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What's new in endocrinology and diabetes mellitus
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What's new in endocrinology and diabetes mellitus

Disclosures: Kathryn A Martin, MD Nothing to disclose. Jean E Mulder, MD Nothing to disclose.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are addressed by vetting through a multi-level review process, and through requirements for references to be provided to support the content. Appropriately referenced content is required of all authors and must conform to UpToDate standards of evidence.

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All topics are updated as new evidence becomes available and our peer review process is complete.
Literature review current through: Aug 2015. | This topic last updated: Sep 02, 2015.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

DIABETES MELLITUS

SGLT2 inhibitors may predispose to DKA (July 2015)

Sodium-glucose co-transporter 2 (SGLT2) inhibitors promote the renal excretion of glucose and thereby modestly lower elevated blood glucose levels in patients with type 2 diabetes. “Euglycemic” (usually meaning plasma glucose <250 mg/dL) diabetic ketoacidosis (DKA) has been reported in patients with type 2 diabetes taking SGLT2 inhibitors [1,2]. The absence of substantial hyperglycemia delayed recognition of DKA by both the patients and the clinicians. Thus, serum ketones should be obtained in any patient with nausea, vomiting, or malaise while taking SGLT2 inhibitors, and SGLT2 inhibitors should be discontinued if acidosis is confirmed. A warning about SGLT2 inhibitors and ketoacidosis was issued by the US Food and Drug Administration in May 2015. Given the absence of long-term efficacy and safety data, we do not recommend SGLT2 inhibitors for routine use in patients with type 2 diabetes. In addition, off-label use in type 1 diabetes is discouraged in the absence of sufficient safety data. (See "Management of persistent hyperglycemia in type 2 diabetes mellitus", section on 'SGLT2 inhibitors'.)

DPP-4 inhibitors for diabetes and cardiovascular safety (June 2015)

A number of trials have evaluated the cardiovascular effects of DPP-4 inhibitors. In a recent large trial, 14,735 patients with type 2 diabetes and established cardiovascular disease were randomly assigned to sitagliptin or placebo, in addition to other diabetes medications (predominantly metformin, sulfonylurea, insulin) [3]. After a median follow-up of three years, there was no difference in the primary composite cardiovascular outcome (cardiovascular death, nonfatal myocardial infarction, nonfatal stroke, or hospitalization for unstable angina), individual components of the composite, or hospitalization rate for heart failure (3.1 percent in each group). Although these data are reassuring, longer-term clinical trials are needed to definitively assess the cardiovascular safety of DPP-4 inhibitors in patients with heart disease. In addition, there are no data on cardiovascular safety in lower-risk patients. With only modest glucose-lowering effectiveness and relative expense, we do not consider DPP-4 inhibitors as options for initial therapy in the majority of patients with type 2 diabetes. (See "Dipeptidyl peptidase 4 (DPP-4) inhibitors for the treatment of type 2 diabetes mellitus", section on 'Cardiovascular effects'.)

Combination renin-angiotensin system inhibition in diabetic patients (June 2015)

Several randomized trials that directly compared dual versus single renin-angiotensin system inhibition in diabetic patients found that dual therapy produced no benefit and an increase in adverse effects. Findings are similar in a subsequent network meta-analysis [4]. In this analysis in patients with diabetes and hypertension, dual therapy with an angiotensin-converting enzyme (ACE) inhibitor plus an angiotensin II receptor blocker (ARB) was superior to placebo in preventing end-stage renal disease, but monotherapy with either an ACE inhibitor or an ARB, also compared with placebo, produced similar benefits while dual therapy produced more adverse effects. Combination renin-angiotensin system inhibition with an ACE inhibitor and ARB or direct renin inhibitor is not recommended in diabetic patients. (See "Treatment of hypertension in patients with diabetes mellitus", section on 'Avoid combination renin-angiotensin system inhibition'.)

