1
|
Clemenza S, Vannuccini S, Ruotolo A, Capezzuoli T, Petraglia F. Advances in targeting estrogen synthesis and receptors in patients with endometriosis. Expert Opin Investig Drugs 2022; 31:1227-1238. [PMID: 36529967 DOI: 10.1080/13543784.2022.2152325] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Endometriosis is an estrogen-dependent disease on the background of progesterone resistance. Increased estrogen production, low estrogen metabolization, and altered estrogen receptors (ERs) expression contribute to the hyperestrogenic milieu within endometriotic lesions. Since estrogens play a crucial role in the pathogenesis of the disease, inhibition of estrogen production is one of the main targets of available and emerging drugs. AREAS COVERED Firstly, we described the molecular alterations responsible for estrogen dependence. Secondly, we reviewed available and emerging treatments that interfere, through central (gonadotropin-releasing hormone analogs (GnRH-a), GnRH antagonists) or local mechanisms (aromatase inhibitors (AIs), inhibitors of steroid sulfatase (STS) and hydroxysteroid dehydrogenase type 1 (17β-HSD1)), with estrogen dependence. Finally, we focused on emerging treatments targeting ERs (selective estrogen receptor modulators (SERMs), estrogen receptors agonists, and antagonists). EXPERT OPINION Available treatments interfering with estrogen pathways exert a contraceptive effect, have hypoestrogenic side effects, and cannot prevent or definitively treat the disease. Preclinical and animal studies are focusing on emerging drugs targeting ERs in order to overcome limitations of available treatments. These treatments may represent a promising option, as they may produce a more specific inhibition of disease activity within endometriotic implants, avoiding prolonged hypoestrogenic status and limiting systemic side effects.
Collapse
Affiliation(s)
- Sara Clemenza
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Silvia Vannuccini
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Agostino Ruotolo
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Tommaso Capezzuoli
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| | - Felice Petraglia
- Department of Experimental, Clinical and Biomedical Sciences, University of Florence, Careggi University Hospital, Florence, Italy
| |
Collapse
|
2
|
Wu Y, Liu Y, Jia H, Luo C, Chen H. Treatment of endometriosis with dienogest in combination with traditional Chinese medicine: A systematic review and meta-analysis. Front Surg 2022; 9:992490. [PMID: 36386543 PMCID: PMC9663487 DOI: 10.3389/fsurg.2022.992490] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/11/2022] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND Endometriosis is now considered to be a systemic disease rather than a disease that primarily affects the pelvis. Dienogest (DNG) has unique advantages in the treatment of endometriosis, but it also has side effects. Alternatively, Traditional Chinese Medicine (TCM) has been used for over 2000 years in the treatment and prevention of disease and growing numbers of Chinese scholars are experimenting with the combined use of Dienogest and TCM for endometriosis treatment. OBJECTIVES This review evaluated the efficacy and safety of TCM in combination with Dienogest in the treatment of endometriosis through meta-analysis. METHODS MEDLINE, Embase, the Cochrane Library, PubMed, Web of Science, China National Knowledge Infrastructure, Journal Integration Platform, and Wanfang were used in literature searches, with a deadline of May 31, 2022. Literature quality was assessed using the Cochrane Collaboration "risk of bias" (ROB2) tool, and the "meta" package of R software v.4.1 was used for meta-analysis. Dichotomous variables and continuous variables were assessed using the relative risk (RR) and 95% confidence intervals (95% CI); standard mean differences (MD) and 95% CI, respectively. RESULTS Twelve human randomized controlled trials (RCTs) and one retrospective study, all 13 written in the Chinese language, were included in the meta-analysis (720 experiments and 719 controls). The result indicated that TCM plus Dienogest was superior to Dienogest/TCM alone in increasing the cure rates (RR = 1.3780; 95% CI, 1.1058, 1.7172; P = 0.0043), remarkable effect rate (RR = 1.3389; 95% CI, 1.1829, 1.5154; P < 0.0001), invalid rate (RR = 0.2299; 95% CI, 0.1591, 0.3322; P < 0.0001), and rate of adverse effects (RR = 0.6177; 95% CI, 0.4288, 0.8899; P = 0.0097). The same conclusion was drawn from the subgroup analysis. CONCLUSION Results suggest that TCM combined with Dienogest is superior to Dienogest or TCM alone and can be used as a complementary treatment for endometriosis. TCMs have potential to improve clinical efficacy and reduce the side effects of Dienogest. This study was financially supported by Annual Science and Technology Steering Plan Project of Zhuzhou. PROSPERO has registered our meta-analysis as CRD42022339518 (https://www.crd.york.ac.uk/prospero/record_email.php).
