Kate Johnson

NEW ORLEANS — Hormone levels are weakly associated with sexual desire during the menopausal transition, while other sexual desire predictors are more important, according to an analysis of data from the Study of Women's Health Across the Nation.

“This is the first really solid data to nail down the role of hormones in sexual desire,” said investigator Dr. John Randolph, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. But he cautioned that while the study found a significant association between women's sexual desire and their levels of testosterone and follicle-stimulating hormone (FSH), the association was small.

“It's biologically significant but probably not clinically significant—and I'm worried how this information might be misinterpreted,” he said at a press conference during the annual meeting of the American Society for Reproductive Medicine. The study found that much stronger predictors of sexual desire were satisfaction with an existing relationship, availability of a partner, and ethnicity.

The multicenter, multiethnic study, funded by the National Institutes of Health, included 3,302 women who were still menstruating at baseline, and followed them with annual serum hormone measurements and sexual desire questionnaires. The aim was to determine the role of hormone levels and their fluctuations over time in changing sexual desire over the menopausal transition. The hormones measured were testosterone, estradiol, FSH, dehydroepiandrosterone (DHEA), sex hormone-binding globulin, and the free hormone indices FEI and FTI.

The data used were from 3,290 women who had at least one and up to six annual serum hormone measurements and sexual desire questionnaires. Testosterone was positively related and FSH was negatively related to sexual desire, Dr. Randolph reported. There was no association observed with estradiol, DHEA, sex hormone-binding globulin, or the free hormone indices FEI and FTI.

NEW ORLEANS — Hormone levels are weakly associated with sexual desire during the menopausal transition, while other sexual desire predictors are more important, according to an analysis of data from the Study of Women's Health Across the Nation.

“This is the first really solid data to nail down the role of hormones in sexual desire,” said investigator Dr. John Randolph, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. But he cautioned that while the study found a significant association between women's sexual desire and their levels of testosterone and follicle-stimulating hormone (FSH), the association was small.

“It's biologically significant but probably not clinically significant—and I'm worried how this information might be misinterpreted,” he said at a press conference during the annual meeting of the American Society for Reproductive Medicine. The study found that much stronger predictors of sexual desire were satisfaction with an existing relationship, availability of a partner, and ethnicity.

The multicenter, multiethnic study, funded by the National Institutes of Health, included 3,302 women who were still menstruating at baseline, and followed them with annual serum hormone measurements and sexual desire questionnaires. The aim was to determine the role of hormone levels and their fluctuations over time in changing sexual desire over the menopausal transition. The hormones measured were testosterone, estradiol, FSH, dehydroepiandrosterone (DHEA), sex hormone-binding globulin, and the free hormone indices FEI and FTI.

The data used were from 3,290 women who had at least one and up to six annual serum hormone measurements and sexual desire questionnaires. Testosterone was positively related and FSH was negatively related to sexual desire, Dr. Randolph reported. There was no association observed with estradiol, DHEA, sex hormone-binding globulin, or the free hormone indices FEI and FTI.

NEW ORLEANS — Hormone levels are weakly associated with sexual desire during the menopausal transition, while other sexual desire predictors are more important, according to an analysis of data from the Study of Women's Health Across the Nation.

“This is the first really solid data to nail down the role of hormones in sexual desire,” said investigator Dr. John Randolph, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor. But he cautioned that while the study found a significant association between women's sexual desire and their levels of testosterone and follicle-stimulating hormone (FSH), the association was small.

“It's biologically significant but probably not clinically significant—and I'm worried how this information might be misinterpreted,” he said at a press conference during the annual meeting of the American Society for Reproductive Medicine. The study found that much stronger predictors of sexual desire were satisfaction with an existing relationship, availability of a partner, and ethnicity.

The multicenter, multiethnic study, funded by the National Institutes of Health, included 3,302 women who were still menstruating at baseline, and followed them with annual serum hormone measurements and sexual desire questionnaires. The aim was to determine the role of hormone levels and their fluctuations over time in changing sexual desire over the menopausal transition. The hormones measured were testosterone, estradiol, FSH, dehydroepiandrosterone (DHEA), sex hormone-binding globulin, and the free hormone indices FEI and FTI.

The data used were from 3,290 women who had at least one and up to six annual serum hormone measurements and sexual desire questionnaires. Testosterone was positively related and FSH was negatively related to sexual desire, Dr. Randolph reported. There was no association observed with estradiol, DHEA, sex hormone-binding globulin, or the free hormone indices FEI and FTI.

NEW ORLEANS — Premenopausal vasomotor symptoms, particularly night sweats, are a previously unrecognized risk factor for low bone mineral density and enhanced bone turnover in infertile women—and probably in fertile women as well, although this has not yet been confirmed, according to Dr. Lubna Pal of the Albert Einstein College of Medicine, New York.

Her study won the prize paper award from the Society for Reproductive Endocrinology and Infertility at the annual meeting of the American Society for Reproductive Medicine.

Based on these data, “I would advise providers to specifically ask about vasomotor symptoms in premenopausal women and, for those who are symptomatic, to focus on unmasking additional factors that may enhance their fracture risk, such as low body mass; family or personal history of fractures; or smoking,” she said in an interview. “I don't think we are there yet in terms of recommending bone density screening for this population … but these women need to be advised that a further deterioration in their bone density parameters is likely to occur in the postmenopausal period, and measures to optimize skeletal health should be addressed now rather than later.”

The cross-sectional study included 86 premenopausal infertile women aged 42 years or younger without premature ovarian failure or oophorectomy. A questionnaire was used to ask about the presence and frequency of vasomotor symptoms, including hot flashes and night sweats. The study also measured subjects' bone mineral density (BMD) and levels of serum N-telopeptide (NTx), a marker of bone turnover.

A total of 12% of respondents reported one or both vasomotor symptoms, and 21% of respondents had evidence of low BMD, Dr. Pal reported at the meeting.

There was a highly significant correlation between vasomotor symptoms and low BMD, with 62.5% of symptomatic women showing evidence of low BMD, compared with 14% of asymptomatic women (odds ratio 10.18). Similarly, 36% of women with low BMD reported vasomotor symptoms, compared with 5% of those with normal BMD.

After controlling for age, body mass index, menstrual regularity, race, and smoking, the study found that vasomotor symptoms (night sweats and/or hot flashes) were independent predictors of low bone density in the study population. The magnitude of this association was most robust for night sweats, with an adjusted odds ratio (AOR) of 52.47, followed by both symptoms combined (AOR 24.10), and then hot flashes alone (AOR 15.10).

The presence of night sweats was also an independent predictor of bone turnover, with higher levels of serum NTx seen in symptomatic compared with asymptomatic women, she said.

And finally, levels of inhibin B, a marker of ovarian reserve, were also significantly lower in women with night sweats compared with asymptomatic women, “suggesting that declining ovarian reserve may be a unifying physiologic mechanism tying vasomotor symptoms to both increased bone turnover and low bone density in this young population,” she said.

“I anticipate that the association between vasomotor symptoms and low bone density in the premenopause will hold true for fertile women, but I have not yet studied this population,” Dr. Pal said.

NEW ORLEANS — Premenopausal vasomotor symptoms, particularly night sweats, are a previously unrecognized risk factor for low bone mineral density and enhanced bone turnover in infertile women—and probably in fertile women as well, although this has not yet been confirmed, according to Dr. Lubna Pal of the Albert Einstein College of Medicine, New York.

Her study won the prize paper award from the Society for Reproductive Endocrinology and Infertility at the annual meeting of the American Society for Reproductive Medicine.

Based on these data, “I would advise providers to specifically ask about vasomotor symptoms in premenopausal women and, for those who are symptomatic, to focus on unmasking additional factors that may enhance their fracture risk, such as low body mass; family or personal history of fractures; or smoking,” she said in an interview. “I don't think we are there yet in terms of recommending bone density screening for this population … but these women need to be advised that a further deterioration in their bone density parameters is likely to occur in the postmenopausal period, and measures to optimize skeletal health should be addressed now rather than later.”

The cross-sectional study included 86 premenopausal infertile women aged 42 years or younger without premature ovarian failure or oophorectomy. A questionnaire was used to ask about the presence and frequency of vasomotor symptoms, including hot flashes and night sweats. The study also measured subjects' bone mineral density (BMD) and levels of serum N-telopeptide (NTx), a marker of bone turnover.

