Multiple effects on drug-sensitivity, genome stability and malignant potential by combinations of h-ras, C-myc and mutant p53 gene overexpression

Activation of specific oncogenes and inactivation of tumor suppressor genes play major roles in mechanisms leading to neoplastic transformation. The potential involvement of these genes in determining genome stability is an important issue. To examine the relationships between altered oncogene expression and the effects on genome stability, we have investigated the drug sensitivity properties of mouse 10T1/2 fibroblasts transfected with combinations of H-ras, c-myc and the proline 193 mutant form of p53. The relative colony forming efficiencies of these cells were investigated in the absence or presence of various concentrations of the chemotherapeutic agents, methotrexate, N-(phosphonacetyl)-L-aspartate (PALA) or hydroxyurea. The effects of altered oncogene expression were found to be drug and locus specific, and to lead to increased drug resistance (e.g. H-ras transfectants were significantly resistant to methotrexate or PALA), decreased drug resistance (e.g. H-ras/-myc transfectants were significantly less resistant to PALA or hydroxyurea than H-ras transfected cells), or to no significant change in drug sensitivity (e.g. H-ras transfected cells were not significantly different in sensitivity to hydroxyurea than non-transfected cells). Gene amplification was an important but not the only mechanism for drug resistance. Cells that were transfected with p53 (H-ras/p53 or H-ras/c-myc/p53) exhibited the greatest drug resistance properties with all three chemotherapeutic agents, in keeping with the important role of p53 in DNA repair and DNA amplification mechanisms. Although both H-ras/p53 and H-ras/c-myc/p53 groups exhibited very similar genome stability characteristics as determined by drug sensitivity results, they were significantly different in their abilities to produce transformed foci in vitro and lung metastases in vivo. The H-ras/c-myc/p53 transfected cells formed significantly higher numbers of transformed foci and exhibited a greater malignant potential. These results are consistent with observations that H-ras expression directly correlates with malignant potential, and that H-ras/c-myc/p53 transfected cells have higher H-ras expression than H-ras/p53 transfected cells. Alterations in genomic integrity through changes in onocogene expression play important roles in mechanisms determining drug sensitivity; in addition to genome destabilization, other events are critically involved in regulating transformed and malignant characteristics.

Central nervous system atypical teratoid rhabdoid tumours: the Canadian Paediatric Brain Tumour Consortium experience

BACKGROUND

Atypical teratoid rhabdoid tumours (ATRT) are aggressive brain tumours mostly occurring in early childhood. Largest published series arise from registries and institutional experiences (1-4). The aim of this report is to provide population-based data to further characterise this rare entity and to delineate prognostic factors.

PATIENTS AND METHODS

A national retrospective study of children ⩽18years diagnosed with a central nervous system (CNS) ATRT between 1995 and 2007 was undertaken. All cases underwent central pathology review.

RESULTS

There were 50 patients (31 males; median age at diagnosis of 16.7months). Twelve patients were >36months. Infratentorial location accounted for 52% of all cases. Nineteen patients (38%) had metastatic disease. Fifteen (30%) underwent gross total resection (GTR). Ten patients (20%) underwent palliation. Among the 40 remaining patients, 22 received conventional chemotherapy and 18 received high dose chemotherapy regimens (HDC); nine received intrathecal chemotherapy and 15 received adjuvant radiation. Thirty of the 40 treated patients relapsed/progressed at a median time of 5.5months (0-32). The median survival time of the entire cohort was 13.5months (1-117.5months). Age, tumour location and metastatic status were not prognostic. Patients with GTR had a better survival (2years overall survival (OS): 60%±12.6 versus 21.7%±8.5, p=0.03). HDC conferred better outcome (2years OS 47.9%±12.1 versus 27.3%±9.5, p=0.036). Upfront radiation did not provide survival benefit. Six of the 12 survivors (50%) did not receive radiation.

CONCLUSION

The outcome of CNS ATRT remains poor. However, the use of HDC provides encouraging results. GTR is a significant prognostic factor. The role of adjuvant radiation remains unclear.

Impact of radiation avoidance on survival and neurocognitive outcome in infant medulloblastoma

Purpose

Concerns about radiotherapy-related neurocognitive sequelae in young children have led to deferral or avoidance of radiation in contemporary treatment for this fragile group of patients. We compared survival and neurocognitive outcome in two groups of infants with medulloblastoma who received adjuvant conventional craniospinal irradiation (csi) or reduced or no radiotherapy during an era of change in the philosophy of infant medulloblastoma treatment.

