Strategies for Conducting Adolescent Health Research in the Clinical Setting: The Mount Sinai Adolescent Health Center HPV Experience

BackgroundClinical research with adolescents can be challenging due to issues of informed consent, parental involvement, institutional review board requirements, and adolescent psychosocial development. These requirements present a dilemma, particularly in the area of sexual health research, as adolescents are disproportionately affected by sexually transmitted infections such as human papillomavirus (HPV). To successfully conduct adolescent research in the clinical setting, one requires an awareness of state statutes regarding adolescent confidentiality and consent for medical care, and a close partnership with the IRB.Case StudyIn 2007, the Mount Sinai Adolescent Health Center in collaboration with the Albert Einstein College of Medicine developed a longitudinal research study to examine the natural history of oral, cervical, and anal HPV in an adolescent female population engaged in high-risk sexual behaviors. We use this research project as a case study to explore the ethical, methodological, and clinical issues related to conducting adolescent health research.Summary and ConclusionsSeveral strategies were identified to promote adolescent study participation, including: (1) building a research team that is motivated to work with adolescents; (2) combining research and patient care visits to avoid duplication of services; and (3) establishing a personalized communication network with participants. Using these methods, adolescent sexual health research can successfully be integrated into the clinical setting. While retaining a prospective cohort of adolescents has its challenges, a persistent and multi-disciplinary approach can help improve recruitment, sustain participation, and acquire critical data that will lead to improved healthcare knowledge applicable to understudied populations of adolescents.     

青春发动时相对于职校学生性行为及网络生殖健康信息获取的影响

目的:分析青春发动时相对于职校学生性行为和网络生殖健康信息获取的影响。方法:在随机整群选取的1 846名中等职业技术学校学生中,问卷调查青春发育时间、异性间性行为、以及生殖健康信息获取经历。结果:青春发动时相提前男、女生的各种性行为自我报告率均显著高于适时组和延迟组。互联网是职校生寻求性生殖健康信息的重要来源之一,青春发动时相提前对于其网络性生殖健康信息寻求具有独立作用。结论:在开展有针对性的职校生性生殖健康教育中,尤其要关注和合理引导青春发动时相偏离正常的学生。     

Association of Early Menarche with Adolescent Health in the Setting of Rapidly Decreasing Age at Menarche

Study ObjectiveThis study aimed to investigate the association between age at menarche (AAM) and adverse health indicators in adolescent girls.DesignA retrospective cohort study.SettingPopulation-based survey data.ParticipantsA total of 319,437 female participants aged 12-18 years from the Korea Youth Risk Behaviour Web-based Survey.Interventions and Main Outcome MeasuresWe assessed associations between AAM (categorized as ≤10, 11, and ≥12) and health indicators (poor self-rated health, high psychological stress, unhappiness, sexual initiation, and pregnancy). Covariates were individual-level (bodyweight, living with family, parent's education, household wealth, and presence of parents and siblings) and community-level factors (year of birth, single-sex education and level of school, urbanization level of school area, year of survey, and regional deprivation). Odds ratios (ORs) for each adverse health indicator were examined by each AAM group using multivariable regression analyses. For pregnancy, we calculated relative risks (RRs) using a log-binomial regression model.ResultsAge at menarche was <12 in 42% of our study population. Nearly one-half of the girls born in the early 2000s went through menarche before the age of 12 years, whereas only one-third of girls born in the early 1990s went through menarche before the age of 12 years. Girls who experienced menarche at age ≤10 or age 11 years were more likely to show self-rated poor health (AAM ≤ 10: OR, 1.28; 95% confidence intervals [CI], 1.22-1.34; AAM = 11: OR, 1.16; 95% CI, 1.12-1.21), high stress (OR, 1.19; 95% CI, 1.14-1.23, and OR, 1.10; 95% CI, 1.06-1.14), and sexual initiation (OR, 2.21; 95% CI, 2.05-2.38, and OR, 1.32; 95% CI, 1.23-1.41) compared to those with AAM ≥12 years when data were adjusted for all covariates. AAM ≤10 years was associated with consistently higher odds for poor health than AAM ≥12 years. The ORs of sexual initiation increased with earlier AAM. Risk of pregnancy was similar across AAM groups when individual- and community-level covariates were controlled for.ConclusionEarly menarche, defined as <12 years, can be still a useful indicator in adolescent health interventions to identify high-risk groups in the setting of declining AAM.     