Vorapaxar particularly beneficial in patients with recent MI and diabetes (April 2015)

Patients with diabetes and myocardial infarction (MI) are at high risk of subsequent cardiovascular events. The impact of vorapaxar, an antiplatelet agent, on these high-risk individuals was evaluated in a subgroup analysis of the TRA 2P-TIMI 50 trial, which had previously shown benefit with this agent in a broad group of patients with atherosclerotic cardiovascular disease treated with at least one other antiplatelet drug (aspirin or clopidogrel) [5]. Vorapaxar lowered the risk of cardiovascular events to a greater extent in patients with diabetes and a history of MI than those without diabetes. For patients with diabetes and a recent MI who cannot receive either ticagrelor or prasugrel (our preferred P2Y12 receptor blockers; used in combination with aspirin), and who are at low risk for bleeding, we suggest that vorapaxar be added to clopidogrel and aspirin. (See "Secondary prevention of cardiovascular disease", section on 'Vorapaxar'.)

VEGF inhibitors for diabetic macular edema (March 2015)

Vascular endothelial growth factor (VEGF) inhibitors (bevacizumab, ranibizumab, aflibercept) have been widely studied as a treatment for diabetic macular edema. In the only comparison trial, all three drugs had similar efficacy when visual acuity was better than 20/50, but when the baseline visual acuity was 20/50 or worse, aflibercept significantly improved visual acuity compared with the other two drugs (+19 letters versus +12 and +14 letters), with no difference in improvement between ranibizumab and bevacizumab [6]. Given the wide disparity in cost between the anti-VEGF agents, retina specialists must consider cost of care, as well as published treatment efficacy and the specific details of a patient’s ophthalmic history and retinal examination, in making the choice between drugs for a given patient. It is important to note that, at any level of visual acuity, an individual patient may see an improved response with a second or third drug after failing to respond to initial treatment with any of the three drugs. (See "Diabetic retinopathy: Prevention and treatment", section on 'VEGF inhibitors for ME'.)

FEMALE REPRODUCTION

Frozen donor oocyte use impacts live birth rate (August 2015)

Use of donor oocytes (eggs) in assisted reproductive technology has allowed women unable to conceive with their own eggs the opportunity to achieve pregnancy. The use of frozen oocytes is more convenient and less costly compared with fresh oocytes because the donor and recipient don't have to be hormonally synchronized and frozen eggs can be shipped anywhere. Although initial studies reported equivalent pregnancy and live birth rates for donor egg transfers, a study of over 11,000 oocyte donation cycles, including 20 percent using frozen eggs, reported the live birth rate per transfer for frozen donor oocytes was lower than the live birth rate for fresh donor oocytes (47 versus 56 percent) [7]. Despite the possible discrepancy in live birth rate, the improved efficiency and lower cost of cryopreserved donor oocytes makes their use a reasonable and attractive option. (See "Management of infertility and pregnancy in women of advanced age", section on 'Oocyte or embryo donation'.)

Medication approved for low sexual desire in women (August 2015)

Flibanserin is the first and currently only drug approved by the US Food and Drug Administration (FDA) for female sexual dysfunction [8]. Daily use results in modest increases in the frequency of sexually satisfying events and sexual desire. The clinical role of flibanserin may be limited by the need for daily dosing, common adverse effects (eg, somnolence, dizziness), and by safety concerns or lack of safety data regarding combining flibanserin with alcohol or certain medications (eg, fluconazole, CYP3A4 inhibitors, antidepressants). (See "Sexual dysfunction in women: Management", section on 'Flibanserin'.)

Fertility among survivors of childhood Hodgkin lymphoma (June 2015)

Counseling regarding infertility risks associated with Hodgkin lymphoma (HL) therapy is important for HL survivors of childbearing age. The impact of regimens used for childhood HL on long-term fertility was evaluated in a prospective study of over 450 female survivors of childhood HL in continuous remission with a median follow-up of 20 years [9]. For those younger than age 40, the likelihood of parenthood was similar to an age-matched German population. Factors associated with a decreased likelihood of successful pregnancy included age over 40 years and receipt of pelvic radiation. These results should be reassuring to HL survivors. (See "Overview of the approach to the adult survivor of classical Hodgkin lymphoma", section on 'Gonadal dysfunction'.)