Collapse
Affiliation(s)
- Yu’e Wu
- Guangdong Laboratory Animals Monitoring Insitute, Guangdong Provincial Key Laboratory of Laboratory Animals, Guangzhou, China
| | - Yujie Liu
- Department of Obstetrics, Zhuzhou Central Hospital, Zhuzhou, China
| | - Huanhuan Jia
- Guangdong Laboratory Animals Monitoring Insitute, Guangdong Provincial Key Laboratory of Laboratory Animals, Guangzhou, China
| | - Chao Luo
- Department of Neurology, Zhuzhou Central Hospital, Zhuzhou, China
| | - Huan Chen
- Department of Obstetrics, Zhuzhou Central Hospital, Zhuzhou, China
| |
Collapse
|
3
|
Della Corte L, Barra F, Mercorio A, Evangelisti G, Rapisarda AMC, Ferrero S, Bifulco G, Giampaolino P. Tolerability considerations for gonadotropin-releasing hormone analogues for endometriosis. Expert Opin Drug Metab Toxicol 2020; 16:759-768. [DOI: 10.1080/17425255.2020.1789591] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Luigi Della Corte
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples “Federico II”, Naples, Italy
| | - Fabio Barra
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy
| | - Antonio Mercorio
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples “Federico II”, Naples, Italy
| | - Giulio Evangelisti
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy
| | | | - Simone Ferrero
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (Dinogmi), University of Genoa, Italy
| | - Giuseppe Bifulco
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples “Federico II”, Naples, Italy
| | - Pierluigi Giampaolino
- Department of Public Health, School of Medicine, University of Naples Federico II, Naples, Italy
| |
Collapse
|
4
|
Abstract
Drugs may cause bone loss by lowering sex steroid levels (e.g., aromatase inhibitors in breast cancer, GnRH agonists in prostate cancer, or depot medroxyprogestone acetate - DMPA), interfere with vitamin D levels (liver inducing anti-epileptic drugs), or directly by toxic effects on bone cells (chemotherapy, phenytoin, or thiazolidinedions, which diverts mesenchymal stem cells from forming osteoblasts to forming adipocytes). However, besides effects on the mineralized matrix, interactions with collagen and other parts of the unmineralized matrix may decrease bone biomechanical competence in a manner that may not correlate with bone mineral density (BMD) measured by dual energy absorptiometry (DXA).Some drugs and drug classes may decrease BMD like the thiazolidinediones and consequently increase fracture risk. Other drugs such as glucocorticoids may decrease BMD, and thus increase fracture risk. However, glucocorticoids may also interfere with the unmineralized matrix leading to an increase in fracture risk, not mirrored in BMD changes. Some drugs such as selective serotonin reuptake inhibitors (SSRI), paracetamol, and non-steroidal anti-inflammatory drugs (NSAIDs) may not per se be associated with bone loss, but fracture risk may be increased, possibly stemming from an increased risk of falls stemming from effects on postural balance mediated by effects on the central nervous system or cardiovascular system.This paper performs a systematic review of drugs inducing bone loss or associated with fracture risk. The chapter is organized by the Anatomical Therapeutic Chemical (ATC) classification.
Collapse
Affiliation(s)
- Peter Vestergaard
- Department of Endocrinology, Aalborg University Hospital, Aalborg, Denmark.