Patients and Methods

From 1985 to 2007, 29 patients 3 years of age or younger were diagnosed and treated with curative intent in our institution. Children treated before 1994 received adjuvant radiation with chemotherapy; subsequently, radiation was prescribed essentially for disease progression or relapse.

Results

Median age at diagnosis was 24 months (range: 1–36 months); 15 patients (52%) presented with metastatic disease at diagnosis. As part of initial treatment, 8 children received adjuvant radiotherapy with chemotherapy, and 21 children received postoperative chemotherapy only. Five children treated with chemotherapy alone are in prolonged remission. The 5-year event-free and overall survivals were 35.9% ± 9.8% and 50.2% ± 9.6% respectively. Extent of resection, metastatic status, and desmoplastic histology were not found to be significant prognostic factors.

On serial neurocognitive evaluations, patients treated with chemotherapy with or without reduced radiotherapy demonstrated improvement of intellectual function over time. Patients treated with conventional csi exhibited significantly lower intelligence quotient scores and academic performance, with the exception of receptive vocabulary.

Conclusions

Avoidance of conventional csi in treatment of very young children with medulloblastoma appears to be associated with a preserved neurocognitive profile. Neurocognitive evaluation should be integrated into the primary objectives of future infant protocols.

Accepting kidneys from older living donors: impact on transplant recipient outcomes

Older living kidney donors are regularly accepted. Better knowledge of recipient outcomes is needed to inform this practice. This retrospective cohort study observed kidney allograft recipients from Ontario, Canada between January 2000 and March 2008. Donors to these recipients were older living (≥ 60 years), younger living, or standard criteria deceased (SCD). Review of medical records and electronic healthcare data were used to perform survival analysis. Recipients received 73 older living, 1187 younger living and 1400 SCD kidneys. Recipients of older living kidneys were older than recipients of younger living kidneys. Baseline glomerular filtration rate (eGFR) of older kidneys was 13 mL/min per 1.73 m² lower than younger kidneys. Median follow-up time was 4 years. The primary outcome of total graft loss was not significantly different between older and younger living kidney recipients [adjusted hazard ratio, HR (95%CI): 1.56 (0.98-2.49)]. This hazard ratio was not proportional and increased with time. Associations were not modified by recipient age or donor eGFR. There was no significant difference in total graft loss comparing older living to SCD kidney recipients [HR: 1.29 (0.80-2.08)]. In light of an observed trend towards potential differences beyond 4 years, uncertainty remains, and extended follow-up of this and other cohorts is warranted.

Surgical site infection rate is lower in laparoscopic than open colorectal surgery

OBJECTIVE

Few studies have investigated whether surgical site infection (SSI) incidence differs between laparoscopic colorectal surgery (LCS) and open colorectal surgery (OCS). This study investigated the SSI incidence using the validated UK SSI Surveillance Service (SSISS) criteria for diagnosing wound infections.

METHOD

Prospective data collection recorded patients' demographics, operative details, antibiotic use, wound evaluation and microbiological wound culture results, for consecutive patients undergoing elective resectional LCS and OCS. Postdischarge surveillance consisted of patient questionnaires sent out at 30 days and the primary care communication.

RESULTS

A total of 122 patients underwent colorectal resections over 1 year (LCS 43; OCS 79). Patients' demographics and operative case-mix were similar for both groups, including body mass index (BMI), diabetic and smoking status. Operative duration was longer in the LCS group compared with OCS group (P = 0.012, Mann-Whitney U-test), but hospital stay was shorter for LCS (P = 0.0001, Mann-Whitney U-test). The SSI rate was significantly lower in the LCS than OCS group (7%vs 25% respectively; P = 0.015, two-tailed Fisher's exact test). BMI > 30 and operation length > 4 h influenced the risk of SSI formation (P < 0.05, chi-squared test). One LCS patient required conversion to a limited laparotomy.

CONCLUSIONS

Surgical site infection incidence is significantly lower following LCS when compared with OCS. Confounding factors in this study include patient selection for LCS and nonrandomization.