Frequency of Depression and Risk Factors among Adolescent Mothers in Turkey within the First Year of the Postnatal Period

Study ObjectivePostpartum depression (PPD) emerges within the first 4 weeks of the postnatal period and might continue for as long as 1 year. The aims of this prospective study were to examine the prevalence, severity, and risk factors for PPD among adolescent mothers in Turkey.Design, Setting, and ParticipantsThe study consisted of 84 adolescent mothers between the ages of 15 and 19 years.Interventions and Main Outcome MeasuresThe participants were questioned about PPD at 3 postnatal periods: 4 weeks, 6 months, and 1 year. A 23-item question form, prepared to evaluate the risk of PPD, and the Edinburgh Postnatal Depression Scale were used.ResultsThe risk of adolescent PPD was 19 (22.6%). There was a statistically significant association between the risk of PPD and various factors, such as age, educational background, trouble with partner and family, problems with sexual intercourse in the postnatal term, and assertiveness in making decisions about children (P < .05). At the 6-month follow-up, the scores of the Edinburgh Postnatal Depression Scale risk group remained the same, but they were lower at the 1-year follow-up.ConclusionThe results revealed that adolescent mothers need the assistance of partners, families, midwives/nurses, and other support systems, especially during the first postnatal year, to reduce the prevalence of adolescent PPD.     

Documentation of Sexual and Menstrual Histories for Adolescent Patients in the Inpatient Setting

Study ObjectiveIn this study, we aimed to determine the frequency of menstrual history and sexual history documentation in the inpatient setting.Design, Setting, and ParticipantsA retrospective chart review was conducted for 307 female patients ages 11-18 years admitted from the emergency department at a single institution within a 7-month period. These charts were reviewed for documentation of menstrual and sexual history.Interventions and Main Outcome MeasuresRates of menstrual and sexual history documentation were compared according to patient age, chief complaint, admitting specialty, and medical complexity.ResultsSexual history documentation was noted in 158 (45.9%) of the 344 reviewed charts. Sexual history documentation rates were higher for patients with mental health symptoms (62.9%; 61 of 98 charts; P = .02) and lower for patients admitted to surgical services (30.6%; 19 of 62 charts; P = .04). At least 1 aspect of menses was documented in 113 (32.8%) of the 344 reviewed charts. Last menstrual period was the most commonly documented aspect of menstrual history, appearing in 100 (29.1%) of the 344 reviewed charts. Menarche (4.4%; 15/344), menses frequency (7.0%; 24/344), menses duration (2.6%; 9/344), flow quantity (4.9%; 17/344), and dysmenorrhea (4.4%; 15/344) were rarely documented, regardless of chief complaint or admitting service. Menstrual history documentation rates were significantly higher for patients requiring a gynecology consultation (73.3%; 11 of 15 charts; P < .01).ConclusionMenstrual and sexual history documentation rates for adolescent patients requiring inpatient admission were low, with fewer than half of patients having a documented menstrual or sexual history.     

Risky Health Behaviors of Teenage Mothers and Infant Outcomes in the Japan Environment and Children's Study: A Nationwide Cohort Study

Study Objective

Few studies have investigated the risky health behaviors and psychosocial characteristics of teenage mothers in countries with a low teenage birth rate, like Japan. We examined the differences in maternal prenatal risky health behaviors and psychosocial characteristics, and birth weight of infants between teenage and adult mothers.