Empiric progesterone supplementation of no benefit in recurrent pregnancy loss (April 2015)

Recurrent pregnancy loss is an extremely stressful experience for families and clinicians. One proposed mechanism of recurrent pregnancy loss is luteal phase deficiency, or inadequate progesterone production by the corpus luteum. A 2015 Committee Opinion by the American Society of Reproductive Medicine concluded that there is no evidence that empiric treatment of luteal phase deficiency with progesterone supplementation is beneficial to women with recurrent pregnancy loss in natural, unstimulated cycles (ie, no use of fertility therapy) [10]. When abnormal luteal function is the result of an identified medical condition, such as elevated prolactin, the underlying medical problem should be addressed. (See "Management of couples with recurrent pregnancy loss", section on 'Progesterone'.)

MALE REPRODUCTION

Testosterone injectables versus gels and cardiovascular risk (June 2015)

Concerns have been raised that testosterone therapy in men may be associated with an increase in cardiovascular risk. Available data now suggest that the route of testosterone administration may be associated with the excess risk. In a retrospective analysis of three databases of over 544,000 men receiving newly prescribed testosterone therapy, use of injectable testosterone preparations (which result in intermittent supraphysiologic serum testosterone concentrations) was associated with a greater risk of myocardial infarction (MI) and stroke, but not venous thromboembolism, when compared with testosterone gel use [11]. Of note, the absolute risks associated with testosterone injectables were low, and the study did not compare the rate of cardiovascular events in testosterone users versus nonusers. These data do not change our management approach. We typically suggest testosterone gels, but some men prefer injectables because of their lower cost and convenience. (See "Testosterone treatment of male hypogonadism", section on 'Cardiovascular risks'.)

X-linked TEX11 mutations and azoospermia (May 2015)

Y-chromosome defects and a number of autosomal and X-linked gene mutations are increasingly recognized as genetic causes of azoospermia and severe oligospermia. X-linked TEX11 mutations have now been identified as an important cause of meiotic arrest and azoospermia in infertile men [12]. In a report, hemizygous TEX11 mutations on chromosome Xq13.2 were identified in 7 of 289 men with azoospermia (2.4 percent). In testes from normal men, immunohistochemical analysis showed TEX11 expression in late spermatocytes, and in round and elongated spermatids. Testes from patients with azoospermia and TEX11 mutations had meiotic arrest and no TEX11 expression. (See "Causes of male infertility", section on 'Autosomal and X chromosome defects'.)

Testosterone therapy and cardiovascular risk (April 2015)

Testosterone products are approved by the US Food and Drug Administration (FDA) only for use in men who have low serum testosterone levels in conjunction with an associated medical condition. However, there has been a dramatic increase in inappropriate use of testosterone therapy in healthy middle-aged men with nonspecific symptoms, such as decreased energy and sexual interest, and in older men with low testosterone due to normal aging. A number of studies suggest that there may be an increased risk of myocardial infarction and stroke associated with testosterone use. Although data are conflicting, the FDA is now requiring that manufacturers of testosterone products add information to the labeling about this possible increase in cardiovascular risk [13]. Labeling must also be changed to clarify the approved uses of testosterone. (See "Testosterone treatment of male hypogonadism", section on 'Cardiovascular risks'.)

