Have you heard of adenomyosis?

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What is adenomyosis?

Adenomyosis is where the inner lining of the uterus invades the muscle wall of the uterus. It is similar to endometriosis which is where the inner lining of the uterus is found in other parts of the body, such as in the fallopian tubes or attached to the ovaries. Adenomyosis is where it buries into the muscle wall of the uterus.

The causes of adenomyosis are unclear. Three potential causes are postulated1:

  • The lining cells are already present at birth within the uterine wall
  • The lining cells grow into the muscle due to surgery
  • The lining cells grow into the weakened muscle due to the birthing process

Oestrogen is required for adenomyosis to grow. So, the majority of women diagnosed with adenomyosis are in the reproductive age. It is thought that 10% of women of reproductive age who have had children and are aged between 40-55 years old have adenomyosis2. It goes away after menopause when oestrogen production drops.

What are the symptoms for adenomyosis?

In the early stages, patients do not have any symptoms at all. The possibility of adenomyosis is suggested incidentally on ultrasound. Eighty percent of people with adenomyosis have uterine fibroids and patients often present with symptoms related to the uterine fibroids2. When adenomyosis is more advanced, patients can present with1:

  • Painful periods
  • Heavy periods
  • Bleeding between periods
  • Painful intercourse (dyspareunia)
  • Chronic pelvic pain
  • Anaemia from the heavy periods
  • Clinical examination by a doctor can find a tender and bulky uterus


How do you diagnose adenomyosis?

Adenomyosis is quite difficult to diagnose.

The clinical symptoms and examination findings are non-specific.

There is no blood test to diagnose adenomyosis.

Ultrasound or MRI can assist with diagnosis but requires specific expertise to detect subtle changes on imaging studies. A transvaginal ultrasound is often the first line investigation showing mottled appearance of the inner lining of the uterus, cystic spaces within the uterine wall and an enlarged, globular uterus2.

A biopsy of the tissue to confirm diagnosis requires anaesthetising the patient and can still be subjected to sampling error ie. if you take a sample from an area of the uterine wall that doesn’t have adenomyosis you could come to the incorrect diagnosis3.

Ultimately, definitive diagnosis of adenomyosis is made on hysterectomy where the uterine wall can be dissected to confirm the diagnosis. This is not ideal in many cases.

What treatments are available?

Management of the adenomyosis is determined by the severity of symptoms and the childbearing plans of the women.

  • There are options to manage the symptoms of patients with oral medications1:
    • reduce pain eg. non-steroidal anti-inflammatory drugs  – mefenamic acid or naproxen
    • reduce blood flow eg. tranexamic acid
  • For women who need to retain the uterus, the more effective medical management options include2,4:
    • Hormonal intrauterine device (IUD) insertion 
      • it causes thinning of the lining of the uterus reducing the heavy bleeds
      • it does not affect the ovarian hormone production so does not stop the growth of the adenomyosis so the ongoing increase in the size of the uterine will further increase pain
    • GnRH agonists
      • these drugs are used to suppress normal ovarian hormone production and therefore starve the adenomyosis of fuel to grow
      • patients will not experience periods as GnRH agonists induce menopause chemically and so reduce pain and bleeding
      • some patients may not tolerate the side effects of menopause

If the hormonal IUD or GnRH agonist is removed, the patient’s adenomyosis symptoms return. This means that the treatment is reversible and allows the woman to consider childbearing in the future.

  • Uterine artery embolization is an invasive, non-surgical option. In this procedure, the uterine artery is occluded by injection of small particles via a catheter that is inserted from the groin. While symptoms may improve, pregnancy following this procedure has higher complications rates so this option is not recommended for women who are yet to have children2.
  • Surgical options:
    • Removal of localised adenomyosis (adenomyomas) is challenging surgery with a view of maintaining or perhaps improving fertility. The success rate of achieving pregnancy after removal of localised adenomyosis is only 60% if all the disease is removed, and is less than 60% if only partial disease is removed3.
    • Endometrial ablation can be used to remove the inner lining of the uterus, thereby removing bleeding risk. Pregnancy is contraindicated after this procedure is performed.
    • Hysterectomy, the complete removal of the uterus, is the gold standard of treatment for women who have completed or have no desire for childbearing2,3. It alleviates symptoms and removes the risk of recurrence by eliminating the disease by removing the organ. This is not an option for many women who still desire future fertility.

What is the impact on fertility?