A Review of the Health Beliefs and Lifestyle Behaviors of Women with Previous Gestational Diabetes

ObjectiveTo critically review and synthesize original research designed to examine the health beliefs, including risk perceptions and health behaviors related to diet and physical activity of women with previous gestational diabetes mellitus.Data SourcesPubMed and CINAHL databases were searched for studies published in the last decade (1998-2008) that examined variables related to the health beliefs and behaviors of women with previous gestational diabetes mellitus. Keyword searches included health beliefs, health behaviors, perceived risk, gestational diabetes, type 2 diabetes, diet, physical activity, and postpartum.Study SelectionEight articles, representing 6 studies, were selected that met the inclusion criteria of original research, dependent variable of health beliefs and behaviors of women with previous gestational diabetes mellitus, and measurement after pregnancy.Data ExtractionArticles were reviewed and discussed according to the concepts of risk perception and health beliefs, health behaviors related to diet and physical activity, and psychosocial factors related to women's health beliefs and behaviors.Data SynthesisData revealed common health beliefs and behaviors of women with previous gestational diabetes mellitus, including low risk perceptions for future type 2 diabetes mellitus and suboptimal levels of physical activity and fruit and vegetable intake. The majority of studies revealed a distinct knowledge-behavior gap among women with previous gestational diabetes mellitus, whereas others revealed a lack of knowledge regarding necessary lifestyle modifications.ConclusionsFindings from this review may assist women's health researchers and clinicians in developing appropriate interventions for increasing risk awareness, promoting self-efficacy for weight loss and physical activity behaviors, and decreasing rates of diabetes and cardiovascular disease among women with previous gestational diabetes mellitus. Further research is necessary to identify factors that influence the health beliefs and behaviors of women with previous gestational diabetes mellitus. Future research should focus on populations of greater racial, ethnic, and socioeconomic diversity, as the majority of studies have been conducted with non-Hispanic White, socioeconomically advantaged women.     

The Female Athlete Triad: A Comparison of Knowledge and Risk in Adolescent and Young Adult Figure Skaters,Dancers, and Runners

Study Objective

The female athlete triad is often found in sports that value leanness and aesthetics and can lead to adverse health effects. We aimed to compare knowledge and risk of the triad among adolescent figure skaters, dancers, and runners.

Maternal Area of Residence,Socioeconomic Status,and Risk of Adverse Maternal and Birth Outcomes in Adolescent Mothers

ObjectiveAdolescent pregnancy is a significant public health issue in Canada. Current evidence highlights the individual role of social determinants of health such as maternal residence and socioeconomic status (SES) on teen pregnancy outcomes. This study evaluated the joint association between residence/SES and adverse adolescent pregnancy outcomes.MethodsThis was a population-based retrospective cohort study of all singleton, live deliveries (2010-2015) from women aged 15 to 19 who were registered in the Alberta Perinatal Health Program. Information on maternal residence and SES was extracted from the Pampalon Material Deprivation Index data set. The study categorized mothers into four risk dyads: rural/high SES, rural/low SES, urban/high SES, and urban/low SES. Adjusted odds ratios (ORs) of adverse pregnancy outcomes were calculated in logistic regression models (Canadian Task Force Classification II-2).ResultsA total of 9606 births from adolescent mothers were evaluated. Thirty percent of adolescent mothers were classified as urban/high SES; 27% were urban/low SES; 7% were rural/high SES; and 36% were placed in the rural/low SES category. Compared with urban/high SES mothers, rural/low SES mothers had increased odds of postpartum hemorrhage (OR 1.57; 95% confidence interval [CI] 1.41–1.74), operative vaginal delivery (OR 1.37; 95% CI 1.18–1.60), Caesarean section (OR 1.39; 95% CI 1.19–1.62), large for gestational age infants (OR 1.39; 95% CI 1.16–1.66), low birth weight (OR 1.11; 95% CI 1.07–1.65), and preterm birth (OR 1.48; 95% CI 1.17–1.87).ConclusionRural pregnant adolescents of low SES have the highest odds for adverse pregnancy outcomes. Social determinants of health that affect adolescent pregnancies need further examination to identify high-risk subgroups and understand pathways to health disparities in this vulnerable population.     