MENOPAUSE

Menopausal hormone therapy and cardiovascular risk: Timing of exposure (June 2015)

Current evidence suggests that the use of menopausal hormone therapy (MHT) in the early menopausal years (<10 years from menopause) may not be associated with excess cardiovascular risk when compared with use in the later menopausal years. This has been referred to as the "timing hypothesis." Additional support for this hypothesis comes from a 2015 meta-analysis of 19 trials of oral (including the Womens Health Initiative), but not transdermal, MHT in over 40,000 postmenopausal women [14]. A subgroup analysis in women who started MHT less than 10 years after menopause showed a lower risk of coronary heart disease (CHD) compared with placebo (RR 0.52; 8 fewer cases of heart disease per 1000 women treated/year) and a lower mortality rate (RR 0.70; 6 fewer deaths per 1000 women treated/year). However, there were important limitations in this analysis; when one methodologically flawed trial was removed, the beneficial effects on CHD and mortality were no longer significant (but no adverse effects were seen). These data provide additional evidence that oral MHT use in younger postmenopausal women is not associated with excess CHD risk. (See "Menopausal hormone therapy: Benefits and risks", section on 'Younger postmenopausal women'.)

Menopausal hormone therapy effect on cognition and mood in younger menopausal women (June 2015)

Menopausal hormone therapy (MHT) in older menopausal women (>65 years) has an adverse effect on cognitive function and an inconsistent effect on mood. The KEEPS study (Kronos Early Estrogen Prevention Study), a trial of menopausal hormone therapy (MHT) in younger menopausal women ages 45 to 54 years who underwent extensive cognitive and mood testing, reported that four years of MHT had no overall effect on cognition when compared with placebo [15]. However, oral estrogen appeared to improve mood, as women receiving oral conjugated estrogen combined with micronized progesterone had lower depression and anxiety scores than those receiving either transdermal estradiol (with micronized progesterone) or placebo. (See "Menopausal hormone therapy: Benefits and risks", section on 'Cognitive function and dementia'.)

Long duration of hot flashes (March 2015)

For many if not most menopausal women, hot flashes last considerably longer than the duration currently recommended for treatment of symptoms (maximum 4 to 5 years to minimize excess breast cancer risk). Among 1449 women with hot flashes followed longitudinally in the Study of Women Across the Nation (SWAN), the median total hot flash duration was 7.4 years, with symptoms persisting for a median of 4.5 years after the final menstrual period (FMP) [16]. Women who were premenopausal or early perimenopausal when they first experienced hot flashes had the longest total duration (>11.8 years, post-FMP median duration 9.4 years). The long duration of hot flashes raises important treatment challenges for many women, particularly those with early onset symptoms. (See "Menopausal hot flashes", section on 'Duration'.)

Menopausal hormone therapy and risk of ovarian cancer (March 2015)

There have been concerns that menopausal hormone therapy (MHT) may be associated with an increase in ovarian cancer risk, but data are conflicting. A meta-analysis of 52 epidemiologic studies including 21,488 postmenopausal women with ovarian cancer now suggests that there is a small excess risk of ovarian cancer with MHT [17]. While the relative risk of ovarian cancer was greater in ever-users than never-users of MHT (RR 1.14), the calculated absolute excess risk associated with MHT was very low: five years of MHT use in women ages 50 to 54 years would result in about one additional ovarian cancer case per 1000 users and one ovarian cancer death per 1700 users. Given these low absolute risks, we do not consider ovarian cancer to be a major consideration when deciding to take MHT for symptomatic relief. (See "Menopausal hormone therapy: Benefits and risks", section on 'Ovarian cancer'.)

OBESITY

FTO variant and obesity (September 2015)

Large genome wide association studies have demonstrated that variants in the FTO gene have the strongest association with obesity risk in the general population, but the mechanism of the association has been unclear. However, a nonocoding causal variant in FTO has now been identified that changes the function of adipocytes from energy utilization (beige fat) to energy storage (white fat) with a fivefold decrease in mitochondrial thermogenesis [18]. When the effect of the variant was blocked in genetically engineered mice, thermogenesis increased and weight gain did not occur, despite eating a high-fat diet. Blocking the gene's effect in human adipocytes also increased energy utilization. This observation has important implications for potential new anti-obesity drugs. (See "Pathogenesis of obesity", section on 'FTO variants'.)