Women in their 30s and 40s have less spontaneous pregnancies and less success with in-vitro fertilisation (IVF). The presence of adenomyosis can change the way the fallopian tubes and uterus contract leading to poor passage of sperm to allow for conception to occur and inhibits implantation of the embryo into the uterus3. Success rates with IVF are reported to be reduced to less than 50% due to a combination of factors3.

What is the impact on pregnancy3?

Adenomyosis can affect how the placenta grows, affecting the growth of the baby. It can lead to poorer growth of the baby, premature rupture of membranes, rupturing of uterine wall due to thinning and a greater risk of placental problems.

Adenomyosis is a complex condition with much more to be learnt about why it occurs and how to treat it. Please see your local doctor to discuss further about this condition if you have any questions or concerns.

References:

  1. Jean Hailes, 29 June 2021, Health topics, vulva vagina ovaries & uterus, adenomyosis, https://www.jeanhailes.org.au/health-a-z/vulva-vagina-ovaries-uterus/adenomyosis
  2. Sydney Care Centre for Advance Reproductive Endosurgery, 2021, patients, conditions, adenomyosis, https://www.sydneycare.com.au/patients/conditions/adenomyosis/
  3. Endometriosis Australia, 9 September 2020, Prof Jason Abbott; Adenomyosis – sister to endometriosis or distant cousin? https://www.endometriosisaustralia.org/post/2016/11/08/adenomyosis-sister-to-endometriosis-or-distant-cousin
  4. Sydney Fibroid Clinic, 2019, Adenomyosis treatment, https://www.sydneyfibroidclinic.com.au/adenomyosis/adenomyosis-treatment/

Osteopaenia

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What is osteopaenia1?

Osteopaenia is the thinning of bones due to reduction in bone density. Low bone density increases the risk of bone breaking (fracture) if you have an accident. If osteopaenia worsens, then you get can osteoporosis, which is a severe reduction in bone density causing the bone to be very fragile, increasing the risk of fracture. Not everyone who gets osteopaenia will get osteoporosis. But if you have osteopaenia, then it would be important to reduce the risk of getting osteoporosis and preventing the risk of fracture in the future.

What are the risks for osteopaenia1?

  • Older age >70 years
  • Not enough vitamin D or calcium in diet
  • Family history of poor bone health
  • Excessive alcohol intake
  • Low level of physical activity
  • Smoking
  • Underweight
  • Medical conditions eg. coeliac disease, rheumatoid arthritis, liver / kidney disease, eating disorders, early menopause, low levels of hormones in men, diabetes
  • Medications eg. steroids, breast cancer treatment, prostate cancer treatment, 


How do you diagnose osteopaenia1?

Often you don’t know you have low bone density until you have an accident that is often minor but you sustain a fracture, like a small trip or slip. The fracture is confirmed on xray. Half of all fractures occur in people over the age of 50 with osteopaenia2. The osteopaenia is confirmed when you have a bone mineral density scan. This can be organised by your GP. If you want to know what your bone health is like, your GP can also organise a bone mineral density scan without any fracture history.

What treatments are available?

3 key elements for osteopaenia treatment:

  1. Adequate vitamin D
    1. Your level of vitamin D can be checked by a blood test, organised by your GP. 
    2. You can get vitamin D from sunlight exposure – a few minutes a day during summer and slightly longer in winter. When the UV index is above 3, sunscreen is advised. Be mindful of not getting excessive sunlight exposure that can cause sun damaged skin or skin cancer.
    3. Vitamin D supplements can be used if you are unable to get adequate sunlight exposure.
  2. Adequate calcium3 
    1. For an adult, 1000mg per day is recommended. For women >50 years old and men >70 years old, 1300mg per day is recommended. 
    2. You can get calcium from your diet. The most common dietary source of calcium is from dairy products eg. milk, yoghurt, cheese. You can also get calcium from other sources eg. tofu, broccoli, salmon. Please check:
    3. You can get a calcium supplement if dietary options are not available, although you must be careful you don’t over supplement as you can end up with kidney stones.
  3. Adequate exercise
    1. Ideally, the exercise should be weight bearing, improve balance and include resistence.