A total of 12% of respondents reported one or both vasomotor symptoms, and 21% of respondents had evidence of low BMD, Dr. Pal reported at the meeting.

There was a highly significant correlation between vasomotor symptoms and low BMD, with 62.5% of symptomatic women showing evidence of low BMD, compared with 14% of asymptomatic women (odds ratio 10.18). Similarly, 36% of women with low BMD reported vasomotor symptoms, compared with 5% of those with normal BMD.

After controlling for age, body mass index, menstrual regularity, race, and smoking, the study found that vasomotor symptoms (night sweats and/or hot flashes) were independent predictors of low bone density in the study population. The magnitude of this association was most robust for night sweats, with an adjusted odds ratio (AOR) of 52.47, followed by both symptoms combined (AOR 24.10), and then hot flashes alone (AOR 15.10).

The presence of night sweats was also an independent predictor of bone turnover, with higher levels of serum NTx seen in symptomatic compared with asymptomatic women, she said.

And finally, levels of inhibin B, a marker of ovarian reserve, were also significantly lower in women with night sweats compared with asymptomatic women, “suggesting that declining ovarian reserve may be a unifying physiologic mechanism tying vasomotor symptoms to both increased bone turnover and low bone density in this young population,” she said.

“I anticipate that the association between vasomotor symptoms and low bone density in the premenopause will hold true for fertile women, but I have not yet studied this population,” Dr. Pal said.

NEW ORLEANS — Premenopausal vasomotor symptoms, particularly night sweats, are a previously unrecognized risk factor for low bone mineral density and enhanced bone turnover in infertile women—and probably in fertile women as well, although this has not yet been confirmed, according to Dr. Lubna Pal of the Albert Einstein College of Medicine, New York.

Her study won the prize paper award from the Society for Reproductive Endocrinology and Infertility at the annual meeting of the American Society for Reproductive Medicine.

Based on these data, “I would advise providers to specifically ask about vasomotor symptoms in premenopausal women and, for those who are symptomatic, to focus on unmasking additional factors that may enhance their fracture risk, such as low body mass; family or personal history of fractures; or smoking,” she said in an interview. “I don't think we are there yet in terms of recommending bone density screening for this population … but these women need to be advised that a further deterioration in their bone density parameters is likely to occur in the postmenopausal period, and measures to optimize skeletal health should be addressed now rather than later.”

The cross-sectional study included 86 premenopausal infertile women aged 42 years or younger without premature ovarian failure or oophorectomy. A questionnaire was used to ask about the presence and frequency of vasomotor symptoms, including hot flashes and night sweats. The study also measured subjects' bone mineral density (BMD) and levels of serum N-telopeptide (NTx), a marker of bone turnover.

A total of 12% of respondents reported one or both vasomotor symptoms, and 21% of respondents had evidence of low BMD, Dr. Pal reported at the meeting.

There was a highly significant correlation between vasomotor symptoms and low BMD, with 62.5% of symptomatic women showing evidence of low BMD, compared with 14% of asymptomatic women (odds ratio 10.18). Similarly, 36% of women with low BMD reported vasomotor symptoms, compared with 5% of those with normal BMD.

After controlling for age, body mass index, menstrual regularity, race, and smoking, the study found that vasomotor symptoms (night sweats and/or hot flashes) were independent predictors of low bone density in the study population. The magnitude of this association was most robust for night sweats, with an adjusted odds ratio (AOR) of 52.47, followed by both symptoms combined (AOR 24.10), and then hot flashes alone (AOR 15.10).

The presence of night sweats was also an independent predictor of bone turnover, with higher levels of serum NTx seen in symptomatic compared with asymptomatic women, she said.

And finally, levels of inhibin B, a marker of ovarian reserve, were also significantly lower in women with night sweats compared with asymptomatic women, “suggesting that declining ovarian reserve may be a unifying physiologic mechanism tying vasomotor symptoms to both increased bone turnover and low bone density in this young population,” she said.

“I anticipate that the association between vasomotor symptoms and low bone density in the premenopause will hold true for fertile women, but I have not yet studied this population,” Dr. Pal said.

NEW ORLEANS — Mandated restrictions on in vitro fertilization practices, such as those in place in parts of Europe, would have a negative impact on success rates in the United States, according to fertility experts at Cornell University, New York.

However, flexible restrictions in selected, good-prognosis patients could have a positive impact, they said during a press conference at the annual meeting of the American Society for Reproductive Medicine.

“We are worried that although policies and protocols limiting the number of embryos transferred are undoubtedly a good idea, nonselective regulations may harm pregnancy rates,” Dr. Peter Klatsky said in an interview.

“It's the wrong way to try to reduce multiple gestations,” said Marco Toschi, M.S.

The researchers outlined their separate studies, which simulated the impact of European-type restrictions on their patient populations. “We wanted to underline the possible threat of similar legislation here,” said Mr. Toschi, who previously worked in Italy, where some of the tightest restrictions have dramatically reduced pregnancy rates.

Mr. Toschi calculated the impact Italy's restrictions would have had if they had been applied on 12,301 cycles of intracytoplasmic sperm injection (ICSI) performed at Cornell. Italian law forbids the fertilization of more than three oocytes and requires the transfer of all resulting embryos—embryo freezing is not allowed. He compared the results of 785 patients who had only three oocytes available for insemination with the results of a group of 11,233 patients who had more than three oocytes inseminated as well as 283 patients who had only one oocyte available for insemination.

As expected, a restrictive oocyte insemination policy did result in fewer multiple gestations. However, it also resulted in a significantly reduced overall pregnancy rate, reported Mr. Toschi. Patients with the most oocytes inseminated had the highest rate of multiple gestations (33% twins, 4% triplets, 0.8% quadruplets), compared with patients who had only three oocytes inseminated (20% twins and no higher-order multiples) and patients who had only one oocyte inseminated (no multiple gestations).

Pregnancy success rates followed a similar pattern with a 40% delivery rate for the group with the most oocytes inseminated, a 19% rate for the group with three oocytes inseminated, and a 6% rate for those with one oocyte inseminated, he reported. Adjustment for male-factor infertility and maternal age did not alter the findings, but he acknowledged that the biggest limitation of the study was the fact that women who received fewer embryos did so because they had not produced more and were therefore classified as poor responders to IVF therapy. Similar restrictions imposed in a population of good responders may have resulted in higher pregnancy rates.

In a separate study, Dr. Klatsky reviewed 11,237 ICSI cycles performed at Cornell and estimated the impact of a different restrictive policy, that of single-embryo transfer (SET), which is mandated in certain Scandinavian countries. He found that if SET had been performed in his study population classified as “good responders” (patients with at least two extra cleavage-stage embryos) it would have resulted in an average delivery rate of 36% in women under age 38 years, and an average rate of 22% in those aged 38–42.

The results show that SET is “a reasonable option with potentially high pregnancy rates” in good responders, said Dr. Klatsky, noting that 40% of his study population had previously failed two cycles of ICSI. “But we want to be clear that there are women who are poor responders and will not do well. Physicians need to take seriously the risks associated with transferring multiple embryos; however, in order to help the most patients possible and to individualize care, we need the flexibility to put back more embryos in specific individuals whose prognosis is not as promising.”

To that end, he also calculated the impact of transferring two embryos instead of one in his study population. He found this would result in no increase in the singleton pregnancy rate but a substantial increase in twin pregnancies (from 0 to 26%). And when examining the impact of transferring three embryos instead of two in the same population, he found minimal increases in the singleton and twin pregnancy rate but a significant increase in higher-order multiple gestations (from 1% to 6%).

NEW ORLEANS — Mandated restrictions on in vitro fertilization practices, such as those in place in parts of Europe, would have a negative impact on success rates in the United States, according to fertility experts at Cornell University, New York.

However, flexible restrictions in selected, good-prognosis patients could have a positive impact, they said during a press conference at the annual meeting of the American Society for Reproductive Medicine.

“We are worried that although policies and protocols limiting the number of embryos transferred are undoubtedly a good idea, nonselective regulations may harm pregnancy rates,” Dr. Peter Klatsky said in an interview.

“It's the wrong way to try to reduce multiple gestations,” said Marco Toschi, M.S.