- Steno Diabetes Center North Jutland, Aalborg, Denmark.
| |
Collapse
|
5
|
Liu HJ, Kim SA, Shim DJ, Jung JM, Lee EJ. Influence of Supplementary Vitamin D on Bone Mineral Density When Used in Combination with Selective Estrogen Receptor Modulators. J Menopausal Med 2019; 25:94-99. [PMID: 31497579 PMCID: PMC6718647 DOI: 10.6118/jmm.19193] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 03/05/2019] [Accepted: 04/04/2019] [Indexed: 11/09/2022] Open
Abstract
Objectives Vitamin D is regarded as one of the major nutrients that significantly influence bone metabolism. This study aims to look at the effect of supplementary vitamin D on bone mineral density (BMD) in female osteoporosis patients. Methods The retrospective hospital record review was performed on 282 patients who were diagnosed with osteoporosis and treated with selective estrogen receptor modulators (SERMs) between January 2015 and December 2016. Of these patients, 151 were treated with SERMs only while 131 were treated using both SERMs and vitamin D supplements. The BMD and any occurrence of osteoporotic fracture episode were investigated after one year. The result of two groups was compared to find the significance of vitamin D. Results Overall, improvement in BMD score was observed in 76% of the patients. The BMD of the SERMs only group improved by 3% in spine and 1% in the hip while that of the SERMs with vitamin D group improved by 6% and 1% respectively. Statistical significance was noticed in the spine only. One distal radius fracture and one single level vertebral fracture occurred in patients of SERMs group while two distal radius fractures occurred in SERMs with vitamin D group. There was no occurrence of around hip fracture in both groups. Conclusion The result of the current study suggests that additional vitamin D may have some additive effect on improving BMD of the spine. Further study with the larger study population and the extended study period is recommended.
Collapse
Affiliation(s)
- Hyun Ju Liu
- Department of Obstetrics and Gynecology, Veteran's Hospital, Gwangju, Korea
| | - Soo Ah Kim
- Department of Obstetrics and Gynecology, Chosun University Hospital, Gwangju, Korea.,Department of Obstetrics and Gynecology, School of Medicine, Chosun University, Gwangju, Korea
| | - Da Joung Shim
- Department of Obstetrics and Gynecology, Chosun University Hospital, Gwangju, Korea
| | - Ji Min Jung
- Department of Obstetrics and Gynecology, Chosun University Hospital, Gwangju, Korea
| | - Eun Jeong Lee
- Department of Obstetrics and Gynecology, Chosun University Hospital, Gwangju, Korea
| |
Collapse
|
6
|
Azami A, Anari H, Iranparvar M, Azizi A, Habibzadeh A. Comparison of Bone Mineral Densitometry at 2 Sites Versus 3 Sites in Patients Suspicious for Osteoporosis. CLINICAL MEDICINE INSIGHTS-ARTHRITIS AND MUSCULOSKELETAL DISORDERS 2019; 12:1179544119849017. [PMID: 31205427 PMCID: PMC6535902 DOI: 10.1177/1179544119849017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 04/13/2019] [Indexed: 11/15/2022]
Abstract
Objectives: In this study, we aim to evaluate the bone mineral density (BMD) results of 2 standard sites with 3 sites including wrist in diagnosing osteoporosis. Methods: We evaluated the BMD results of 1272 individuals referred for suspected osteoporosis between 2012 and 2015. Those individuals were included with BMD at lumbar spine, femur neck, and wrist. Bone mineral density was measured using a dual-energy X-ray absorptiometry (DXA) device. Bone mineral density and T score were measured for all 3 sites. Results: There was significant correlation between wrist T score with hip T score (r = 0.606, P < .001) and lumbar T score (r = 0.527, P < .001). With BMD of 2 sites, patients had osteopenia in 46.3% and osteoporosis in 23.7%, while by adding wrist T-BMD, subjects had osteopenia in 46.6% and osteoporosis in 33%. Between BMD at 2 sites and 3 sites, there was concordance in 81.9%, minor discordance in 17.6%, and major discordance in 0.5%. Conclusions: We observed discordance between BMD measurements of 2 sites and 3 sites, with latter detecting more cases with osteoporosis. In fact, measurement of T scores of wrist along with lumbar and femur neck improves the diagnosis.