References:

  1. Australian Government, Department of Health, Healthdirect, osteopaenia https://www.healthdirect.gov.au/osteopaenia

2) Healthy Bones Australia, 2020, Osteopaenia and bone health factsheet, https://healthybonesaustralia.org.au/wp-content/uploads/2020/11/HBA-Fact-Sheet-Osteopenia.pdf

3) Health Bones Australia, 2020, Calcium and bone health factsheet, https://healthybonesaustralia.org.au/wp-content/uploads/2020/11/HBA-Fact-Sheet-Calcium.pdf

Pregnancy and Varicose Veins




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What is a varicose vein?


A varicose vein is the dilated purple/blue-green veins that can be seen most often on the legs. It is caused by a valve in the vein that is not working efficiently to move blood back to the heart. As a result, blood drains back down the legs and pools together to cause varicose veins. It can cause no symptoms, or it can cause itching, swelling, burning, aching, throbbing pain and in worse case scenarios, it can cause discolouration on the skin, bleeding, clotting and ulceration. While it mostly occurs in the legs, it can also occur in the buttocks or vulva area and also within the pelvis as well.

Why does it cause problems in pregnancy?


While varicose veins are often seen in older people, it often start to develop problems with varicose veins in their pregnancy. This occurs because1:
1)      Hormones – the surge in hormones helps the development of varicose veins because it dilates the blood vessels to help accommodate the increased blood volume that is required in pregnancy
2)      Foetus – the growing foetus in the abdominopelvic cavity causes increased pressure on the veins in the pelvis and lower limbs increasing the risk of valve failure
3)      Blood volume – the increase the blood volume causes increase central venous pressure and can also contribute the valve failure and varices forming
4)      Multiple pregnancies – the more pregnancies a woman has, the more cumulative stress on the veins and the potential worsening of varicose veins over time


Do they go away after pregnancy?


For the women whose varicose veins developed during pregnancy, these will often subside within 3-4 months after birth. But for some women, who had varicose veins prior to pregnancy, these often do not resolve, may worsen, and may require treatment if they cause symptoms.


Can I prevent varicose veins from developing?


Unfortunately, there is nothing that has been found, to significantly prevent then development of varicose veins in pregnancy. Compression stockings were touted to be a potential success, but have since been found to be only helpful in alleviating symptoms effectively2.


References:
1)      Australian Government, Department of Health, Pregnancy care guidelines, Part I: Common conditions during pregnancy, Varicose veins, https://www.health.gov.au/resources/pregnancy-care-guidelines/part-i-common-conditions-during-pregnancy/varicose-veins
2)      Thaler, E, Huch, R, Huch, A, Zimmermann, R, 2001, Compression stockings prophylaxis of emergent varicose veins in pregnancy: a prospective randomised controlled study’, Swiss Medical Weekly, 131:659-662.

Breast soreness

5 June 2021

Photo 66205848 / Breast © Kiosea39 | Dreamstime.com

Causes of breast soreness in women

Is this common?

Yes, breast soreness is common. For some women, it is only on one breast or part of one breast, for other women it is both breasts. It can be aching, stabbing, throbbing, dull or sharp. It can be constant or intermittent. It can range from mild to severe.

What are the causes?

  • Hormonal
    • Non-pregnant, premenopausal

Lots of women have breast soreness due to hormonal fluctuations through the menstrual cycle. In the few days to the week prior to the period, the hormonal rise in oestrogen causes glands to swell causing the breast tenderness. This breast tenderness is often bilateral. Often, once the period comes, the soreness subsides. By the end of the period, the breast soreness is often resolved. This swelling of the breast can often cause lumpiness. If a women is able to feel a lump or is unsure about lumpiness in her breast, she needs to have a clinical examination with her doctor.

Hormonal breast soreness is normal, but often not severe. If it is limiting daily function or lasts for longer, then it should be reviewed by a medical practitioner and further investigations may be warranted.

  • Pregnant

In the first trimester of pregnancy, breast soreness is very common. In fact, it is often the first sign that the woman is pregnant. This is due to the sudden surge in hormones to accommodate the growing embryo.

  • Non-hormonal
    • Breast cysts

Breast cysts can often become sore with possible lumps, able to be felt by the woman, especially during the time the hormones are rising. They can become more sensitive, increase in size and make the breast feel lumpy. To confirm the presence of breast cysts, an ultrasound can be organized by your doctor.