The researchers outlined their separate studies, which simulated the impact of European-type restrictions on their patient populations. “We wanted to underline the possible threat of similar legislation here,” said Mr. Toschi, who previously worked in Italy, where some of the tightest restrictions have dramatically reduced pregnancy rates.

Mr. Toschi calculated the impact Italy's restrictions would have had if they had been applied on 12,301 cycles of intracytoplasmic sperm injection (ICSI) performed at Cornell. Italian law forbids the fertilization of more than three oocytes and requires the transfer of all resulting embryos—embryo freezing is not allowed. He compared the results of 785 patients who had only three oocytes available for insemination with the results of a group of 11,233 patients who had more than three oocytes inseminated as well as 283 patients who had only one oocyte available for insemination.

As expected, a restrictive oocyte insemination policy did result in fewer multiple gestations. However, it also resulted in a significantly reduced overall pregnancy rate, reported Mr. Toschi. Patients with the most oocytes inseminated had the highest rate of multiple gestations (33% twins, 4% triplets, 0.8% quadruplets), compared with patients who had only three oocytes inseminated (20% twins and no higher-order multiples) and patients who had only one oocyte inseminated (no multiple gestations).

Pregnancy success rates followed a similar pattern with a 40% delivery rate for the group with the most oocytes inseminated, a 19% rate for the group with three oocytes inseminated, and a 6% rate for those with one oocyte inseminated, he reported. Adjustment for male-factor infertility and maternal age did not alter the findings, but he acknowledged that the biggest limitation of the study was the fact that women who received fewer embryos did so because they had not produced more and were therefore classified as poor responders to IVF therapy. Similar restrictions imposed in a population of good responders may have resulted in higher pregnancy rates.

In a separate study, Dr. Klatsky reviewed 11,237 ICSI cycles performed at Cornell and estimated the impact of a different restrictive policy, that of single-embryo transfer (SET), which is mandated in certain Scandinavian countries. He found that if SET had been performed in his study population classified as “good responders” (patients with at least two extra cleavage-stage embryos) it would have resulted in an average delivery rate of 36% in women under age 38 years, and an average rate of 22% in those aged 38–42.

The results show that SET is “a reasonable option with potentially high pregnancy rates” in good responders, said Dr. Klatsky, noting that 40% of his study population had previously failed two cycles of ICSI. “But we want to be clear that there are women who are poor responders and will not do well. Physicians need to take seriously the risks associated with transferring multiple embryos; however, in order to help the most patients possible and to individualize care, we need the flexibility to put back more embryos in specific individuals whose prognosis is not as promising.”

To that end, he also calculated the impact of transferring two embryos instead of one in his study population. He found this would result in no increase in the singleton pregnancy rate but a substantial increase in twin pregnancies (from 0 to 26%). And when examining the impact of transferring three embryos instead of two in the same population, he found minimal increases in the singleton and twin pregnancy rate but a significant increase in higher-order multiple gestations (from 1% to 6%).

NEW ORLEANS — Mandated restrictions on in vitro fertilization practices, such as those in place in parts of Europe, would have a negative impact on success rates in the United States, according to fertility experts at Cornell University, New York.

However, flexible restrictions in selected, good-prognosis patients could have a positive impact, they said during a press conference at the annual meeting of the American Society for Reproductive Medicine.

“We are worried that although policies and protocols limiting the number of embryos transferred are undoubtedly a good idea, nonselective regulations may harm pregnancy rates,” Dr. Peter Klatsky said in an interview.

“It's the wrong way to try to reduce multiple gestations,” said Marco Toschi, M.S.

The researchers outlined their separate studies, which simulated the impact of European-type restrictions on their patient populations. “We wanted to underline the possible threat of similar legislation here,” said Mr. Toschi, who previously worked in Italy, where some of the tightest restrictions have dramatically reduced pregnancy rates.

Mr. Toschi calculated the impact Italy's restrictions would have had if they had been applied on 12,301 cycles of intracytoplasmic sperm injection (ICSI) performed at Cornell. Italian law forbids the fertilization of more than three oocytes and requires the transfer of all resulting embryos—embryo freezing is not allowed. He compared the results of 785 patients who had only three oocytes available for insemination with the results of a group of 11,233 patients who had more than three oocytes inseminated as well as 283 patients who had only one oocyte available for insemination.

As expected, a restrictive oocyte insemination policy did result in fewer multiple gestations. However, it also resulted in a significantly reduced overall pregnancy rate, reported Mr. Toschi. Patients with the most oocytes inseminated had the highest rate of multiple gestations (33% twins, 4% triplets, 0.8% quadruplets), compared with patients who had only three oocytes inseminated (20% twins and no higher-order multiples) and patients who had only one oocyte inseminated (no multiple gestations).

Pregnancy success rates followed a similar pattern with a 40% delivery rate for the group with the most oocytes inseminated, a 19% rate for the group with three oocytes inseminated, and a 6% rate for those with one oocyte inseminated, he reported. Adjustment for male-factor infertility and maternal age did not alter the findings, but he acknowledged that the biggest limitation of the study was the fact that women who received fewer embryos did so because they had not produced more and were therefore classified as poor responders to IVF therapy. Similar restrictions imposed in a population of good responders may have resulted in higher pregnancy rates.

In a separate study, Dr. Klatsky reviewed 11,237 ICSI cycles performed at Cornell and estimated the impact of a different restrictive policy, that of single-embryo transfer (SET), which is mandated in certain Scandinavian countries. He found that if SET had been performed in his study population classified as “good responders” (patients with at least two extra cleavage-stage embryos) it would have resulted in an average delivery rate of 36% in women under age 38 years, and an average rate of 22% in those aged 38–42.

The results show that SET is “a reasonable option with potentially high pregnancy rates” in good responders, said Dr. Klatsky, noting that 40% of his study population had previously failed two cycles of ICSI. “But we want to be clear that there are women who are poor responders and will not do well. Physicians need to take seriously the risks associated with transferring multiple embryos; however, in order to help the most patients possible and to individualize care, we need the flexibility to put back more embryos in specific individuals whose prognosis is not as promising.”

To that end, he also calculated the impact of transferring two embryos instead of one in his study population. He found this would result in no increase in the singleton pregnancy rate but a substantial increase in twin pregnancies (from 0 to 26%). And when examining the impact of transferring three embryos instead of two in the same population, he found minimal increases in the singleton and twin pregnancy rate but a significant increase in higher-order multiple gestations (from 1% to 6%).

NEW YORK — Celiac disease doesn't look like it used to, and consequently the diagnosis is frequently missed by physicians who think of it as a disease of wasting, reported experts at an international symposium on celiac disease.

Traditionally, textbook pictures of celiac patients have shown the wasted limbs and swollen abdomens characteristic of malnutrition—but today, up to 40% of patients are overweight and 13% are obese at presentation, according to Dr. William Dickey of Altnagelvin Hospital, Londonderry, Northern Ireland.

Dr. Dickey's study of body mass index at presentation in 371 celiac patients over a 10-year period found that only 5% were underweight, and few presented with the classic symptoms of diarrhea and anemia (Am. J. Gastroenterol. 2006;101:2356–9). The well-documented problem of missed or delayed diagnosis of celiac disease may be partially explained by physicians' failure to recognize its modern presentation, he suggested.

In response to physicians' “significant lack of awareness and very substantial underdiagnosis of patients,” the National Institutes of Health has embarked on an awareness campaign aimed mainly at primary care providers, said Dr. Stephen James, director of the digestive diseases and nutrition division of the NIH, who also spoke at the meeting.

“Physicians do not perceive the underdiagnosis of celiac to be problematic or to have long-term consequences,” he said, citing findings from the recent NIH Consensus Development Conference on Celiac Disease (www.consensus.nih.gov/2004/2004CeliacDisease118html.htm

Although celiac disease was once regarded as a disorder found only in people of European descent, recent evidence suggests that its prevalence—about 1%—is the same in both Europe and North America (Arch. Intern. Med. 2003;163:286–92). Higher prevalence rates are seen in first-degree relatives (5%–15%), monozygotic twins (70%–75%), and patients with other autoimmune disorders.

The prevalence of celiac disease is slightly higher than that of either type 1 diabetes or Crohn's disease, but many physicians still have the misperception that celiac disease is a rare disorder, Dr. James said. Although many primary care physicians surveyed said they had never seen a case of celiac disease, they probably had several patients in their practice who were undiagnosed, he said.