Baseline Endogenous Estradiol and the Association of Hormone Therapy with Breast Cancer Risk, the Women's Health Initiative Clinical Trials

Background: The effect of exogenous hormones on breast cancer risk may depend on baseline endogenous levels of estradiol (E2). We investigated whether women with lower E2 levels will have the greatest increase in breast cancer risk during treatment with estrogen plus progestin ((E+P); combined conjugated equine estrogens (CEE) plus medroxyprogesterone acetate) or estrogen-alone ((E-alone); CEE) therapy. Additionally, we examined whether the risk of breast cancer varies by untreated levels of endogenous E2.Methods: We performed an ancillary study within the Women's Health Initiative E+P and E-alone clinical trials. We used a case-only design to test for interactions between untreated levels of E2 and hormone therapy (E+P or E-alone) on breast cancer risk. We measured baseline levels of bioavailable E2 in 346 cases of invasive breast cancer from the E+P trial and 231 cases from the E-alone trial. To estimate the risk of breast cancer by endogenous E2 levels (expressed as quartiles), we used a case-cohort design which included the cases described above in addition to a randomly selected comparison group (N=387; 203 from the E+P and 184 from the E-alone trial). Incident breast cancer cases were identified over an average follow-up of 4.1 years in the E+P trial and 5.4 years in the E-alone trial. All analyses were performed separately for the E+P and the E-alone trials.Results: In the case-only study, the effect of E+P therapy on breast cancer risk did not seem to vary by endogenous E2 quartiles (p-heterogeneity= 0.16). Breast cancer risk associated with E-alone treatment tended to be greater among women with the lowest E2 levels; however this association was not significant (hazard ratio (HR)= 1.44, 95% confidence interval (CI)= 0.79-2.59).Table 1. Effects of E+P and E-alone treatments on breast cancer risk (HR (95% CI)) by quartiles of baseline estradiol: case-only results E+PE-aloneEstradiol  Quartile 11.20 (0.80-1.80)1.44 (0.79-2.59)Quartile 20.88 (0.58-1.34)0.98 (0.58-1.67)Quartile 31.27 (0.81-2.00)0.79 (0.47-1.33)Quartile 40.67 (0.43-1.06)0.92 (0.57-1.49)P-heterogeneity0.160.51P-trend0.160.20 In the case-cohort analysis, higher endogenous E2 levels were associated with increased breast cancer risk (p-trend= 0.01), independent of hormone therapy.Table 2. Effects of baseline estradiol and hormone therapy (E+P vs. E-alone) on breast cancer risk (HR (95% CI)): case-cohort results E+PE-aloneHormone therapy treatment (Reference= placebo group)1.01 (0.96-1.07)0.84 (0.56-1.26)   Estradiol  Quartile 1 (Reference)1.001.00Quartile 21.22 (0.75-2.00)1.30 (0.77-2.17)Quartile 31.41 (0.87-2.32)1.32 (0.77-2.27)Quartile 41.85 (1.12-3.03)2.38 (1.32-4.35)P-trend0.010.01 Conclusion: The risk of breast cancer increases with higher levels of untreated endogenous E2. However, untreated E2 level does not modify the effect of E+P or E-alone therapy on breast cancer risk. Estradiol measurement is unlikely to identify women where hormone therapy may substantially increase the risk of breast cancer.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 906.

Sex Hormones and Risk of Estrogen Receptor (ER)-Positive and ER-Negative Breast Cancer