  • Medications eg. oral contraceptive pill and hormone replacement therapy
    • Breast injury – eg. from previous surgery causing scars or from radiotherapy from treatment for breast cancer or from breast implants
    • Chest wall pain – eg. from physical activity that strains the chest wall muscles or from conditions affecting chest wall, muscle or ribs
    • Breast infection – this is more common when the woman is breastfeeding
    • Non-supportive bra
    • Excess weight

Breast soreness and breast cancer

Breast soreness does not usual associate with breast cancer, but is not impossible. Inflammatory breast cancer is rare, but can present with red, swollen and painful breast. Therefore, it is important that breast soreness MUST BE reviewed by a medical practitioner.

What will the doctor do?

The doctor will begin by taking a history followed by a clinical examination. An ultrasound or mammogram or MRI may be required after. Referral to specialist care may be necessary depending on the findings.

Please ensure that you see a doctor when you have breast soreness so that you can be properly reviewed and the cause of the breast soreness can be found.

If you have any questions or concerns, please see your doctor.

References:

https://www.hopkinsmedicine.org/health/conditions-and-diseases/breast-pain-10-reasons-your-breasts-may-hurt

https://www.mayoclinic.org/diseases-conditions/breast-pain/symptoms-causes/syc-20350423

https://www.thewomens.org.au/health-information/breast-health/breast-soreness

PMDD

20 March 2021

Premenstrual Dysphoric Disorder (PMDD)

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Have you ever felt like you were going crazy just before your period? That you were moody, irritable, couldn’t focus, had sleep disturbance? Perhaps you have PMDD.

PMDD is premenstrual dysphoric disorder. It is a more severe form of PMS (premenstrual syndrome) that occurs from 5 to 7 days before the commencement of a woman’s period. In addition to the physical symptoms of PMS like breast tenderness, headache, bloating, body aching – all of which might be more severe in PMDD; additionally, there are psychological symptoms that are prominent in PMDD; these include sadness, worthlessness, anger, irritability or depression. It becomes difficult to concentrate at work, there is a reduction in interest to socialize or strained interactions with other people – partners, kids, colleagues, friends. These symptoms resolve 2 to 3 days after the period commences. These symptoms repeat nearly every month.

While there is no clear cause of PMDD, it is thought that the brain’s response to the presence of hormones in different women causes these experiences. Non-medical lifestyle management options are available and if appropriate, pharmacological and medical options may also be appropriate.

If this sounds like you, please feel free to book an appointment and we can have a discussion about the possibility of PMDD or please see your doctor.

Obesity and Pregnancy

2 April 2021

Obesity and Pregnancy

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Overweight and obesity are defined as abnormal or excessive fat accumulation that poses a risk to health of the individual. For women, it can increase your risk of infertility, increase complications in pregnancy and increase adverse consequences for mother and child.

Some women with obesity have elevated levels of insulin and insulin resistance, causing a hormonal imbalance which can lead of excess androgens that can prevent ovulation from occurring. Without ovulation, a woman cannot fall pregnant. Obesity in pregnancy can mean it takes longer for you to fall pregnant. It has been shown that for women with BMI (body mass index) from 29kg/m2, the chance of conception falls by 4% every year for every 1kg/m2 gained. (Stubert et al, 2018)

The risks of miscarriage and recurrent early miscarriages were also significantly higher for obese women (Lashen et al, 2004). During pregnancy, the relative risks for gestational diabetes and pre-eclampsia (elevated blood pressure) increases by 10% when there is a 10% increase in pre-pregnancy BMI. (Shummers et al, 2015). Congenital malformation risks have also been shown to have a strong correlation with maternal obesity. These include heart defects, orofacial cleft and limb malformations.(Stubert et al, 2018).

Preventative measures to achieve a normal BMI is important to allow for successful conception and an uncomplicated pregnancy to achieve success with a healthy mother and healthy baby.

Please book an appointment for further discussion about weight management in preparation for a pregnancy or during pregnancy or please talk to your own doctor.

References:

Lashen, H, Fear, K, & Sturdee, DW, 2004, ‘Obesity is associated with increased risk of first trimester and recurrent miscarriage: matched case control study’, Human Reproduction, 19(7): 1644 1646.

Shummers, L, Hutcheon, JA, Bodnar, LM, Lieberman, E & Himes, K, 2015, Risk of adverse pregnancy outcomes by prepregnancy body mass index: A population-based study to inform prepregnancy weight loss counselling’, Obstetrics & Gynaecology, 125(1): 133-143.

Stubert, J, Reister, F, Hartmann, S & Janni W, 2018, ‘The risks associated with obesity in pregnancy’, Deutsches Ärzteblatt International, 115: 276–83.