Extragastrointestinal signs and symptoms of celiac disease, such as dermatitis herpetiformis, neurologic disorders, osteoporosis, recurrent miscarriage, and dental and oral problems, often go unrecognized, he noted.

The ambiguity of diagnostic tests contributes to the elusiveness of celiac disease, once called a “clinical chameleon” by Dr. Alessio Fasano, a leading expert from the University of Maryland Medical Center, Baltimore. In addition to the nonspecific spectrum of clinical symptoms, diagnostic criteria have hinged on positive serum antibodies and small bowel biopsies, but equivocal serologic and histologic results are frequently found, experts agreed.

The combination of positive serology followed by a positive bowel biopsy and response to a gluten-free diet confirms the disease with roughly 95% accuracy, said Dr. Edward J. Hoffenberg, of the University of Colorado Health Sciences Center in Denver. But his work, and that of others, has shown that an individual's degree of immune response can fluctuate, especially if they are not ingesting gluten at the time of testing, and the characteristic villous atrophy seen on bowel biopsies is not always present.

NEW YORK — Celiac disease doesn't look like it used to, and consequently the diagnosis is frequently missed by physicians who think of it as a disease of wasting, reported experts at an international symposium on celiac disease.

Traditionally, textbook pictures of celiac patients have shown the wasted limbs and swollen abdomens characteristic of malnutrition—but today, up to 40% of patients are overweight and 13% are obese at presentation, according to Dr. William Dickey of Altnagelvin Hospital, Londonderry, Northern Ireland.

Dr. Dickey's study of body mass index at presentation in 371 celiac patients over a 10-year period found that only 5% were underweight, and few presented with the classic symptoms of diarrhea and anemia (Am. J. Gastroenterol. 2006;101:2356–9). The well-documented problem of missed or delayed diagnosis of celiac disease may be partially explained by physicians' failure to recognize its modern presentation, he suggested.

In response to physicians' “significant lack of awareness and very substantial underdiagnosis of patients,” the National Institutes of Health has embarked on an awareness campaign aimed mainly at primary care providers, said Dr. Stephen James, director of the digestive diseases and nutrition division of the NIH, who also spoke at the meeting.

“Physicians do not perceive the underdiagnosis of celiac to be problematic or to have long-term consequences,” he said, citing findings from the recent NIH Consensus Development Conference on Celiac Disease (www.consensus.nih.gov/2004/2004CeliacDisease118html.htm

Although celiac disease was once regarded as a disorder found only in people of European descent, recent evidence suggests that its prevalence—about 1%—is the same in both Europe and North America (Arch. Intern. Med. 2003;163:286–92). Higher prevalence rates are seen in first-degree relatives (5%–15%), monozygotic twins (70%–75%), and patients with other autoimmune disorders.

The prevalence of celiac disease is slightly higher than that of either type 1 diabetes or Crohn's disease, but many physicians still have the misperception that celiac disease is a rare disorder, Dr. James said. Although many primary care physicians surveyed said they had never seen a case of celiac disease, they probably had several patients in their practice who were undiagnosed, he said.

Extragastrointestinal signs and symptoms of celiac disease, such as dermatitis herpetiformis, neurologic disorders, osteoporosis, recurrent miscarriage, and dental and oral problems, often go unrecognized, he noted.

The ambiguity of diagnostic tests contributes to the elusiveness of celiac disease, once called a “clinical chameleon” by Dr. Alessio Fasano, a leading expert from the University of Maryland Medical Center, Baltimore. In addition to the nonspecific spectrum of clinical symptoms, diagnostic criteria have hinged on positive serum antibodies and small bowel biopsies, but equivocal serologic and histologic results are frequently found, experts agreed.

The combination of positive serology followed by a positive bowel biopsy and response to a gluten-free diet confirms the disease with roughly 95% accuracy, said Dr. Edward J. Hoffenberg, of the University of Colorado Health Sciences Center in Denver. But his work, and that of others, has shown that an individual's degree of immune response can fluctuate, especially if they are not ingesting gluten at the time of testing, and the characteristic villous atrophy seen on bowel biopsies is not always present.

NEW YORK — Celiac disease doesn't look like it used to, and consequently the diagnosis is frequently missed by physicians who think of it as a disease of wasting, reported experts at an international symposium on celiac disease.

Traditionally, textbook pictures of celiac patients have shown the wasted limbs and swollen abdomens characteristic of malnutrition—but today, up to 40% of patients are overweight and 13% are obese at presentation, according to Dr. William Dickey of Altnagelvin Hospital, Londonderry, Northern Ireland.

Dr. Dickey's study of body mass index at presentation in 371 celiac patients over a 10-year period found that only 5% were underweight, and few presented with the classic symptoms of diarrhea and anemia (Am. J. Gastroenterol. 2006;101:2356–9). The well-documented problem of missed or delayed diagnosis of celiac disease may be partially explained by physicians' failure to recognize its modern presentation, he suggested.

In response to physicians' “significant lack of awareness and very substantial underdiagnosis of patients,” the National Institutes of Health has embarked on an awareness campaign aimed mainly at primary care providers, said Dr. Stephen James, director of the digestive diseases and nutrition division of the NIH, who also spoke at the meeting.

“Physicians do not perceive the underdiagnosis of celiac to be problematic or to have long-term consequences,” he said, citing findings from the recent NIH Consensus Development Conference on Celiac Disease (www.consensus.nih.gov/2004/2004CeliacDisease118html.htm

Although celiac disease was once regarded as a disorder found only in people of European descent, recent evidence suggests that its prevalence—about 1%—is the same in both Europe and North America (Arch. Intern. Med. 2003;163:286–92). Higher prevalence rates are seen in first-degree relatives (5%–15%), monozygotic twins (70%–75%), and patients with other autoimmune disorders.

The prevalence of celiac disease is slightly higher than that of either type 1 diabetes or Crohn's disease, but many physicians still have the misperception that celiac disease is a rare disorder, Dr. James said. Although many primary care physicians surveyed said they had never seen a case of celiac disease, they probably had several patients in their practice who were undiagnosed, he said.

Extragastrointestinal signs and symptoms of celiac disease, such as dermatitis herpetiformis, neurologic disorders, osteoporosis, recurrent miscarriage, and dental and oral problems, often go unrecognized, he noted.

The ambiguity of diagnostic tests contributes to the elusiveness of celiac disease, once called a “clinical chameleon” by Dr. Alessio Fasano, a leading expert from the University of Maryland Medical Center, Baltimore. In addition to the nonspecific spectrum of clinical symptoms, diagnostic criteria have hinged on positive serum antibodies and small bowel biopsies, but equivocal serologic and histologic results are frequently found, experts agreed.

The combination of positive serology followed by a positive bowel biopsy and response to a gluten-free diet confirms the disease with roughly 95% accuracy, said Dr. Edward J. Hoffenberg, of the University of Colorado Health Sciences Center in Denver. But his work, and that of others, has shown that an individual's degree of immune response can fluctuate, especially if they are not ingesting gluten at the time of testing, and the characteristic villous atrophy seen on bowel biopsies is not always present.

NEW YORK — Dental enamel defects and aphthous ulcers are both strongly associated with celiac disease, and their presence should be followed up with a full investigation for the disorder in undiagnosed people, Theologos Malahias, D.D.S., suggested at an international symposium on celiac disease.

Dental enamel defects that are seen in permanent teeth form when the teeth first develop, and thus will not reverse when celiac patients are treated with a gluten-free diet, said Dr. Malahias, a dentist from Groton, Conn.

“For example, the 6-year molars—also known as adult permanent first molars—start forming enamel when a baby is 3–4 months old,” he said in an interview. “So if celiac disease is present at that time, it can affect the enamel, but you won't see the defect until the tooth erupts at 6 years old.” Patients with these problems also may experience a delay in the eruption of permanent teeth, he added.

The bilateral, symmetrical markings are most commonly seen on central incisors and molars and are evident in all four quadrants of the mouth, Dr. Malahias explained. They are opaque and can be white, yellow, or brown, causing the enamel to look mottled, and not shiny.

“There are other causes for this type of dental appearance, so I always stress that celiac disease should be considered in the context of the rest of the patient's medical history,” he said.