Collapse
Affiliation(s)
- Ahad Azami
- Department of Internal Medicine, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Hasan Anari
- Department of Radiology, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Manouchehr Iranparvar
- Department of Internal Medicine, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Amin Azizi
- Department of Internal Medicine, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Afshin Habibzadeh
- Department of Internal Medicine, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran
- Afshin Habibzadeh, Department of Internal Medicine, Imam Khomeini Hospital, Ardabil University of Medical Sciences, Ardabil, Iran.
| |
Collapse
|
7
|
Gheorghisan-Galateanu AA, Gheorghiu ML. HORMONAL THERAPY IN WOMEN OF REPRODUCTIVE AGE WITH ENDOMETRIOSIS: AN UPDATE. ACTA ENDOCRINOLOGICA-BUCHAREST 2019; 15:276-281. [PMID: 31508191 DOI: 10.4183/aeb.2019.276] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Medical therapy of endometriosis is under continuous reevaluation. Hereby we updated the drugs currently available or under investigation for the hormonal treatment of endometriosis.
Collapse
Affiliation(s)
- A A Gheorghisan-Galateanu
- "Carol Davila" University of Medicine and Pharmacy - Dept. of Cellular and Molecular Biology and Histology, Bucharest, Romania.,"C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| | - M L Gheorghiu
- "Carol Davila" University of Medicine and Pharmacy - Dept. of Endocrinology, Bucharest, Romania.,"C.I. Parhon" National Institute of Endocrinology, Bucharest, Romania
| |
Collapse
|
8
|
Khorsand I, Kashef R, Ghazanfarpour M, Mansouri E, Dashti S, Khadivzadeh T. The Beneficial and Adverse Effects of Raloxifene in Menopausal Women: A Mini Review. J Menopausal Med 2018; 24:183-187. [PMID: 30671411 PMCID: PMC6336572 DOI: 10.6118/jmm.2018.24.3.183] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 08/12/2018] [Accepted: 09/24/2018] [Indexed: 11/06/2022] Open
Abstract
Objectives The present mini review aimed to summarize the existing knowledge regarding the beneficial and adverse effects of raloxifene in menopausal women. Methods This study is a review of relevant publications about the effects of raloxifene on sleep disorder, depression, venous thromboembolism, the plasma concentration of lipoprotein, breast cancer, and cognitive function among menopausal women. Results Raloxifene showed no significant effect on depression and sleep disorder. Verbal memory improved with administration of 60 mg/day of raloxifene while a mild cognitive impairment risk reduction by 33% was observed with administration of 120 mg/day of raloxifene. Raloxifene was associated with a 50% decrease in the need for prolapse surgery. The result of a meta-analysis showed a significant decline in the plasma concentration of lipoprotein in the raloxifene group compared to placebo (standardized mean difference, −0.43; 10 trials). A network meta-analysis showed that raloxifene significantly decreased the risk of breast cancer (relative risk, 0.572; 95% confidence interval, 0.327–0.881; P = 0.01). In terms of adverse effects of raloxifene, the odds ratio (OR) was observed to be 1.54 (P = 0.006), indicating 54% increase in the risk of deep vein thrombosis (DVT) while the OR for pulmonary embolism (PE) was 1.05, suggesting a 91% increase in the risk of PE alone (P = 0.03). Conclusions Raloxifene had no significant effect on depression and sleep disorder but decreased the concentration of lipoprotein. Raloxifene administration was associated with an increased risk of DVT and PE and a decreased risk of breast cancer and pelvic organ prolapse in postmenopausal women.
Collapse
Affiliation(s)
- Imaneh Khorsand
- Department of Parasitology and Mycology, Ghaem Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Reyhaneh Kashef
- Hope Generation Genetic & Feto Maternal Clinic, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Masumeh Ghazanfarpour
- Department of Nursing and Midwifery, Razi School of Nursing and Midwifery, Kerman University of Medical Sciences, Kerman, Iran
| | | | - Sareh Dashti
- Department of Community Health, Faculty of Medicine and Health Sciences, University Putra Malaysia, Serdang, Malaysia
| | | |
Collapse
|
9
|
Park BK, Yun KY, Kim SC, Joo JK, Lee KS, Choi OH. The Relationship between Renal Function and Bone Marrow Density in Healthy Korean Women. J Menopausal Med 2017; 23:96-101. [PMID: 28951857 PMCID: PMC5606916 DOI: 10.6118/jmm.2017.23.2.96] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2017] [Revised: 03/15/2017] [Accepted: 03/27/2017] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVES The relationship between renal function and bone mineral density (BMD) is controversial. We evaluated the relationship between markers of renal function and BMD in healthy Korean women. METHODS A total of 1,093 women who visited the health promotion center at Pusan National University hospital were included in the cross-sectional study. We divided the study population into two groups by BMD: osteopenia-osteoporosis and normal in the lumbar and femur regions, respectively. We compared the relationship between renal function and BMD using a logistic regression model and used SAS 9.3 (SAS Institute, Inc., Cary, NC, USA) for all statistical analysis. RESULTS Blood urea nitrogen (BUN), creatinine, and cystatin C (Cys-C) were correlated with BMD in both the normal and osteopenia-osteoporosis groups, and in logistic regression analysis, BUN and Cys-C were correlated with lumbar and femur BMD. However, after we adjusted for age, menopause, and body mass index, only creatinine showed a negative correlation with lumbar BMD, and estimated glomerular filtration rate (eGFR) was related positively with femur BMD. CONCLUSIONS Serum creatinine could be a marker for lumbar BMD and eGFR for femur BMD in Korean women without overt nephropathy.