Are you concerned about your spider veins or varicose veins?

23 May 2021

Are you concerned about your spider veins or varicose veins?

Photo 214265712 / Spider Veins © Pongsak Deethongngam | Dreamstime.com

Photo 88916434 / Spider Veins © Zlikovec | Dreamstime.com

What are they?

Spider veins are small dilated veins just below the skin, most commonly on the legs. These are mostly red, purple, or with a bluish tinge. Varicose veins are deeper and bigger. They are often green or purplish-blue. Spider veins are often just unsightly but do not cause any significant symptoms. Varicose veins are often unsightly with bumps or small bulges on the surface of the skin if they are significant, but they can be subtle and not visible early in their formation. They can cause itching, aching, pain and in worse cases, changes in the colour of the skin, skin irritation and ulceration.

How will I know if I only have spider veins or varicose veins as well?

An ultrasound to look at the blood flow in the veins can be organised to determine the severity of the problem.

Treatment

Depending on the severity of varicose veins, they may need to be removed to alleviate the symptoms or to prevent complications. This can be done as a clinic-based ablation procedure or it may need an operation. If you have varicose veins and spider veins, varicose veins need to be treated first. If you treat spider veins first when you have varicose veins, the treatment will be futile, as the spider veins will return. Spider veins alone often don’t need to be treated. But many people wish to have them treated to improve appearance.

Sclerotherapy

Sclerotherapy is a procedure to inject a liquid solution into the spider veins. This solution then irritates the walls of the veins causing them to collapse and constrict. It eventually forms a fibrous cord which the body breaks down and then the vein disappears. This procedure can be done in a clinic and can be repeated to improve the appearance of the legs.

If you have any questions or concerns regarding spider veins or varicose veins, please talk to your doctor.

Acupuncture for osteoarthritis of the knee or hip

9 May 2021

Acupuncture for osteoarthritis of the knee or hip

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In the National Health Survey conducted by the Australian Bureau of Statistics (ABS) 2016-2017, 2.2million Australians (9.3%) suffered from osteoarthritis. It is a chronic and progressive condition where the cartilage that protects the ends of your bones is worn down over time. It can affect any joint, but commonly affects hands, spine, hips and knees. It is the predominant condition that leads to hip and knee replacement surgery in Australia. (Australian Institute of Health and Welfare, 2020).

In a study completed in Germany, acupuncture for patients with knee and hip osteoarthritis receiving needle acupuncture, averaging 10 session over 3 months shows a statistical improvement in subjective measure of symptoms of osteoarthritis, including pain, physical function and stiffness, using Western Ontario and McMaster Universities Arthritis Index (WOMAC) when used in addition to standard routine care. (Witt et al, 2006) It also showed that the quality of life improvements were maintained through to 6 months (3 months post completion of acupuncture), more prominent in the acupuncture than control group, though not statistically significant. (Witt et al, 2006).

Acupuncture is applicable to only a limited number of medical conditions and its role is appropriate only in addition to standard medical care.

Please book an appointment to find out more or talk to your doctor.

References:

National Health Survey, 2017-2018, Table 3.1 Long-term health conditions(a), Persons  — Persons, Australian Bureau of Statistics, viewed on 5 April 2021, https://www.abs.gov.au/statistics/health/health-conditions-and-risks/national-health-survey-first-results/latest-release#data-download

Australian Institute of Health and Welfare 2020. Osteoarthritis. Cat. no. PHE 232. Canberra: AIHW. Viewed 05 April 2021, https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/osteoarthritis

Witt, CM, Jena, S, Brinkhaus, B, Liecker, B, Wegscheider, K & Willich, S, 2006, ‘Acupuncture in patients with osteoarthritis of the knee or hip’, Arthritis & Rheumatism, 54(11), 3485-3493.

What about an intrauterine devince (IUD) for contraception?

25 April 2021

What about an intrauterine device (IUD) for contraception?

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(IUDs have also been known as IUCD- intrauterine contraceptive device)

What is an IUD?

An IUD is a small T-shaped contraceptive device that sits inside the uterus. There are 2 types, the first is a hormone-based where progestogen is contained within a cylinder that forms the stem of the device. The second is non-hormone-based, where copper is wrapped around the stem of the device.

How does it work?

IUDs work by thickening cervical mucous to reduce sperm movement and survival and it makes the uterine lining (endometrium) inhospitable to a fertilized egg.