His study of 136 patients, 67 with celiac disease and 69 without, found dental enamel defects in 51% of the celiac cohort and in 30% of the nonceliac group. Among the pediatric subgroup of 47 children aged 6–16 years, 87% of the 23 celiac patients had enamel defects, compared with 33% of the 24 who did not have celiac disease. In children younger than age 12 with mixed dentition, the enamel defect rate was 90% among those with celiac disease and 44% among the others.

The rate of dental decay was similar for children with and without celiac disease, but was higher in the 44 adult celiac patients than in the 45 adults without celiac disease, he reported. Decay rates need to be studied further because other studies have not found an increased decay rate in adult celiac patients, he said.

According to Dr. John Zone, a dermatologist from the University of Utah, Salt Lake City, who also spoke at the meeting, about 5% of people with unexplained aphthous ulcers have occult celiac disease. “They are presumably due to chronic stimulation of the immune system by gluten,” he suggested.

The ulcers continue to occur, but less frequently, after celiac patients start a gluten-free diet, Dr. Malahias noted.

If celiac disease is present when adult teeth are forming, it can affect the enamel. Courtesy Dr. Theologos Malahias

NEW YORK — Dental enamel defects and aphthous ulcers are both strongly associated with celiac disease, and their presence should be followed up with a full investigation for the disorder in undiagnosed people, Theologos Malahias, D.D.S., suggested at an international symposium on celiac disease.

Dental enamel defects that are seen in permanent teeth form when the teeth first develop, and thus will not reverse when celiac patients are treated with a gluten-free diet, said Dr. Malahias, a dentist from Groton, Conn.

“For example, the 6-year molars—also known as adult permanent first molars—start forming enamel when a baby is 3–4 months old,” he said in an interview. “So if celiac disease is present at that time, it can affect the enamel, but you won't see the defect until the tooth erupts at 6 years old.” Patients with these problems also may experience a delay in the eruption of permanent teeth, he added.

The bilateral, symmetrical markings are most commonly seen on central incisors and molars and are evident in all four quadrants of the mouth, Dr. Malahias explained. They are opaque and can be white, yellow, or brown, causing the enamel to look mottled, and not shiny.

“There are other causes for this type of dental appearance, so I always stress that celiac disease should be considered in the context of the rest of the patient's medical history,” he said.

His study of 136 patients, 67 with celiac disease and 69 without, found dental enamel defects in 51% of the celiac cohort and in 30% of the nonceliac group. Among the pediatric subgroup of 47 children aged 6–16 years, 87% of the 23 celiac patients had enamel defects, compared with 33% of the 24 who did not have celiac disease. In children younger than age 12 with mixed dentition, the enamel defect rate was 90% among those with celiac disease and 44% among the others.

The rate of dental decay was similar for children with and without celiac disease, but was higher in the 44 adult celiac patients than in the 45 adults without celiac disease, he reported. Decay rates need to be studied further because other studies have not found an increased decay rate in adult celiac patients, he said.

According to Dr. John Zone, a dermatologist from the University of Utah, Salt Lake City, who also spoke at the meeting, about 5% of people with unexplained aphthous ulcers have occult celiac disease. “They are presumably due to chronic stimulation of the immune system by gluten,” he suggested.

The ulcers continue to occur, but less frequently, after celiac patients start a gluten-free diet, Dr. Malahias noted.

If celiac disease is present when adult teeth are forming, it can affect the enamel. Courtesy Dr. Theologos Malahias

NEW YORK — Dental enamel defects and aphthous ulcers are both strongly associated with celiac disease, and their presence should be followed up with a full investigation for the disorder in undiagnosed people, Theologos Malahias, D.D.S., suggested at an international symposium on celiac disease.

Dental enamel defects that are seen in permanent teeth form when the teeth first develop, and thus will not reverse when celiac patients are treated with a gluten-free diet, said Dr. Malahias, a dentist from Groton, Conn.

“For example, the 6-year molars—also known as adult permanent first molars—start forming enamel when a baby is 3–4 months old,” he said in an interview. “So if celiac disease is present at that time, it can affect the enamel, but you won't see the defect until the tooth erupts at 6 years old.” Patients with these problems also may experience a delay in the eruption of permanent teeth, he added.

The bilateral, symmetrical markings are most commonly seen on central incisors and molars and are evident in all four quadrants of the mouth, Dr. Malahias explained. They are opaque and can be white, yellow, or brown, causing the enamel to look mottled, and not shiny.

“There are other causes for this type of dental appearance, so I always stress that celiac disease should be considered in the context of the rest of the patient's medical history,” he said.

His study of 136 patients, 67 with celiac disease and 69 without, found dental enamel defects in 51% of the celiac cohort and in 30% of the nonceliac group. Among the pediatric subgroup of 47 children aged 6–16 years, 87% of the 23 celiac patients had enamel defects, compared with 33% of the 24 who did not have celiac disease. In children younger than age 12 with mixed dentition, the enamel defect rate was 90% among those with celiac disease and 44% among the others.

The rate of dental decay was similar for children with and without celiac disease, but was higher in the 44 adult celiac patients than in the 45 adults without celiac disease, he reported. Decay rates need to be studied further because other studies have not found an increased decay rate in adult celiac patients, he said.

According to Dr. John Zone, a dermatologist from the University of Utah, Salt Lake City, who also spoke at the meeting, about 5% of people with unexplained aphthous ulcers have occult celiac disease. “They are presumably due to chronic stimulation of the immune system by gluten,” he suggested.

The ulcers continue to occur, but less frequently, after celiac patients start a gluten-free diet, Dr. Malahias noted.

If celiac disease is present when adult teeth are forming, it can affect the enamel. Courtesy Dr. Theologos Malahias

NEW ORLEANS — Overweight is a significant risk factor for poor in vitro fertilization success rates, particularly in African American women, according to the results of a new study.

“It is highly recommended that patients be encouraged to lose weight,” advised Dr. Mohamed Mitwally, who presented the findings at the annual meeting of the American Society for Reproductive Medicine.

There is conflicting evidence in the literature regarding the impact of obesity on in vitro fertilization (IVF) success rates, said Dr. Mitwally of Wayne State University, Detroit. But many previous studies have not controlled for confounding risk factors, he said.

His study analyzed 193 consecutive patients undergoing IVF, 161 white and 32 black patients. After controlling for confounding factors, patients with a body mass index (BMI) of 25 kg/m

NEW ORLEANS — Overweight is a significant risk factor for poor in vitro fertilization success rates, particularly in African American women, according to the results of a new study.

“It is highly recommended that patients be encouraged to lose weight,” advised Dr. Mohamed Mitwally, who presented the findings at the annual meeting of the American Society for Reproductive Medicine.

There is conflicting evidence in the literature regarding the impact of obesity on in vitro fertilization (IVF) success rates, said Dr. Mitwally of Wayne State University, Detroit. But many previous studies have not controlled for confounding risk factors, he said.

His study analyzed 193 consecutive patients undergoing IVF, 161 white and 32 black patients. After controlling for confounding factors, patients with a body mass index (BMI) of 25 kg/m

NEW ORLEANS — Overweight is a significant risk factor for poor in vitro fertilization success rates, particularly in African American women, according to the results of a new study.

“It is highly recommended that patients be encouraged to lose weight,” advised Dr. Mohamed Mitwally, who presented the findings at the annual meeting of the American Society for Reproductive Medicine.

There is conflicting evidence in the literature regarding the impact of obesity on in vitro fertilization (IVF) success rates, said Dr. Mitwally of Wayne State University, Detroit. But many previous studies have not controlled for confounding risk factors, he said.

His study analyzed 193 consecutive patients undergoing IVF, 161 white and 32 black patients. After controlling for confounding factors, patients with a body mass index (BMI) of 25 kg/m

NEW ORLEANS — The majority of women who are at risk for anxiety and depression following a failed in vitro fertilization cycle can be identified by a one-page screening questionnaire administered before treatment, Christianne M. Verhaak, Ph.D., reported at the annual meeting of the American Society for Reproductive Medicine.

“If you can identify who is at risk before the start of treatment you can offer them tailored intervention in time to prevent future emotional problems,” said Dr. Verhaak, a clinical psychologist at Radboud University Nijmegen Medical Center in the Netherlands.