Comparison of Perception of Pregnancy Risk of Nulliparous Women of Advanced Maternal Age and Younger Age

Introduction : Over the last 3 decades, the proportion of women who have delayed childbearing into their mid 30s and early 40s has been increasing. Because advanced maternal age (AMA) is associated with several adverse maternal, fetal, and neonatal outcomes, these pregnancies are considered to be “high risk.” Research indicates that pregnancy risk perception is an important factor in pregnant women's health care use and decision making during pregnancy. The objectives of this study were to compare risk perception in pregnant women of AMA (aged 35 years or older) with that of younger women and to explore the relationship between perception of pregnancy risk and selected variables. Methods : A sample of 159 nulliparous pregnant women (105 aged 20‐29 years and 54 aged 35 years or older) was recruited from a variety of settings in Winnipeg, Manitoba, Canada. Women were asked to complete questionnaires to assess perception of pregnancy risk, risk knowledge, pregnancy‐related anxiety, perceived control, health status, and medical risk. Results : Women of AMA had higher education levels, were more likely to work during pregnancy, and had higher medical risk scores than younger women. Women of AMA perceived higher pregnancy risk for both themselves and their fetuses than did younger women. They rated their risks of cesarean birth, dying during pregnancy, preterm birth, and having a newborn with a birth defect or one needing admission to a neonatal intensive care unit higher than those of younger women. There were no significant differences between the 2 age groups in pregnancy‐related anxiety, knowledge of risk, perceived control, and health status. Discussion : Women of AMA have a higher perception of pregnancy risk than younger women, regardless of their medical risk. This evidence suggests that incorporating discussions of pregnancy risk into prenatal care visits may assist pregnant women of AMA to make more informed choices, reduce anxiety, and avoid unnecessary interventions.     

Crisis Pregnancy Centers in the United States: Lack of Adherence to Medical and Ethical Practice Standards; A Joint Position Statement of the Society for Adolescent Health and Medicine and the North American Society for Pediatric and Adolescent Gynecology

Crisis pregnancy centers (CPCs) attempt to dissuade pregnant people from considering abortion, often using misinformation and unethical practices. While mimicking health care clinics, CPCs provide biased, limited, and inaccurate health information, including incomplete pregnancy options counseling and unscientific sexual and reproductive health information. The centers do not provide or refer for abortion or contraception but often advertise in ways that give the appearance that they do provide these services without disclosing the biased nature and marked limitations of their services. Although individuals working in CPCs in the United States have First Amendment rights to free speech, their provision of misinformation might be harmful to young people and adults. The Society for Adolescent Health and Medicine and North American Society for Pediatric and Adolescent Gynecology support the following positions: (1) CPCs pose risk by failing to adhere to medical and ethical practice standards; (2) governments should only support health programs that provide accurate, comprehensive information; (3) CPCs and individuals who provide CPC services should be held to established standards of ethics and medical care; (4) schools should not outsource sexual education to CPCs or other entities that do not provide accurate and complete health information; (5) search engines and digital platforms should enforce policies against misleading advertising by CPCs; and (6) health professionals should educate themselves, and young people about CPCs and help young people identify safe, quality sources of sexual and reproductive health information and care.     