Collapse
Affiliation(s)
- Byung Kyu Park
- Department of Obstetrics and Gynecology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ka Yeong Yun
- Department of Obstetrics and Gynecology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Seung Chul Kim
- Department of Obstetrics and Gynecology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Jong Kil Joo
- Department of Obstetrics and Gynecology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Kyu Sup Lee
- Department of Obstetrics and Gynecology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| | - Ook Hwan Choi
- Department of Obstetrics and Gynecology, Medical Research Institute, Pusan National University Hospital, Busan, Korea
| |
Collapse
|
10
|
Um MJ, Cho EA, Jung H. Combination Therapy of Raloxifene and Alendronate for Treatment of Osteoporosis in Elderly Women. J Menopausal Med 2017; 23:56-62. [PMID: 28523260 PMCID: PMC5432468 DOI: 10.6118/jmm.2017.23.1.56] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Revised: 03/21/2017] [Accepted: 03/23/2017] [Indexed: 12/22/2022] Open
Abstract
Objectives To evaluate and compare the efficacy and safety of the combination of raloxifene and alendronate with those of monotherapies in elderly women with osteoporosis. Methods Sixty-two postmenopausal women (mean age 63.5 ± 0.5 years) attending gynecologic osteoporosis clinics with established osteoporosis were randomly allocated to one of four treatment groups and monitored for 3 years. All patients enrolled in this study, including those in the control group (n = 14), received 1.0 g elemental calcium and 400 units of vitamin D per day. The raloxifene group (n = 16) received raloxifene 60 mg (Evista®) per day; alendronate group (n = 17) received low-dose (5 mg) alendronate with calcitriol 0.5 µg (Maxmarvil®) per day; and the combination therapy group (n = 15) received both raloxifene 60 mg and low-dose (5 mg) alendronate with calcitriol 0.5 µg. Bone mineral density (BMD) was measured in the lumbar spine and hip before and after 3 years of treatment. Results In patients who received the combined therapy, BMD increased in the lumbar spine and the hip by 7.2% (P<0.001) and 4.8% (P<0.001) at 3 years. For patients in the alendronate group, the increases were 6.7% (P<0.001) and 3.1% (P<0.01) respectively, for the raloxifene group, the increases were 4.36% (P<0.001) and 1.9% (P<0.05) in the vertebrae and femora, respectively; however, the BMD of patients in the control group decreased by 1.81% (P<0.05) and 1.6% (P<0.05), respectively, after 3 years. Patients who received the combination therapy had significantly higher BMD in both the vertebrae femora (P<0.01) in comparison to that in those treated with raloxifene or alendronate individually. Conclusions This 3-year randomized study showed the improved effects of alendronate and raloxifene combination on spine and hip BMD in elderly postmenopausal women with established osteoporosis.
Collapse
Affiliation(s)
- Mi Jung Um
- Department of Obstetrics and Gynecology, Chosun University Hospital, Gwangju, Korea
| | - Eun A Cho
- Department of Nursing, Honam University, Gwangju, Korea
| | - Hyuk Jung
- Department of Obstetrics and Gynecology, Chosun University Hospital, Gwangju, Korea.,Department of Obstetrics and Gynecology, Chosun University School of Medicine, Gwangju, Korea
| |
Collapse
|