Simply informing patients about the emotional impact of unsuccessful treatment can help them prepare appropriately. “For most patients and their families, the emotional impact of infertility is unknown because it is still not easy for people to talk about,” she said in an interview.

Her study followed 400 women who were starting in vitro fertilization (IVF) cycles at eight different fertility clinics in the Netherlands. Psychological questionnaires were administered before treatment, after each IVF cycle, and 6 months after the last IVF cycle. The questionnaires included the short version Spielberger State Trait Anxiety Inventory (STAI) to assess state anxiety, the Beck Depression Inventory (BDI) to assess depression, the Illness cognition questionnaire to assess cognitions of helplessness and acceptance regarding infertility, and a social support inventory.

Six months after the end of all IVF treatment, 20% of the women who had failed to become pregnant showed clinically relevant levels of anxiety and 25% showed clinically relevant levels of depression, reported Dr. Verhaak. “What is important is that in these women no recovery had taken place since the end of treatment.”

The study found five pretreatment risk factors that were associated with persistent emotional problems after treatment: anxiety, depression, cognitions of helplessness, reduced cognitions of acceptance, and lack of social support. Patients with at least one of these risk factors had a fourfold chance of developing posttreatment emotional problems compared with patients who had no risk factors, she said.

The researchers then developed a one-page screening tool to identify these risk factors before treatment and validated the tool in a separate group of 512 patients. They found the screening tool identified 74% of the overall cohort correctly as either at risk or not—with a sensitivity of 69% and a specificity of 79%. The sensitivity increased to 70% and the specificity to 87% in the subgroup of women who did not get pregnant.

Dr. Verhaak said the findings suggest that screening all patients is worthwhile before they start IVF—this would include both those with primary and secondary infertility. “The longing for a second child is the same as the longing for a first child, and the emotional impact of not getting pregnant is the same in both cases,” she said.

NEW ORLEANS — The majority of women who are at risk for anxiety and depression following a failed in vitro fertilization cycle can be identified by a one-page screening questionnaire administered before treatment, Christianne M. Verhaak, Ph.D., reported at the annual meeting of the American Society for Reproductive Medicine.

“If you can identify who is at risk before the start of treatment you can offer them tailored intervention in time to prevent future emotional problems,” said Dr. Verhaak, a clinical psychologist at Radboud University Nijmegen Medical Center in the Netherlands.

Simply informing patients about the emotional impact of unsuccessful treatment can help them prepare appropriately. “For most patients and their families, the emotional impact of infertility is unknown because it is still not easy for people to talk about,” she said in an interview.

Her study followed 400 women who were starting in vitro fertilization (IVF) cycles at eight different fertility clinics in the Netherlands. Psychological questionnaires were administered before treatment, after each IVF cycle, and 6 months after the last IVF cycle. The questionnaires included the short version Spielberger State Trait Anxiety Inventory (STAI) to assess state anxiety, the Beck Depression Inventory (BDI) to assess depression, the Illness cognition questionnaire to assess cognitions of helplessness and acceptance regarding infertility, and a social support inventory.

Six months after the end of all IVF treatment, 20% of the women who had failed to become pregnant showed clinically relevant levels of anxiety and 25% showed clinically relevant levels of depression, reported Dr. Verhaak. “What is important is that in these women no recovery had taken place since the end of treatment.”

The study found five pretreatment risk factors that were associated with persistent emotional problems after treatment: anxiety, depression, cognitions of helplessness, reduced cognitions of acceptance, and lack of social support. Patients with at least one of these risk factors had a fourfold chance of developing posttreatment emotional problems compared with patients who had no risk factors, she said.

The researchers then developed a one-page screening tool to identify these risk factors before treatment and validated the tool in a separate group of 512 patients. They found the screening tool identified 74% of the overall cohort correctly as either at risk or not—with a sensitivity of 69% and a specificity of 79%. The sensitivity increased to 70% and the specificity to 87% in the subgroup of women who did not get pregnant.

Dr. Verhaak said the findings suggest that screening all patients is worthwhile before they start IVF—this would include both those with primary and secondary infertility. “The longing for a second child is the same as the longing for a first child, and the emotional impact of not getting pregnant is the same in both cases,” she said.

NEW ORLEANS — The majority of women who are at risk for anxiety and depression following a failed in vitro fertilization cycle can be identified by a one-page screening questionnaire administered before treatment, Christianne M. Verhaak, Ph.D., reported at the annual meeting of the American Society for Reproductive Medicine.

“If you can identify who is at risk before the start of treatment you can offer them tailored intervention in time to prevent future emotional problems,” said Dr. Verhaak, a clinical psychologist at Radboud University Nijmegen Medical Center in the Netherlands.

Simply informing patients about the emotional impact of unsuccessful treatment can help them prepare appropriately. “For most patients and their families, the emotional impact of infertility is unknown because it is still not easy for people to talk about,” she said in an interview.

Her study followed 400 women who were starting in vitro fertilization (IVF) cycles at eight different fertility clinics in the Netherlands. Psychological questionnaires were administered before treatment, after each IVF cycle, and 6 months after the last IVF cycle. The questionnaires included the short version Spielberger State Trait Anxiety Inventory (STAI) to assess state anxiety, the Beck Depression Inventory (BDI) to assess depression, the Illness cognition questionnaire to assess cognitions of helplessness and acceptance regarding infertility, and a social support inventory.

Six months after the end of all IVF treatment, 20% of the women who had failed to become pregnant showed clinically relevant levels of anxiety and 25% showed clinically relevant levels of depression, reported Dr. Verhaak. “What is important is that in these women no recovery had taken place since the end of treatment.”

The study found five pretreatment risk factors that were associated with persistent emotional problems after treatment: anxiety, depression, cognitions of helplessness, reduced cognitions of acceptance, and lack of social support. Patients with at least one of these risk factors had a fourfold chance of developing posttreatment emotional problems compared with patients who had no risk factors, she said.

The researchers then developed a one-page screening tool to identify these risk factors before treatment and validated the tool in a separate group of 512 patients. They found the screening tool identified 74% of the overall cohort correctly as either at risk or not—with a sensitivity of 69% and a specificity of 79%. The sensitivity increased to 70% and the specificity to 87% in the subgroup of women who did not get pregnant.

Dr. Verhaak said the findings suggest that screening all patients is worthwhile before they start IVF—this would include both those with primary and secondary infertility. “The longing for a second child is the same as the longing for a first child, and the emotional impact of not getting pregnant is the same in both cases,” she said.

COPENHAGEN — Parents of children with type 1 diabetes intensely experience the psychological impact of the disease, according to new study findings.

“Both parents and children may need counseling to help them cope with worries associated with the disease,” said Douglas C. A. Taylor, who presented the study at the annual meeting of the European Society for the Study of Diabetes.

The study, which was supported by Sanofi-Aventis U.S., was part of a baseline assessment of participants who were enrolled in a 24-week randomized clinical trial comparing insulin glargine to twice-daily intermediate-acting insulin, said Mr. Taylor, who is director of health economics and outcomes research for i3 Innovus in Medford, Mass.

A total of 175 children and adolescents (aged 9–17 years), and one parent of each, answered either the youth or the caregiver modified versions of the Diabetes Quality-of-Life Measure, a self-administered questionnaire gauging life satisfaction, diabetes worry, and diabetes impact.

Life satisfaction questions assessed issues such as disease management, checkups, treatment, flexibility, and family burden of diabetes. Disease impact questions asked about embarrassment related to the disease, and interference of the disease on family, school, and leisure. And diabetes worry questions addressed future concerns about the disease's impact on education, marriage, job prospects, and future health.

The female parent was the respondent in 86% of the parental surveys.

Overall, parents scored worse (higher) than their children in all domains of the questionnaire. In the domain of life satisfaction, the parents' mean score was 28, compared with a mean score of 27 for the children; however, this difference was not statistically significant.

For both the disease impact and the disease worry, the parents' score was 23, compared with 21 for the children, a difference that in both cases was statistically significant.

When the responses were divided according to the gender of the children, boys reported better quality of life than girls, yet in the domains of disease impact and disease worry, parents of sons scored worse than those of daughters.

COPENHAGEN — Parents of children with type 1 diabetes intensely experience the psychological impact of the disease, according to new study findings.