Please Be Careful with Me: Discrepancies between Adolescent Expectations and Clinician Perspectives on the Management of Pelvic Inflammatory Disease

Study ObjectiveTo compare clinician perspectives for the treatment of pelvic inflammatory disease (PID) with those of adolescent patients and parents.DesignCross-sectional study.SettingUrban academic pediatric and adolescent medicine practices and school-based health clinics in a large urban community with a high prevalence of sexually transmitted infections and a national sample of adolescent-serving clinicians.ParticipantsFemale patients aged 12-19 years, parents raising an adolescent older than the age of 12 years in the urban community, and clinicians who serve adolescents recruited from regional and national listservs.InterventionsNone.Main Outcome MeasuresVisual analogue scale scores on a scale of 0-10 corresponding to preferences on patient disposition in 17 clinical scenarios for a hypothetical patient with PID.ResultsCompared with adolescents, clinicians were significantly more likely to endorse hospitalizations when patients presented with severe or complicated illness (β = 0.9; standard error [SE], 0.22; P < .001), possible surgical emergency (β = 0.83; SE, 0.2; P < .001), concurrent pregnancy (β = 0.59; SE, 0.3; P = .046), or failure of outpatient treatment (β = 0.58; SE, 0.29; P = .045). Compared with clinicians, adolescents were significantly more likely to endorse hospitalizations when patients presented at a young age (β = 1.36; SE, 0.38; P < .001), were homeless (β = 0.88; SE, 0.32; P = .007), were afraid to inform a partner (β = 1.66; SE, 0.40; P < .001), or had unaware parents (β = 2.86; SE, 0.39; P < .001).ConclusionClinicians were more likely to recommend hospitalization when doing so adhered to national guidelines on PID treatment. Adolescents opted for hospitalization more often than clinicians in scenarios in which patients exhibited social vulnerability. Clinicians should engage with adolescents in shared disposition planning and use a more nuanced approach to PID management for adolescents who might not be able to tolerate an outpatient regimen.     

Photovoice: A Strategy to Better Understand the Reproductive and Sexual Health Needs of Young Mothers

Study ObjectiveAdolescent women face significant sexual and reproductive health challenges and are more vulnerable than their male peers. Photovoice methodology might allow them to provide more meaningful and accurate representations of the health challenges they encounter. Our objectives were to: (1) use Photovoice to understand how young mothers frame reproductive and sexual health within the context of their lives; (2) explore how they define reproductive and sexual health; (3) identify youth perspectives on how their life situations influence their ability to affect their health; and (4) connect their perspectives to social determinants of health framework to facilitate implementation of effective programs and policies to address their needs.Design, Setting, Participants, Interventions, and Main Outcome MeasuresThis was a prospective qualitative community-based participatory research study involving young women (ages 15-25 years) recruited from a local youth outreach center. A 9-step validated qualitative participatory approach that combined documentary photography with focus groups was used. Qualitative analysis was conducted with NVivo version 10 software (QSR International Inc., Burlington, MA, USA). Data were coded and themes were developed.ResultsThirty women were recruited and nine women completed the study. Key themes included: personal sexual health practices and coping skills, influence of poverty, physical environments, community resources and sexual health services, education, and stigma of pregnancy. Participating in community-based participatory research empowered participants to advocate for their own health.ConclusionPhotovoice methodology contributes to understanding complex factors influencing sexual and reproductive health of young mothers. This participatory-based methodology highlights their individual situations, allowing us to seek connections, create analytical perspectives from which to relate their situations to root causes, and consider strategies for change.     

Rupture of the Pregnant Uterus: The Evidence from this Decade on Risk Factors,Predictability and Prognosis

