Osteoporosis and premature ovarian insufficiency: geographic variation in clinicians’ and consumers’ knowledge gaps and barriers to care



To determine whether geographic variation exists in osteoporosis knowledge, management, and barriers to care in the setting of premature ovarian insufficiency (POI), among general practitioners (GPs) and women with POI.


Australian GPs completed an online questionnaire regarding osteoporosis knowledge, barriers to care and educational preferences for managing osteoporosis in POI. Women with POI/early menopause (EM) completed an online questionnaire regarding osteoporosis knowledge, risk factors and health beliefs. Clinicians and consumers in metropolitan areas were compared to those in rural areas.


Of 688 GP respondents, 62.2% practised in major capital cities, 13.1% in major regional cities, 7.8% in regional centres, 8.7% in rural areas and 8.1% in remote areas. Mean ± SD osteoporosis knowledge score was 9.1 ± 1.5/13, with no difference by location. Forty-one percent of GPs reported barriers to care which varied by location. Of 316 women with POI/EM, 61.1% lived in metropolitan, 22.5% in regional, 11.7% in rural and 4.4% in remote locations. The mean osteoporosis knowledge score was 8.2 ± 3.1/20, with lower scores in women living in rural and remote versus metropolitan locations (difference − 1.3; 95% CI − 2.3, − 0.25; p = 0.02). Women in rural areas were less likely to use vitamin D supplements and more likely to have a family history of osteoporosis (both p < 0.05).


GP knowledge gaps and specific, location-dependent care barriers for osteoporosis in POI were identified. Geographic differences in osteoporosis knowledge and risk factors exist in women with POI/EM. These factors require consideration when designing programs to improve bone health in POI.

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  1. 1.

    Webber L, Davies M, Anderson R, Bartlett J, Braat D, Cartwright B, Cifkova R, de Muinck Keizer-Schrama S, Hogervorst E, Janse F, Liao L, Vlaisavljevic V, Zillikens C, Vermeulen N, The ESHRE Guideline Group on POI (2016) ESHRE guideline: management of women with premature ovarian insufficiency. Hum Reprod 31(5):926–937. https://doi.org/10.1093/humrep/dew027

    CAS  Article  PubMed  Google Scholar 

  2. 2.

    Collaborative Group on Hormonal Factors in Breast C (2012) Menarche, menopause, and breast cancer risk: individual participant meta-analysis, including 118 964 women with breast cancer from 117 epidemiological studies. Lancet Oncol 13(11):1141–1151. https://doi.org/10.1016/S1470-2045(12)70425-4

    Article  Google Scholar 

  3. 3.

    Popat BV, Calis AK, Vanderhoof HV, Cizza CG, Reynolds FJ, Sebring MN, Troendle MJ, Nelson ML (2009) Bone mineral density in estrogen-deficient young women. J Clin Endocrinol Metab 94(7):2277–2283. https://doi.org/10.1210/jc.2008-1878

    CAS  Article  PubMed  PubMed Central  Google Scholar 

  4. 4.

    Nguyen HH, Wong P, Strauss BJ, Jones G, Ebeling PR, Milat F, Vincent A (2017) Delay in estrogen commencement is associated with lower bone mineral density in Turner syndrome. Climacteric 20(5):436–441. https://doi.org/10.1080/13697137.2017.1325461

    CAS  Article  PubMed  Google Scholar 

  5. 5.

    Cintron D, Rodriguez-Gutierrez R, Serrano V, Latortue-Albino P, Erwin PJ, Murad MH (2017) Effect of estrogen replacement therapy on bone and cardiovascular outcomes in women with turner syndrome: a systematic review and meta-analysis. Endocrine 55(2):366–375. https://doi.org/10.1007/s12020-016-1046-y

    CAS  Article  PubMed  Google Scholar 

  6. 6.

    Tauchmanova L, De Simone G, Musella T, Orio F, Ricci P, Nappi C, Lombardi G, Colao A, Rotoli B, Selleri C (2006) Effects of various antireabsorptive treatments on bone mineral density in hypogonadal young women after allogeneic stem cell transplantation. Bone Marrow Transplant 37(1):81–88. https://doi.org/10.1038/sj.bmt.1705196

    CAS  Article  PubMed  Google Scholar 

  7. 7.

    Deeks AA, Gibson-Helm M, Teede H, Vincent A (2011) Premature menopause: a comprehensive understanding of psychosocial aspects. Climacteric 14(5):565–572. https://doi.org/10.3109/13697137.2011.566390

    CAS  Article  PubMed  Google Scholar 

  8. 8.

    Goh M, Nguyen HH, Khan NN, Milat F, Boyle JA, Vincent AJ (2019) Identifying and addressing osteoporosis knowledge gaps in women with premature ovarian insufficiency and early menopause: a mixed-methods study. Clin Endocrinol 0 (0). doi:https://doi.org/10.1111/cen.14049

  9. 9.

    Gibson-Helm M, Teede H, Vincent A (2014) Symptoms, health behavior and understanding of menopause therapy in women with premature menopause. Climacteric 17(6):666–673. https://doi.org/10.3109/13697137.2014.913284

    CAS  Article  PubMed  Google Scholar 

  10. 10.

    Lai MMY, Ang WM, McGuiness M, Larke AB (2012) Undertreatment of osteoporosis in regional Western Australia. Australas J Ageing 31(2):110–114. https://doi.org/10.1111/j.1741-6612.2011.00544.x

    Article  PubMed  Google Scholar 

  11. 11.

