Evidence only supports exercise programs that include a balance training component in reducing falls 4,5.

• The ability to see edges clearly and to see in poor lighting, declines significantly by 60, so regular eye tests and correction of vision are very important to prevent a fall.

Recommendations for controlling bone loss (osteopenia or osteoporosis)• Change in lifestyle to ensure diet has a minimum of 1200 mg of

calcium daily to reduce likelihood of osteoporosis. Vitamin D and calcium supplements to diet.

• Ensure adequate Vitamin D levels from sun or supplements as needed for bone building.

• Increase level of physical activity and reduce sedentary time as this has been linked to prevention of osteoporosis.

• Take up a novel exercise program that requires speed of muscle contraction, loads the bones and focuses on muscles that attach to bones near where most fractures occur to maximise bone building effect. Eg Pilates, Tai Chi, physiotherapist led balance training that challenges limits of stability control, progressing resisted exercise6. Minimal or no effect on bone was found in exercise programs that only concentrated on building bone7.

Combining the recommendations for improving balance and bones is the best approach to preventing falls and fractures as you age.

References:1 Nitz JC, Low Choy NL (2008). ‘Falling is not just for older women’ Climacteric 11; 6, 461-466

2 Nitz JC, Stock L, Khan A. (2012) “Health-related predictors of falls and fractures in women over 40. Osteoporosis International DOI:10.1007/s00198-012-2004-z

3 Low Choy NL, Brauer SG, Nitz JC: (2007). Timed stance – a tool for screening age-related differences in balance. Australasian Journal on Ageing 26; 1, 29-34.

4 Sherrington C, Whitney JC, Lord SR, Herbert RD, Cumming RG, Close JCT. Effective exercise for the prevention of falls: A systematic review and meta-analysis. J Am Geriatr Soc 2008;56: 2234-2243

5 Fu S, Low Choy NL, Nitz JC. (2009) Controlling balance decline across the menopause using a specific balance strategy training program. Climacteric 12; 2, 165-176

6 Hourigan SR, Nitz JC, Brauer SG, O’Neill S, Wong J, Richardson C (2008): Positive effects of exercise on falls and fracture risk in osteopenic women. Osteoporosis International 19; 1077-1086

7 Howe TE, Shea B, Dawson LJ, Downie F, Murray A, Ross C, Harbour RT, Caldwell LM, Creed G. Exercise for preventing and treating osteoporosis in postmenopausal women. Cochrane Database of Systematic Reviews 2011; 7: Art. No.: CD000333. DOI: 10.1002/14651858.CD000333.pub2.

Prevention of falls and fractures as you age past the menopause

NEW AMS INFORMATION SHEET

www.menopause.org.au December 2012 Volume 2012:4 11

Changes

Dear AMS members,

It has been a good year for AMS particularly with our organisation really clarifying its purpose in terms of our role as an educator of health professionals in the area of women’s midlife health.

We are developing the organisational structure and systems including new changes to the website that will enable AMS to deliver information in a more accessible and timely manner.

Our Melbourne Congress this year had a lot of positive feedback and was one of our best – noting that the variety of medical topics really pleased many registrants.

AMS is also seeing increasing membership interest from general practitioners and specialist gynaecologists who are finding AMS information is particularly relevant for everyone’s daily practice of medicine.

There has been an apparent turnaround of both media and mainstream medicine in being more open to consider treatment of women for menopause symptoms. The interest of patients and GP’s in relooking at safe prescribing of HRT in particular, has strengthened the importance and relevance of the role of the AMS . It is perhaps still to be fully recognised by some that well-being at menopause is a significant contributor to quality of life and health of individuals. The recent International Menopause Society focus on weight gain at menopause would have been relevant to all who work in this area.

At the AMS AGM in Melbourne, Anna Fenton, our President Elect, and I announced the outcomes of some AMS Council discussions including those about how AMS could be more relevant to NZ members. Pleasingly this has lead to a very constructive series of initiatives which we will review at February’s AMS Council meeting. These are:

• That AMS Council recognises the unmet needs of New Zealand Members and endorses NZ Members to form a New Zealand Chapter of the AMS with an elected Chair and that chairperson will become the NZ representative on the AMS Council.

• That a pilot of a New Zealand Chapter be reviewed in six months time at the AMS Council meeting

• That the AMS Council is proactive in supporting relevant education activities in New Zealand and strives to have an AMS presence at those meetings

Thanks to all of AMS Council, Committee Members and Lee Tregloan for their untiring work to drive AMS forward to provide good quality information for our members to use every day in their consultation rooms.

On behalf of the AMS Council I would like to wish all AMS members and families a happy and safe holiday season and all the best for 2013.

Dr. Jane ElliottPresident, Australasian Menopause Society

President’s Report

AMS WebsiteHave you visited the Australasian Menopause Society website lately?The website is a major way of rapidly and accurately sharing information about menopausal health issues for the members.Check the NEW LOOK AMS site whichwill be operating at the end of January.

President Dr Jane Elliott (SA)

President-Elect Dr Anna Fenton (NZ)

Honorary Treasurer Professor Bronwyn Stuckey (WA)

Honorary Secretary Dr Christine Read (NSW)

Past President & APMF representative Dr Elizabeth Farrell (Vic)

Chairperson – Education & Research Sub-Committee Dr Linda Spinks (Qld)

Changes Editor Dr Sonia Davison (Vic)

Members Professor Martha Hickey (Vic) Dr Jenny Nitz (Qld) Dr Amanda Vincent (Vic) Assoc Professor Beverley Vollenhoven (Vic)

Dr Ann Olsson (SA)

Website CommitteeChair: Dr Anna Fenton

AMS SecretariatExecutive Director: Lee Tregloan

AMS Contact DetailsAUSTRALASIAN MENOPAUSE SOCIETYams@menopause.org.auwww.menopause.org.auPO Box 264, East Melbourne, Vic 8002, AUSTRALIATel: 61 3 9428 8738Fax: 61 3 9923 6569ABN: 69 867 357 105

PRESENTING A POSITIVE

OUTLOOK ON THE MENOPAUSE

THE 2012 EDITION OF PRESENTING APOSITIVE OUTLOOK IS AVAILABLE

ONLINE AND IN PRINT.To download your copy, check the Resources

heading in the Health Professionals section on www.menopause.org.au For orders, packages of 2012

booklets are available in quantities of 25.

While the booklets are FREE, members are asked to pay postage costs. An additional packaging and

handling fee is charged to non-members.To order, send an email to ams@menopause.org.auor call the AMS Secretariat on 61 (0)3 9428 8738,

or fax to 61 (0)3 9923 6569, for details.

Council of theAustralasian Menopause Society 2011–2013

sharing information about menopausal health sharing information about menopausal health

will be operating at the end of January.will be operating at the end of January.