“Both parents and children may need counseling to help them cope with worries associated with the disease,” said Douglas C. A. Taylor, who presented the study at the annual meeting of the European Society for the Study of Diabetes.

The study, which was supported by Sanofi-Aventis U.S., was part of a baseline assessment of participants who were enrolled in a 24-week randomized clinical trial comparing insulin glargine to twice-daily intermediate-acting insulin, said Mr. Taylor, who is director of health economics and outcomes research for i3 Innovus in Medford, Mass.

A total of 175 children and adolescents (aged 9–17 years), and one parent of each, answered either the youth or the caregiver modified versions of the Diabetes Quality-of-Life Measure, a self-administered questionnaire gauging life satisfaction, diabetes worry, and diabetes impact.

Life satisfaction questions assessed issues such as disease management, checkups, treatment, flexibility, and family burden of diabetes. Disease impact questions asked about embarrassment related to the disease, and interference of the disease on family, school, and leisure. And diabetes worry questions addressed future concerns about the disease's impact on education, marriage, job prospects, and future health.

The female parent was the respondent in 86% of the parental surveys.

Overall, parents scored worse (higher) than their children in all domains of the questionnaire. In the domain of life satisfaction, the parents' mean score was 28, compared with a mean score of 27 for the children; however, this difference was not statistically significant.

For both the disease impact and the disease worry, the parents' score was 23, compared with 21 for the children, a difference that in both cases was statistically significant.

When the responses were divided according to the gender of the children, boys reported better quality of life than girls, yet in the domains of disease impact and disease worry, parents of sons scored worse than those of daughters.

COPENHAGEN — Parents of children with type 1 diabetes intensely experience the psychological impact of the disease, according to new study findings.

“Both parents and children may need counseling to help them cope with worries associated with the disease,” said Douglas C. A. Taylor, who presented the study at the annual meeting of the European Society for the Study of Diabetes.

The study, which was supported by Sanofi-Aventis U.S., was part of a baseline assessment of participants who were enrolled in a 24-week randomized clinical trial comparing insulin glargine to twice-daily intermediate-acting insulin, said Mr. Taylor, who is director of health economics and outcomes research for i3 Innovus in Medford, Mass.

A total of 175 children and adolescents (aged 9–17 years), and one parent of each, answered either the youth or the caregiver modified versions of the Diabetes Quality-of-Life Measure, a self-administered questionnaire gauging life satisfaction, diabetes worry, and diabetes impact.

Life satisfaction questions assessed issues such as disease management, checkups, treatment, flexibility, and family burden of diabetes. Disease impact questions asked about embarrassment related to the disease, and interference of the disease on family, school, and leisure. And diabetes worry questions addressed future concerns about the disease's impact on education, marriage, job prospects, and future health.

The female parent was the respondent in 86% of the parental surveys.

Overall, parents scored worse (higher) than their children in all domains of the questionnaire. In the domain of life satisfaction, the parents' mean score was 28, compared with a mean score of 27 for the children; however, this difference was not statistically significant.

For both the disease impact and the disease worry, the parents' score was 23, compared with 21 for the children, a difference that in both cases was statistically significant.

When the responses were divided according to the gender of the children, boys reported better quality of life than girls, yet in the domains of disease impact and disease worry, parents of sons scored worse than those of daughters.

NEW ORLEANS — Infertile women with polycystic ovary syndrome are three times more likely to become pregnant when treated with clomiphene citrate than they are when treated with metformin alone, according to a new study that is predicted to change clinical practice.

“Clomiphene remains the gold standard, and metformin, the newcomer, has been dethroned,” lead investigator Dr. Richard S. Legro said in an interview, adding that the results refuted his hypothesis that improving insulin sensitivity with metformin would have a more significant impact than clomiphene on fertility. “I will take the hit for being wrong in this hypothesis. … Metformin was abysmal in terms of its cumulative pregnancy rate.”

The study was a prize paper candidate at the annual meeting of the American Society for Reproductive Medicine, where the results were called “stunning” by session moderator Dr. Robert N. Taylor of Emory University, Atlanta. “This is the first time anyone has compared Clomid and metformin head to head,” commented Dr. William Buckett of McGill University, Montreal. “It will definitely change clinical practice because currently metformin is the drug of choice for treating this population,” he said in an interview.

The multicenter trial, conducted by the Reproductive Medicine Network and funded by the National Institutes of Health, included 626 infertile women with polycystic ovary syndrome (PCOS) who were randomized to either metformin extended release (2,000 mg/day), clomiphene citrate (50–150 mg/day for 5 days per cycle), or a combination of both, for six cycles.

The primary outcome was live birth, which was achieved in 22.5% of the clomiphene arm, compared with 7.2% of the metformin arm, a statistically significant difference. The live birth rate was even higher in the combined clomiphene/metformin arm (26.8%), compared with the clomiphene-only arm, but this difference was not statistically significant, said Dr. Legro of the Pennsylvania State University, Hershey.

“These findings are vitally important because people have been using metformin really like it's vitamin M, thinking that it's of benefit in infertile women with [PCOS]. But our results are relatively dismal for metformin, and certainly our first conclusion is you should not use metformin alone to achieve pregnancy.” Body mass index was a significant factor in pregnancy success, with obesity lowering the live birth rate. However, it did not alter the basic findings, although there was a nonsignificant trend toward a benefit for combination therapy, compared with clomiphene alone, in obese women, he said.

The most remarkable finding of the study, according to Dr. Legro, was that fecundity, defined as live births per ovulated cycle, was significantly higher in clomiphene-treated subjects—at 9.6% in the combined arm and 10.2% in the clomiphene-only arm, compared with 5.1% in the metformin arm.

“This documents, really for the first time, that all ovulations are not alike,” he said. “An ovulation with clomiphene is more fecund than an ovulation with metformin.” There was also a nonsignificant trend toward an increased rate of first-trimester pregnancy loss in the metformin group (40%), compared with the combined group (25.5%) and the clomiphene-only group (22.6%), said Dr. Legro.

“Although this study was not powered to detect differences in pregnancy loss rates, this certainly gives us caution about the use of metformin to prevent pregnancy loss,” said Dr. Legro.

Dr. Legro noted that the study did not explore the effects of metformin for other indications in PCOS. “I do not want to condemn metformin overall—this study did not explore the effects of metformin on the prevention of diabetes or hirsutism—but I think we just have to be a little more cautious. If we're using it alone, it's probably a relatively ineffective agent for infertility.”

NEW ORLEANS — Infertile women with polycystic ovary syndrome are three times more likely to become pregnant when treated with clomiphene citrate than they are when treated with metformin alone, according to a new study that is predicted to change clinical practice.

“Clomiphene remains the gold standard, and metformin, the newcomer, has been dethroned,” lead investigator Dr. Richard S. Legro said in an interview, adding that the results refuted his hypothesis that improving insulin sensitivity with metformin would have a more significant impact than clomiphene on fertility. “I will take the hit for being wrong in this hypothesis. … Metformin was abysmal in terms of its cumulative pregnancy rate.”

The study was a prize paper candidate at the annual meeting of the American Society for Reproductive Medicine, where the results were called “stunning” by session moderator Dr. Robert N. Taylor of Emory University, Atlanta. “This is the first time anyone has compared Clomid and metformin head to head,” commented Dr. William Buckett of McGill University, Montreal. “It will definitely change clinical practice because currently metformin is the drug of choice for treating this population,” he said in an interview.

The multicenter trial, conducted by the Reproductive Medicine Network and funded by the National Institutes of Health, included 626 infertile women with polycystic ovary syndrome (PCOS) who were randomized to either metformin extended release (2,000 mg/day), clomiphene citrate (50–150 mg/day for 5 days per cycle), or a combination of both, for six cycles.

The primary outcome was live birth, which was achieved in 22.5% of the clomiphene arm, compared with 7.2% of the metformin arm, a statistically significant difference. The live birth rate was even higher in the combined clomiphene/metformin arm (26.8%), compared with the clomiphene-only arm, but this difference was not statistically significant, said Dr. Legro of the Pennsylvania State University, Hershey.

“These findings are vitally important because people have been using metformin really like it's vitamin M, thinking that it's of benefit in infertile women with [PCOS]. But our results are relatively dismal for metformin, and certainly our first conclusion is you should not use metformin alone to achieve pregnancy.” Body mass index was a significant factor in pregnancy success, with obesity lowering the live birth rate. However, it did not alter the basic findings, although there was a nonsignificant trend toward a benefit for combination therapy, compared with clomiphene alone, in obese women, he said.