Liraglutide for the treatment of obesity (July 2015)

Along with diet, exercise, and behavior modification, drug therapy may be a helpful component of treatment for select patients who are overweight or obese. Liraglutide is a glucagon-like peptide-1 (GLP-1) receptor agonist, used for the treatment of type 2 diabetes. In a randomized trial in nondiabetic patients who had a body mass index (BMI) of ≥30 kg/m2 or ≥27 kg/m2 with dyslipidemia and/or hypertension, liraglutide 3 mg once daily, compared with placebo, resulted in greater mean weight loss (-8.0 versus -2.6 kg with placebo) [19]. In addition, cardiometabolic risk factors, glycated hemoglobin (A1C), and quality of life improved modestly. Gastrointestinal side effects transiently affected at least 40 percent of the liraglutide group and were the most common reason for withdrawal (6.4 percent). Liraglutide is an option for select overweight or obese patients, particularly those with type 2 diabetes, although gastrointestinal side effects (nausea, vomiting) and the need for a daily injection may limit the use of this drug. (See "Obesity in adults: Drug therapy", section on 'Liraglutide'.)

Comparison of commercial weight loss programs in the United States (April 2015)

A comprehensive lifestyle intervention (combined diet, exercise, and behavioral treatment) is the most important strategy for weight management. Self-help or commercial weight loss programs incorporate varying degrees of behavioral modification strategies with dietary change. A systematic review of the major available programs in the United States reported outcomes based upon a variety of measures [20]. Only two programs (Weight Watchers and Jenny Craig) reported 12-month outcomes. Compared with control groups that included education or education plus counseling, trials found an approximately 3 to 5 percent greater weight loss at 12 months for participants in the intervention arms. Longer-term outcomes are needed to better evaluate the effectiveness of other commercial programs. Commercial programs are an option for weight management of overweight or obese patients, with the recommendation that programs with clinically demonstrated efficacy be the first choice. (See "Obesity in adults: Behavioral therapy", section on 'Self-help or commercial weight loss programs'.)

Pregnancy outcomes after bariatric surgery (March 2015)

Bariatric surgery prior to pregnancy appears to reduce the risk of certain adverse pregnancy outcomes associated with maternal obesity. In the largest study to date evaluating this issue, women who had bariatric surgery prior to pregnancy were less likely to have gestational diabetes and large-for-gestational-age infants compared with women matched for age and presurgical body mass index (BMI) who had not undergone bariatric surgery [21]. However, they were more likely to have small-for-gestational-age infants. The risks of preterm birth, stillbirth or neonatal death, and congenital malformations were not statistically different between the two groups. (See "Fertility and pregnancy after bariatric surgery", section on 'Pregnancy outcomes'.)

OSTEOPOROSIS

Exercise and vitamin D for fall prevention in older women (March 2015)

A randomized trial in home-dwelling women aged 70 to 80 years old with a history of at least one fall in the previous year evaluated the effect of exercise and/or vitamin D supplementation (800 IU per day) on fall prevention [22]. Strength and balance training did not affect the rate of falls, but halved the number of injurious falls and injured fallers, and improved muscle strength and balance compared with no exercise. Vitamin D, compared with placebo, did not prevent falls or fall-related injuries. Baseline 25-hydroxyvitamin D levels in the trial participants (26 to 28 ng/mL) were above the threshold for what is generally considered deficient. Prior meta-analyses have inconsistent findings on the effectiveness of vitamin D in fall prevention. We continue to suggest an exercise program to improve strength and balance for older adults at risk for falls. Given the low risk associated with vitamin D supplementation, and the possibility of benefit at least in adults with low baseline levels of vitamin D, we also continue to advise vitamin D supplementation. (See "Falls: Prevention in community-dwelling older persons", section on 'Exercise' and "Falls: Prevention in community-dwelling older persons", section on 'Vitamin D supplementation'.)