Objectives: to identify the incidence of risk factors for and the tools to predict and diagnose uterine wall disruptions. To elaborate on the perinatal and maternal prognosis and on the future reproductive potential of patients who suffered uterine wall disruptions.Method: this is a comprehensive review of the evidence published over the past decade in the English language. Publications were retrieved through Medline search, categorized as to topic and evaluated as to quality of evidence.Results: in contrast to the incidence of uterine rupture in the developing world, the incidence in the developed world is low (0.04%). Grand multiparity, dysfunctional labour and fetal malpresentations remain the major risk factors for uterine wall disruption in the unscarred uterus. Undertaking a trial of labour in the previously scarred uterus is identified as the major risk factor for uterine rupture. Evidence supports the recommendation of a cautionary and highly selective approach to the use of oxytocin to correct dysfunctional labour at any phase, and in the use of prostaglandin for ripening the cervix and induction of labour. Use of epidural anaesthesia, fetal macrosomia, type of lower uterine segment scar (vertical or horizontal) and previous Caesarean section for cephalopelvic disproportion do not seem to be important risk factors. Evidence is lacking as to the safety of trials of labour in multifetal pregnancies. Past history of a previous vaginal birth after Caesarean section (VBAC) seems to be reassuring. Sonography emerges as having a role in evaluating the potential for uterine rupture in labour. Use of partographs in labour could help to reduce the risk of uterine rupture. The most consistent sign of uterine wall disruption in labour is a non-reassuring fetal heart pattern, the severity of which seems to correlate well with the degree of disruption and fetal expulsion. Expediting delivery within 18 minutes of a non-reassuring fetal heart rate pattern carries a good neonatal prognosis, but maternal reproductive potential, while possible, will become guarded.Conclusion: while rare, uterine wall disruption may carry high rates of perinatal morbidity and mortality and maternal morbidity. In the past decade, risk factors have been better defined, with trials of labour after a previous Caesarean section being the most prominent of the risk factors. Overzealous advocacy of such trials cannot be supported. Trials of labour after previous Caesarean section need to be undertaken on a selective basis. Evidence is needed about the safety of trials of labour when certain conditions prevail, including those pertaining to the use of oxytocin, prostaglandin, trials involving patients with more than one previous Caesarean section, and the multifetal pregnancy. Sonography and partographs seem to have potential roles as tools that might help in the selection of candidates for a safe trial of scar and identify women at increased risk for uterine wall disruption.     

Risk factors and the choice of long-acting reversible contraception following medical abortion: effect on subsequent induced abortion and unwanted pregnancy

Objective: To analyse the post-abortion effect of long-acting reversible contraception (LARC) plans and initiation on the risk of subsequent unwanted pregnancy and abortion.

Materials and methods: retrospective cohort study of 666 women who underwent medical abortion between January–May 2013 at Helsinki University Hospital, Finland. Altogether 159 (23.8%) women planning post-abortion use of levonorgestrel-releasing intrauterine system (LNG-IUS) participated in a randomized study and had an opportunity to receive the LNG-IUS free-of-charge from the hospital. The other 507 (76.2%) women planned and obtained their contraception according to clinical routine. Demographics, planned contraception, and LARC initiation at the time of the index abortion were collected. Data on subsequent abortions were retrieved from the Finnish Abortion Register and electronic patient files until the end of 2014.

Results: During the 21 months ([median], IQR 20–22) follow-up, 54(8.1%) women requested subsequent abortions. When adjusted for age, previous pregnancies, deliveries, induced abortions and gestational-age, planning LARC for post-abortion contraception failed to prevent subsequent abortion (33 abortions/360 women, 9.2%) compared to other contraceptive plans (21/306, 6.9%) (HR 1.22, 95% CI 0.68–2.17). However, verified LARC initiation decreased the abortion rate (4 abortions/177 women, 2.3%) compared to women with uncertain LARC initiation status (50/489, 10.2%) (HR 0.17, 95% CI 0.06–0.48). When adjusted for LARC initiation status, age?<25 years was a risk factor for subsequent abortion (27 abortions/283 women, 9.5%) compared to women?≥25 years (27/383, 7.0%, HR1.95, 95% CI 1.04–3.67).

Conclusions: Initiation of LARC as part of abortion service at the time of medical abortion is an important means to prevent subsequent abortion, especially among young women.     