Is it an effective contraception?

IUDs are at least 99% effective.

Who can be considered for an IUD?

  • Any woman who wants a reliable effective form of long term contraception, including any woman who has not been pregnant before
  • Any woman at low risk of contracting a sexually transmitted infection (STI)
  • Breastfeeding women

Who cannot use an IUD?

  • Pregnant women
  • Women with current undiagnosed vaginal bleeding
  • Women with current pelvic inflammatory disease (PID) or STI

What are the advantages of both the hormonal and copper IUD?

  • Long acting device (5 years)
  • Set and forget
  • Reliable and effective
  • Cheaper than other forms of contraception in the long run
  • Reversible – once removed, you can try to conceive a baby
  • For the hormonal IUD, it reduces the volume of menstrual bleeding, so it’s helpful for those with heavy menstrual bleeding. In some cases, it can stop your period completely.

What are the disadvantages?

  • It does not protect against STIs or PID
  • Insertion of the IUD requires a minor procedure that can be uncomfortable
  • During insertion, there is a small risk of perforation of the uterus, embedment into the uterus and infection
  • It is very rare risk that pregnancy, or ectopic pregnancy can occur if the IUD fails
  • For the hormonal IUD, there is a period of 3-6 months where there may be irregular spotting or bleeding before everything settles down. It may also cause bloating, headache, reduced mood, acne, reduced libido.
  • For the copper IUD, it may cause heavier and more painful periods

For a more detailed discussion of IUD, please make an appointment to see Dr. Kua or talk to your doctor.

References:

The Women’s, The Royal Women’s Hospital, Victoria, Australia, 2021, Intrauterine Device (IUD), The Women’s, The Royal Women’s Hospital, Victoria, Australia, viewed 5 April2021, <https://www.thewomens.org.au/health-information/contraception/intra-uterine-device-iud>

Family Planning NSW, 2021, Hormonal IUD, Family Planning NSW, viewed 5 April 2021, <https://www.fpnsw.org.au/factsheets/individuals/contraception/hormonal-iud>

Family Planning NSW,2021, Copper IUD, Family Planning NSW, viewed 5 April 2021, < https://www.fpnsw.org.au/health-information/individuals/contraception/copper-iud>

Is obesity linked to our genes?

9 April 2021

Is obesity linked to our genes?

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Many factors have been given for influencing body weight in humans. These include the built environment, medical conditions, human behavior, medications, but increasingly there is a strong association of a genetic role in obesity. In a landmark study, Stunkard et al 1986 found that there was a correlation between the weight of Danish adoptees and the body mass index (BMI) of their biological parents that was statistically significant, particularly for their mothers. Furthermore, he found that there was no correlation between the weight of adoptees and their adoptive parents and that this was applicable across all weight classes, not just the obese adoptees, but also those who were thin. (Stunkard et al, 1986)

Mutations in genes alone, which occur slowly, cannot explain the obesity epidemic that has occurred in the past few decades around the world. It Australia, there has been a 11.3% rise in the prevalence of obesity in Australia from 1980 to 2000 which is 2.5 times increase, over 20 years. (Cameron et al, 2003) Interest is growing in the role of the environment and the gene-environment interaction in the increase prevalence of obesity and obesity related comorbidities. Epigenetics the activation or deactivation of gene expression across certain tissues without DNA sequence changes to the genome. It is thought that through this mechanism, environmental chemicals, gut microbiota modifications and poor nutritional intake can have an impact on metabolism and contribute to obesity and its comorbidities. (Thaker VV, 2017).

If you have any questions please book an appointment or talk to your doctor.

References:

Stunkard, AJ, Sørensen, TI, Hanis, C, Teasdale, TW, Chakraborty, R, Schull, WJ, & Schulsinger, F, 1986, ‘An adoption study of human obesity’, The New England journal of medicine, 314(4): 193–198.

Cameron, AJ, Zimmet, PZ, Dunstan, DW, Dalton M, Shaw, JE, Welborn, TA, Owen, N, Salmon, J & Jolley, D, 2003, ‘Overweight and obesity in Australia: the 1999-2000 Australian Diabetes, Obesity and Lifestyle Study (AusDiab)’, Medical Journal of Australia, 178 (9): 427- 432.

Thaker V. V. (2017). ‘Genetic and epigenetic causes of obesity’ Adolescent medicine: state of the art reviews,28(2), 379–405.