Background: There is a need for improved breast cancer risk prediction by tumor estrogen receptor (ER) status. Endogenous sex hormone levels are associated with risk of overall breast cancer and the ER-positive subtype. However, the role of estradiol (E2) and testosterone (T) in the development of ER-negative tumors remains unclear. We investigated the associations of circulating levels of endogenous E2 and T with the risk of ER-positive as well as ER-negative breast cancer in postmenopausal women.Methods: We performed a case-cohort study within the Women's Health Initiative- Observational Study of postmenopausal women not taking exogenous hormones (age range: 50-79 years). Baseline endogenous levels of bioavailable E2 and T were measured using radioimmunoassays (University of Southern California, LA, CA) in 196 cases of invasive ER-positive breast cancer, 107 cases of invasive ER-negative cancer, and 560 randomly selected controls. The average follow-up time was 7.3 years.Results: After adjustment for putative risk factors, women with E2 levels in the upper three quartiles had an approximately 2-fold increased risk of ER-positive breast cancer, compared to those with E2 in the lowest quartile. These associations were only modestly decreased after adjustment for T. Higher T levels also indicated increased risk of ER-positive breast cancer; women in the third quartile of T had a 1.7-fold significantly higher risk, compared to those in the first quartile. However, this association was substantially diminished and not significant after controlling for E2.No association was observed between E2 levels and ER-negative cancer. However, women with T levels in the second, third, and fourth quartiles had lower risks of ER-negative cancer in the order of 54% (p= 0.018), 38% (p= 0.13), and 46% (p= 0.05), respectively, compared to women with T in the lowest quartile. These associations did not change materially after adjusting for E2.Table 1. Risk (Hazard Ratio (HR) and 95% CI) of ER-positive and ER-negative breast cancer by E2 and T quartiles ER-positive (HR (95% CI))ER-negative (HR (95% CI)) Model 1*Model 2**Model 1*Model 2*E2    Q11.001.001.001.00Q22.19 (1.25-3.84)2.12 (1.16-3.87)0.57 (0.29-1.12)0.72 (0.34-1.53)Q31.92 (1.10-3.35)1.74 (0.92-3.33)0.75 (0.40-1.42)1.09 (0.51-2.3)Q42.11 (1.21-3.68)1.86 (0.97-3.56)0.88 (0.48-1.62)1.36 (0.60-3.08)P for trend0.020.150.840.44T    Q11.001.001.001.00Q21.01 (0.57-1.78)0.82 (0.44-1.53)0.46 (0.24-0.88)0.45 (0.22-0.92)Q31.72 (1.04-2.84)1.36 (0.75-2.48)0.62 (0.34-1.15)0.56 (0.27-1.18)Q41.45 (0.85-2.46)1.16 (0.62-2.17)0.54 (0.29-1.00)0.44 (0.20-1.00)P for trend0.050.280.100.09*Model1: adjusted for age, race, age at menopause, alcohol use, physical activity, history of needle aspiration, lifetime use of estrogen+progestin, and time since quitting hormone therapy use. **Model2: adjusted for Model1 + sex hormones.Conclusion: Higher endogenous E2 levels were associated with increased risk of ER-positive breast cancer, independent of risk factors and T. In contrast, higher concentrations of endogenous T were related to lower risk of ER-negative breast cancer, independent of risk factors and E2. This is the first study to report an association of testosterone with ER-negative breast cancer. Further studies are needed to confirm this association.

Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 907.

Co-existence of breast and ovarian cancers in BRCA germ-line mutation carriers

The co-existence of breast and ovarian cancers in the same individual should raise suspicion of a hereditary process. Patients with either BRCA1 or BRCA2 germ-line mutations have an average risk of 39% and 11% respectively of developing ovarian cancer by the age of 70; they have a risk of 35-85% of developing breast cancer in their lifetime. We report here unusual pathologic features in a BRCA2 germ-line mutation carrier recently diagnosed with synchronous breast and ovarian cancers, and summarize the findings in six other women who were diagnosed with ovarian cancer either simultaneously with the diagnosis of breast cancer or at varying times after the diagnosis. While in most instances this may be a coincidental occurrence in highly susceptible individuals, the patient we highlight raises the provocative hypothesis that at times breast cancer metastasizes to the ovaries of mutation carriers and stimulates the development of an ovarian cancer as well as other cancers. In addition, these ovarian cancers may have different mechanisms of metastases predisposing them to travel to unusual sites.

Parastomal hernia prevention using a novel collagen implant: a randomised controlled phase 1 study

BACKGROUND

Parastomal hernias can be prevented or repaired using synthetic mesh; however, reported complications include infection, fibrosis and potential bowel erosion. The study aim was to assess the safety, feasibility and potential efficacy of using a prophylactic collagen implant.

METHODS

Twenty patients undergoing defunctioning stomas were randomised to a conventional procedure or reinforcement with the implant. Follow-up included regular symptom questionnaires, clinical examination, stoma site ultrasound, and serum inflammatory markers.

RESULTS

Ten patients (four males; mean BMI 26.3) had a conventional stoma, and ten (three males; mean BMI 26.3) received the implant. At a median of 6.5 months follow-up, a parastomal hernia was clinically evident in three of ten patients without the implant, and in none of ten patients with the implant. There were no clinical complications, ultrasound evidence of chronic seromas or serological evidence of a systemic inflammatory response.