The most remarkable finding of the study, according to Dr. Legro, was that fecundity, defined as live births per ovulated cycle, was significantly higher in clomiphene-treated subjects—at 9.6% in the combined arm and 10.2% in the clomiphene-only arm, compared with 5.1% in the metformin arm.

“This documents, really for the first time, that all ovulations are not alike,” he said. “An ovulation with clomiphene is more fecund than an ovulation with metformin.” There was also a nonsignificant trend toward an increased rate of first-trimester pregnancy loss in the metformin group (40%), compared with the combined group (25.5%) and the clomiphene-only group (22.6%), said Dr. Legro.

“Although this study was not powered to detect differences in pregnancy loss rates, this certainly gives us caution about the use of metformin to prevent pregnancy loss,” said Dr. Legro.

Dr. Legro noted that the study did not explore the effects of metformin for other indications in PCOS. “I do not want to condemn metformin overall—this study did not explore the effects of metformin on the prevention of diabetes or hirsutism—but I think we just have to be a little more cautious. If we're using it alone, it's probably a relatively ineffective agent for infertility.”

NEW ORLEANS — Infertile women with polycystic ovary syndrome are three times more likely to become pregnant when treated with clomiphene citrate than they are when treated with metformin alone, according to a new study that is predicted to change clinical practice.

“Clomiphene remains the gold standard, and metformin, the newcomer, has been dethroned,” lead investigator Dr. Richard S. Legro said in an interview, adding that the results refuted his hypothesis that improving insulin sensitivity with metformin would have a more significant impact than clomiphene on fertility. “I will take the hit for being wrong in this hypothesis. … Metformin was abysmal in terms of its cumulative pregnancy rate.”

The study was a prize paper candidate at the annual meeting of the American Society for Reproductive Medicine, where the results were called “stunning” by session moderator Dr. Robert N. Taylor of Emory University, Atlanta. “This is the first time anyone has compared Clomid and metformin head to head,” commented Dr. William Buckett of McGill University, Montreal. “It will definitely change clinical practice because currently metformin is the drug of choice for treating this population,” he said in an interview.

The multicenter trial, conducted by the Reproductive Medicine Network and funded by the National Institutes of Health, included 626 infertile women with polycystic ovary syndrome (PCOS) who were randomized to either metformin extended release (2,000 mg/day), clomiphene citrate (50–150 mg/day for 5 days per cycle), or a combination of both, for six cycles.

The primary outcome was live birth, which was achieved in 22.5% of the clomiphene arm, compared with 7.2% of the metformin arm, a statistically significant difference. The live birth rate was even higher in the combined clomiphene/metformin arm (26.8%), compared with the clomiphene-only arm, but this difference was not statistically significant, said Dr. Legro of the Pennsylvania State University, Hershey.

“These findings are vitally important because people have been using metformin really like it's vitamin M, thinking that it's of benefit in infertile women with [PCOS]. But our results are relatively dismal for metformin, and certainly our first conclusion is you should not use metformin alone to achieve pregnancy.” Body mass index was a significant factor in pregnancy success, with obesity lowering the live birth rate. However, it did not alter the basic findings, although there was a nonsignificant trend toward a benefit for combination therapy, compared with clomiphene alone, in obese women, he said.

The most remarkable finding of the study, according to Dr. Legro, was that fecundity, defined as live births per ovulated cycle, was significantly higher in clomiphene-treated subjects—at 9.6% in the combined arm and 10.2% in the clomiphene-only arm, compared with 5.1% in the metformin arm.

“This documents, really for the first time, that all ovulations are not alike,” he said. “An ovulation with clomiphene is more fecund than an ovulation with metformin.” There was also a nonsignificant trend toward an increased rate of first-trimester pregnancy loss in the metformin group (40%), compared with the combined group (25.5%) and the clomiphene-only group (22.6%), said Dr. Legro.

“Although this study was not powered to detect differences in pregnancy loss rates, this certainly gives us caution about the use of metformin to prevent pregnancy loss,” said Dr. Legro.

Dr. Legro noted that the study did not explore the effects of metformin for other indications in PCOS. “I do not want to condemn metformin overall—this study did not explore the effects of metformin on the prevention of diabetes or hirsutism—but I think we just have to be a little more cautious. If we're using it alone, it's probably a relatively ineffective agent for infertility.”

NEW ORLEANS — Hormone levels are weakly associated with sexual desire during the menopausal transition, while other sexual desire predictors are more important, according to an analysis of data from the Study of Women's Health Across the Nation.

Study investigator Dr. John Randolph, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor, cautioned that while researchers found a significant association between women's sexual desire and their levels of testosterone and follicle-stimulating hormone (FSH), the association was small.

“It's biologically significant but probably not clinically significant—and I'm worried how this information might be misinterpreted,” he said at a press conference during the annual meeting of the American Society for Reproductive Medicine. The study found that satisfaction with an existing relationship and ethnicity were much stronger predictors of sexual desire.

The multicenter, multiethnic study, funded by the National Institutes of Health, included 3,302 women who were still menstruating at baseline, and followed them with annual serum hormone measurements and sexual desire questionnaires. The aim was to determine the role of hormone fluctuations over time in changing sexual desire over the menopausal transition. Testosterone, estradiol, FSH, dehydroepiandrosterone, and sex hormone-binding globulin were among the hormones measured.

Data were available from 3,290 women who had up to six annual serum hormone measurements and sexual desire questionnaires. The researchers found that higher testosterone levels and lower levels of FSH were associated with higher levels of sexual desire, and vice versa, Dr. Randolph reported.

NEW ORLEANS — Hormone levels are weakly associated with sexual desire during the menopausal transition, while other sexual desire predictors are more important, according to an analysis of data from the Study of Women's Health Across the Nation.

Study investigator Dr. John Randolph, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor, cautioned that while researchers found a significant association between women's sexual desire and their levels of testosterone and follicle-stimulating hormone (FSH), the association was small.

“It's biologically significant but probably not clinically significant—and I'm worried how this information might be misinterpreted,” he said at a press conference during the annual meeting of the American Society for Reproductive Medicine. The study found that satisfaction with an existing relationship and ethnicity were much stronger predictors of sexual desire.

The multicenter, multiethnic study, funded by the National Institutes of Health, included 3,302 women who were still menstruating at baseline, and followed them with annual serum hormone measurements and sexual desire questionnaires. The aim was to determine the role of hormone fluctuations over time in changing sexual desire over the menopausal transition. Testosterone, estradiol, FSH, dehydroepiandrosterone, and sex hormone-binding globulin were among the hormones measured.

Data were available from 3,290 women who had up to six annual serum hormone measurements and sexual desire questionnaires. The researchers found that higher testosterone levels and lower levels of FSH were associated with higher levels of sexual desire, and vice versa, Dr. Randolph reported.

NEW ORLEANS — Hormone levels are weakly associated with sexual desire during the menopausal transition, while other sexual desire predictors are more important, according to an analysis of data from the Study of Women's Health Across the Nation.

Study investigator Dr. John Randolph, professor of obstetrics and gynecology at the University of Michigan, Ann Arbor, cautioned that while researchers found a significant association between women's sexual desire and their levels of testosterone and follicle-stimulating hormone (FSH), the association was small.

“It's biologically significant but probably not clinically significant—and I'm worried how this information might be misinterpreted,” he said at a press conference during the annual meeting of the American Society for Reproductive Medicine. The study found that satisfaction with an existing relationship and ethnicity were much stronger predictors of sexual desire.

The multicenter, multiethnic study, funded by the National Institutes of Health, included 3,302 women who were still menstruating at baseline, and followed them with annual serum hormone measurements and sexual desire questionnaires. The aim was to determine the role of hormone fluctuations over time in changing sexual desire over the menopausal transition. Testosterone, estradiol, FSH, dehydroepiandrosterone, and sex hormone-binding globulin were among the hormones measured.

Data were available from 3,290 women who had up to six annual serum hormone measurements and sexual desire questionnaires. The researchers found that higher testosterone levels and lower levels of FSH were associated with higher levels of sexual desire, and vice versa, Dr. Randolph reported.