THYROID DISORDERS

Subclinical hyperthyroidism and fracture risk (July 2015)

Patients with subclinical hyperthyroidism have normal serum concentrations of free thyroxine (T4) and triiodothyronine (T3), but subnormal concentrations of thyroid-stimulating hormone (TSH). Common causes of subclinical hyperthyroidism include autonomously functioning thyroid adenomas and multinodular goiters, Graves’ disease, or excessive thyroid hormone therapy. Subclinical hyperthyroidism is associated with reduced bone density, particularly in cortical-rich bone in postmenopausal women. The risk of fracture has been less certain. A meta-analysis of 13 prospective cohort studies showed that compared with euthyroidism, endogenous subclinical hyperthyroidism (autonomy or Graves' disease) was associated with an increased risk of hip fracture (6.1 versus 4.4 percent) [23]. In this analysis, lower TSH levels (<0.10 mU/L) were associated with higher fracture rates. (See "Bone disease with hyperthyroidism and thyroid hormone therapy", section on 'Fracture risk'.)

Lenvatinib for progressive unresponsive differentiated thyroid cancer (February 2015)

For patients with metastatic differentiated thyroid cancer (DTC) that progresses despite traditional therapy, treatment with kinase inhibitors can stabilize disease. In an international, randomized, double-blind trial, 392 patients with progressive, radioiodine refractory thyroid cancer were randomly assigned to lenvatinib, a multitargeted kinase inhibitor (MKI), or placebo [24]. The median progression-free survival (18.3 versus 3.6 months) and the response rate (64.8 versus 1.5 percent) were significantly better in the lenvatinib group. For most patients with progressive unresponsive DTC, we prefer enrollment in a clinical trial of therapies targeting the molecular and cellular pathogenesis of DTC. For patients who are unable to participate in clinical trials, we suggest an oral MKI, such as lenvatinib. (See "Differentiated thyroid cancer refractory to standard treatment: Chemotherapy", section on 'Lenvatinib'.)

VITAMIN D

Vitamin D supplementation during pregnancy (May 2015)

Several observational studies suggest an association between poor maternal vitamin D status and adverse pregnancy outcomes. A meta-analysis of 13 trials showed that, compared with a control group, vitamin D administration (in varied dosing, types, and schedules) resulted in higher serum 25(OH)D levels at delivery but no difference in the incidence rates of preeclampsia or gestational diabetes [25]. There was also no difference in the incidence rates of small for gestational age, low birth weight, and preterm birth in the neonates. Although routine prenatal vitamin D supplementation does not appear to prevent low birthweight, preterm birth, or preeclampsia, the earliest interventions in the published trials were made in the late first trimester. Initiation of therapy with vitamin D prior to conception has not been evaluated. (See "Vitamin D and extraskeletal health", section on 'Pregnancy outcomes'.)

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REFERENCES

  1. Peters AL, Buschur EO, Buse JB, et al. Euglycemic Diabetic Ketoacidosis: A Potential Complication of Treatment With Sodium-Glucose Cotransporter 2 Inhibition. Diabetes Care 2015.
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  4. Palmer SC, Mavridis D, Navarese E, et al. Comparative efficacy and safety of blood pressure-lowering agents in adults with diabetes and kidney disease: a network meta-analysis. Lancet 2015; 385:2047.
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  6. Diabetic Retinopathy Clinical Research Network, Wells JA, Glassman AR, et al. Aflibercept, bevacizumab, or ranibizumab for diabetic macular edema. N Engl J Med 2015; 372:1193.
  7. Kushnir VA, Barad DH, Albertini DF, et al. Outcomes of Fresh and Cryopreserved Oocyte Donation. JAMA 2015; 314:623.
  8. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm458734.htm (Accessed on August 24, 2015).
  9. Brämswig JH, Riepenhausen M, Schellong G. Parenthood in adult female survivors treated for Hodgkin's lymphoma during childhood and adolescence: a prospective, longitudinal study. Lancet Oncol 2015; 16:667.
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