CONCLUSIONS

Xenogeneic collagen has been demonstrated to aid soft tissue reinforcement. In this study, in contrast to published data relating to the use of conventional synthetic mesh, there were no complications related to infection or the implant's proximity to the bowel. This trial demonstrates that the implant is safe, feasible to use and has the potential to prevent parastomal herniation.

Multiphase CT angiography versus single-phase CT angiography: comparison of image quality and radiation dose

BACKGROUND AND PURPOSE

Conventional CT angiography (CTA) is acquired during only a short interval in the arterial phase, which limits its ability to evaluate the cerebral circulation. Our aim was to compare the image quality and radiation dose of conventional single-phase CTA (SP-CTA) with a multiphase CTA (MP-CTA) algorithm reconstructed from a perfusion CT (PCT) dataset.

MATERIALS AND METHODS

Fifty consecutive patients undergoing head CTA and PCT in 1 examination were enrolled. The PCT dataset was obtained with 40.0-mm-detector coverage, 5.0-mm axial thickness, 80 kilovolt peak (kVp), 180 mA, and 30 mL of contrast medium. MP-CTA was reconstructed from the same PCT dataset with an axial thickness of 0.625 mm by using a new axial reconstruction algorithm. A conventional SP-CTA dataset was obtained with 0.625-mm axial thickness, 120 kVp, 350 mA, and 60 mL of contrast medium. We compared image quality, vascular enhancement, and radiation dose.

RESULTS

SP-CTA and MP-CTA of 50 patients (male/female ratio, 31/19; mean age, 59.25 years) were analyzed. MP-CTA was significantly better than SP-CTA in vascular enhancement (P = .002), in the absence of venous contamination (P = .006), and was significantly higher in image noise (P < .001). MP-CTA used less contrast medium than SP-CTA and could demonstrate hemodynamic information. The effective dose of MP-CTA was 5.73 mSv, which was equal to that in conventional PCT, and it was 3.57 mSv in SP-CTA.

CONCLUSION

It is feasible that MP-CTA may provide both CTA and PCT results. Compared with SP-CTA, MP-CTA provides comparable image quality, better vascular enhancement, hemodynamic information, and more noise with less detail visibility with a lower tube voltage. The radiation dose of MP-CTA is higher than that of SP-CTA, but the dose can be reduced by altering the sampling interval.

The effect of ultralow-dose transdermal estradiol on sexual function in postmenopausal women

OBJECTIVE

This study was undertaken to examine the effect of ultralow-dose transdermal estradiol on sexual function in postmenopausal women.

STUDY DESIGN

Analysis of data from a multicenter, randomized, double-blind, placebo-controlled trial of a 0.014 mg/day transdermal estradiol patch in 417 women aged 60 to 80 years. Sexual function was assessed by self-administered questionnaires at baseline and 4, 12, and 24 months. A linear effects model was used to assess treatment effects using data from all on-study assessments.

RESULTS

Women randomly assigned to estradiol had a 4.3 point greater improvement in the vaginal pain/dryness domain relative to placebo (95% CI = 0.3-8.4, P = .04). No significant differences in frequency of sexual activity or other sexual function domains (desire, satisfaction, problems, or orgasm) were observed between treatment groups (P > or = .10 for all).

CONCLUSIONS

Ultralow-dose estradiol resulted in modest improvement in sexual function related to vaginal pain and dryness, but not in other domains of sexual function.

Change in surface hardness of enamel by a cola drink and a CPP-ACP paste

OBJECTIVES

This in vitro study used surface microhardness to evaluate whether a paste containing casein phosphopeptide amorphous calcium phosphate (CPP-ACP) can reharden tooth enamel softened by a cola drink, and how different saliva-substitute solutions affect the enamel hardness.

METHODS

Twenty-four bovine incisors, each tooth consisting of treatment and control halves, were immersed in a cola drink (Coke) for 8 min, then placed under a 0.4 mL/min drip with various saliva-substitute solutions. The saliva-substitute solutions were: saliva-like solution (SLS) with 1 ppm fluoride, SLS without fluoride, and Biotene mouthwash. CPP-ACP paste was applied to the treatment halves for 3 min at 0, 8, 24, and 36 h. Knoop microhardness measurements were performed at baseline, after the cola drink immersion, and after 24 and 48 h contact with saliva-substitute solution.