生殖健康/计划生育服务满意度及其影响因素分析

目的:了解计划生育优质服务项目实施后已婚育龄妇女对生殖健康/计划生育服务的满意度,分析其影响因素。方法:资料来源于“中国/联合国人口基金生殖健康/计划生育合作项目”中期评估调查。本文就其中5 533名已婚有偶育龄妇女对生殖健康/计划生育服务的满意度进行了分析。结果;已婚育龄妇女对服务的总体满意度高（98.9％）。育龄妇女本人及其丈夫对所用避孕方法适应证、副作用的了解程度、近两年内获得生殖健康/计划生育服务的场所、计划生育/生殖健康宣传品的发放、开展生殖健康知识培训以及生殖健康/计划生育管理和服务方面的变化等因素会影响育龄妇女对服务的满意度。结论:避孕方法知情选择是提高育龄妇女对服务满意度的重要途径。生殖健康/计划生育管理和服务模式的转变是全面推进计划生育优质服务的保障。     

Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stages of labour: a randomised controlled trial

Background

Postpartum haemorrhage is one of the most important causes of maternal death.

Objectives

To evaluate the effect of active management of the third stage of labour on the amount of blood loss in the third and fourth stages of labour, and the duration of the third stage of labour.

Methods

A randomised controlled trial was completed on 200 women who gave birth at a maternity unit in Iran. In the intervention group (n=100), 10 IU of oxytocin was injected intramuscularly into the mother following birth of the anterior shoulder of the baby. After clamping and cutting the umbilical cord, the uterus was pushed upwards and posterior, while the cord was pulled down with constant and intermittent traction until the placenta was delivered. In the control group (n=100), on observing signs of placental separation, the placenta was expulsed by maternal force. In both groups of women, blood loss was measured at birth using collecting devices, and drapes and sheets were weighed to estimate blood loss.

Findings

Mean blood loss during the third stage of labour was 216.93±165.16 ml and 232.12±150.35 ml in the intervention and control groups, respectively; the difference was not significant (p=0.49). In contrast, mean blood loss during the fourth stage of labour differed significantly (422.62±324.7 ml and 327.27±255.99 ml in the intervention and control groups, respectively; p=0.02). The mean duration of the third stage of labour was less in the intervention group than in the control group (4.69±5.51 mins and 6.34±5.03 mins; p=0.028).

Conclusions

Active management did not decrease blood loss during the third stage of labour, but did decrease the duration of this stage. Active management was associated with increased blood loss during the fourth stage of labour. Due to conflicting results between studies, further research should be undertaken to determine the optimal method by which to manage the third stage of labour.     

Comparison of the effects of raloxifene and low-dose hormone replacement therapy on bone mineral density and bone turnover in the treatment of postmenopausal osteoporosis

Objective. The aim of the present study was to compare the effects of raloxifene and low-dose hormone replacement therapy (HRT) on bone mineral density (BMD) and bone turnover markers in the treatment of postmenopausal osteoporosis.

Methods. Forty-two postmenopausal osteoporotic women, who were randomized to receive raloxifene 60 mg or estradiol 1 mg/norethisterone acetate 0.5 mg daily for 1 year, were studied. All women received calcium 600 mg/day and vitamin D 400 IU/day. BMD and markers of bone turnover were measured at baseline and at 12 months.

Results. After 12 months of treatment, there were statistically significant increases in BMD in both groups at all sites (all p < 0.05). For the lumbar spine, the increase in BMD was 2.3% for raloxifene compared with 5.8% for low-dose HRT and corresponding values for total body BMD were 2.9% for raloxifene and 4.6% for low-dose HRT; the increases being significantly greater in the low-dose HRT group (p < 0.001 and p = 0.02, respectively). Although the increase in BMD at the hip was significant for both raloxifene (2.1%) and low-dose HRT (3.2%) compared with baseline, the difference between the two regimens did not reach statistical significance. The decrease in serum C-terminal telopeptide fragment of type I collagen and serum osteocalcin levels for the low-dose HRT group (?53% and ?47%, respectively) was significantly greater than for the raloxifene group (?23% and ?27%, respectively; both p < 0.01).

Conclusions. In postmenopausal women with osteoporosis, low-dose HRT produced significantly greater increases in BMD of the lumbar spine and total body and greater decreases in bone turnover than raloxifene at 12 months.