    Australian Commission on Safety and Quality in Health Care and National Performance Authority (2015) Australian atlas of healthcare variation. Sydney

  12. 12.

    Duyvendak M, Naunton M, van Roon EN, Brouwers JR (2011) Doctors’ beliefs and knowledge on corticosteroid-induced osteoporosis: identifying barriers to improve prevention. J Clin Pharm Ther 36(3):356–366. https://doi.org/10.1111/j.1365-2710.2010.01185.x

    CAS  Article  PubMed  Google Scholar 

  13. 13.

    Australian Government Department of Health Modified Monash Model. https://www.health.gov.au/health-workforce/health-workforce-classifications/modified-monash-model. Accessed 14 Aug 2019

  14. 14.

    Winzenberg TM, Oldenburg B, Frendin S, Jones G (2003) The design of a valid and reliable questionnaire to measure osteoporosis knowledge in women: the osteoporosis knowledge assessment tool (OKAT). BMC Musculoskelet Disord 4(1):17. https://doi.org/10.1186/1471-2474-4-17

    Article  PubMed  PubMed Central  Google Scholar 

  15. 15.

    Kim KK, Horan ML, Gendler P, Patel MK (1991) Development and evaluation of the osteoporosis health belief scale. Res Nurs Health 14(2):155–163

    CAS  Article  Google Scholar 

  16. 16.

    Horan ML, Kim KK, Gendler P, Froman RD, Patel MD (1998) Development and evaluation of the osteoporosis self-efficacy scale. Res Nurs Health 21(5):395–403

    CAS  Article  Google Scholar 

  17. 17.

    Panay N, Lazaridis A, Maclaran K (2012) Investigating UK and international practices for managing premature ovarian failure. Maturitas 71. https://doi.org/10.1016/s0378-5122(12)70104-4

  18. 18.

    Crofton PM, Evans N, Bath LE, Warner P, Whitehead TJ, Critchley HO, Kelnar CJ, Wallace WH (2010) Physiological versus standard sex steroid replacement in young women with premature ovarian failure: effects on bone mass acquisition and turnover. Clin Endocrinol 73(6):707–714. https://doi.org/10.1111/j.1365-2265.2010.03868.x

    CAS  Article  Google Scholar 

  19. 19.

    Ewald DP, Eisman JA, Ewald BD, Winzenberg TM, Seibel MJ, Ebeling PR, Flicker LA, Nash PT (2009) Population rates of bone densitometry use in Australia, 2001-2005, by sex and rural versus urban location. Med J Aust 190(3):126–128

    Article  Google Scholar 

  20. 20.

    Macgregor CB, Meerkin JD, Alley SJ, Vandelanotte C, Reaburn PJ (2018) Osteoporosis and low bone mineral density (osteopenia) in rural and remote Queensland. Aust J Rural Health 26(5):369–374. https://doi.org/10.1111/ajr.12476

    Article  PubMed  Google Scholar 

  21. 21.

    Chen JS, Hogan C, Lyubomirsky G, Sambrook PN (2009) Management of osteoporosis in primary care in Australia. Osteoporos Int 20(3):491–496. https://doi.org/10.1007/s00198-008-0686-z

    CAS  Article  PubMed  Google Scholar 

  22. 22.

    Chevalley T, Herrmann FR, Delmi M, Stern R, Hoffmeyer P, Rapin CH, Rizzoli R (2002) Evaluation of the age-adjusted incidence of hip fractures between urban and rural areas: the difference is not related to the prevalence of institutions for the elderly. Osteoporos Int 13(2):113–118

    CAS  Article  Google Scholar 

  23. 23.

    Diamantopoulos AP, Rohde G, Johnsrud I, Skoie IM, Johnsen V, Hochberg M, Haugeberg G (2012) Incidence rates of fragility hip fracture in middle-aged and elderly men and women in southern Norway. Age Ageing 41(1):86–92. https://doi.org/10.1093/ageing/afr114

    Article  PubMed  Google Scholar 

  24. 24.

    Sanders KM, Nicholson GC, Ugoni AM, Seeman E, Pasco JA, Kotowicz MA (2002) Fracture rates lower in rural than urban communities: the Geelong osteoporosis study. J Epidemiol Community Health 56(6):466–470

    CAS  Article  Google Scholar 

  25. 25.

    Burch J, Tort S, (on behalf of Cochrane Clinical Answers Editors) (2017) What are the effects of professional interventions for general practitioners aimed at improving management of osteoporosis? Cochrane Clinical Answers https://doi.org/10.1002/cca.1674

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The authors acknowledged Dr. Ramesh Manocha of Healthed for distribution of General Practitioner surveys.

Consumers were recruited from Breast Cancer Network Australia’s Review and Survey Group.


AJ holds a National Health and Medical Research Council (NHMRC) postgraduate scholarship and an Avant Doctor in Training Research Scholarship.

JB holds a NHMRC Career Development fellowship.

AV holds an Osteoporosis Australia–Australian and New Zealand Bone and Mineral Society (ANZBMS) grant.

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Correspondence to Alicia R. Jones.

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Jones, A.R., Goh, M., Langham, R. et al. Osteoporosis and premature ovarian insufficiency: geographic variation in clinicians’ and consumers’ knowledge gaps and barriers to care. Arch Osteoporos 15, 38 (2020). https://doi.org/10.1007/s11657-020-00713-8

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  • Osteoporosis
  • Early menopause
  • Primary care
  • Consumer engagement