RESULTS

Enamel hardness significantly decreased after immersion in cola drink (ANOVA, p<0.05). After contact with saliva-like solutions for 48 h, those treated with CPP-ACP paste were significantly harder than those untreated regardless of the presence of 1 ppm fluoride in the saliva-like solution (ANOVA, p<0.05). Biotene mouthwash significantly softened the enamel surface (ANOVA, p<0.05). Two-way ANOVA showed significant effects of the CPP-ACP paste application and types of saliva-substitute solutions on the changes in surface hardness of the softened enamel at a significance level of 0.05.

CONCLUSION

The application of CPP-ACP paste with continuous replenishment of saliva-like solution for 48 h significantly hardened enamel softened by a cola drink. Biotene mouthwash softened enamel surface after 48 h contact.

Laparoscopic colorectal surgery - results from 200 patients

OBJECTIVE

Laparoscopic surgery is increasingly being performed for benign and malignant colorectal disease. This study examines the short-term results in a consecutive series of laparoscopic colorectal procedures performed over 2 years.

METHOD

A prospective database was established for all elective patients undergoing laparoscopic colorectal surgery by one surgeon. The main outcome measures assessed were operative duration, conversion rate, length of hospital stay, morbidity and mortality and lymph node harvest.

RESULTS

Two hundred and thirty-one consecutive patients were referred for elective colorectal surgery, with 18 patients excluded from laparoscopic surgery. Thirteen patients had nonresective laparoscopic colorectal procedures for endometriosis and have been excluded from the series. Of 200 patients who underwent a laparoscopic colorectal procedure, 114 (57%) were female, the median age was 67 years (inter-quartile range (IQR) 57-76), and there were 116 malignancies. The most common operations were anterior resection and sigmoid colectomy (n = 82), right hemicolectomy (n = 62) and left hemicolectomy (n = 12). The median operating time was 120 min (IQR 90-150) and 10 patients (5%) required conversion to open surgery. The median lymph node harvest in malignancies was 21 nodes (IQR 15-30) and no positive resection margins were found. There were two deaths and 29 significant complications (14.5%), with seven patients requiring re-operations because of postoperative complications. The median postoperative hospital stay was 4 days (IQR 3-6) and 13 patients (6.5%) were re-admitted within 30 days of hospital discharge.

CONCLUSION

Laparoscopic colorectal surgery is possible for most benign and malignant conditions, with low conversion and complication rates, as well as short hospital stay.

Hot flushes, bone mineral density, and fractures in older postmenopausal women

OBJECTIVE

To assess whether greater severity of hot flushes is associated with bone loss or fracture risk in older postmenopausal women.

METHODS

This study is a secondary analysis of 3,167 postmenopausal women in the Multiple Outcomes of Raloxifene Evaluation trial. Baseline hot flush severity was assessed by self-report. Femoral neck and lumbar spine bone density was assessed by dual-energy X-ray absorptiometry. Vertebral and nonvertebral fractures were determined radiographically and by interview. Baseline bone density, 3-year bone loss, baseline prevalent fractures, and 3-year fracture incidence were examined in women with varying hot flush severity.

RESULTS

After adjusting for other characteristics, greater severity of hot flushes was associated with higher, rather than lower, baseline bone density (adjusted mean femoral neck bone density=0.633, 95% confidence interval [CI] 0.614-0.652 g/cm2, versus 0.611, 95% CI 0.608-0.613 g/cm2 for women with "severe" versus "minimal" hot flushes). Women with more severe hot flushes were less likely to have a baseline fracture (odds ratio 0.64, 95% CI 0.48-0.84, for vertebral fracture in women with moderate or severe versus minimal hot flushes). The 3-year annualized change in bone density did not differ among women with varying hot flush severity (P>.40 for all). Hot flush severity was not related to incident vertebral or nonvertebral fracture (P>.05 for all).

CONCLUSION

Among osteoporotic women who are 5 or more years postmenopausal, greater severity of persistent hot flushes is not associated with progressive bone loss or risk of fracture, despite previous research linking hot flushes to bone loss during early menopause.

LEVEL OF EVIDENCE

II.