Online Letters to the Editor
Discussion of Protective Effects of Hydrochlorothiazide
to the editor: I am grateful for the thorough review of osteoporosis in the article “Pharmacologic Prevention of Osteoporotic Fractures,”1 that appeared in American Family Physician. However, there was no mention of the possible protective effects of hydrochlorothiazide (HydroDIURIL). Numerous references2-4 are available that cite increased bone density of patients receiving this medication, which is likely a result of its inhibition of calciuria.
Retrospective control-matched studies suggest a lowering of hip fracture incidence with the use of this medication.3,5 However, we will probably never see an example of the gold standard placebo-controlled, double-blind study for this medication, because nobody will ever make any money as a result of conducting such a study. Nevertheless, the evidence is there, the medication is inexpensive, and this information deserves at least a mention in a review article1 of this kind.
REFERENCES
1. Zizic TM. Pharmacologic prevention of osteoporotic fractures. Am Fam Physician 2004;70:1293-300.
2. LaCroix AZ, Ott SM, Ichikawa L, Scholes D, Barlow WE. Low-dose hydrochlorothiazide and preservation of bone mineral density in older adults. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 2000;133:516-26.
3. Cauley JA, Cummings SR, Seeley DG, Black D, Browner W, Kuller LH, et al. Effects of thiazide diuretic therapy on bone mass, fractures, and falls. Ann Intern Med 1993;118:666-73.
4. Sigurdsson G, Franzson L. Increased bone mineral density in a population-based group of 70-year-old women on thiazide diuretics, independent of parathyroid hormone levels. J Intern Med 2001;250:51-6.
5. Schoofs MW, van der Klift M, Hofman A, de Laet CE, Herings RM, Stijnen T, et al. Thiazide diuretics and the risk for hip fracture. Ann Intern Med 2003;139:476-82.
in reply: Dr. Wagman’s points concerning the ability of hydrochlorothiazide to increase bone mineral density are relevant. Retrospective, control-matched studies do suggest a lowering of hip fracture incidence with the use of thiazide diuretics. However, the purpose of our article1 was not to provide an in-depth examination of the full gamut of treatments for osteoporosis, but rather to focus on the most relevant treatment options.
REFERENCES
1. Zizic TM. Pharmacologic prevention of osteoporotic fractures. Am Fam Physician 2004;70:1293-300.
Weighing the Risks and Benefits of Emergency Contraception
to the editor: In response to an article1 by Dr. Weismiller and an editorial2 by Dr. Wellbery in the August 15, 2004, issue of American Family Physician, we are writing to emphasize three points about emergency contraception.
First, the most recent and methodologically sound analyses of the effectiveness of emergency contraception place the typical use effectiveness of the Yuzpe regimen (Preven) at 47 to 53 percent3 and, by extension, the effectiveness of a levonorgestrel (Plan B) regimen at approximately 75 percent,4 both of which are less than the rates quoted by Dr. Weismiller.1
Second, we appreciate Dr. Wellbery's effort to enumerate both sides of the controversial issues around emergency contraception.2 To date, no study has found an actual decrease in pregnancy rates in a population given widespread access to emergency contraception. One study cited by Dr. Weismiller did find a trend toward less consistent use of more reliable contraception in adolescents given advance access to emergency contraception. A full assessment of the public health impact of emergency contraception requires ongoing evidence-based examination, regardless of one’s pre-existing biases.
Third, we agree with Dr. Wellbery's and others' call for appropriate counseling of patients that is sensitive to the patients' moral perspectives.5 The potential for post-fertilization effects of emergency contraception is supported by several lines of medical evidence,6 but in our observation it frequently is minimized or discounted in reference materials for patients. We emphasize that patients deserve full access to this information for adequate informed consent.
REFERENCES
1. Weismiller DG. Emergency contraception. Am Fam Physician 2004;70:707-14.
2. Wellbery C. Emergency contraception: an ongoing debate [Editorial]. Am Fam Physician 2004;70:655,8-9.
3. Trussell J, Ellertson C, von Hertzen H, Bigrigg A, Webb A, Evans M, et al. Estimating the effectiveness of emergency contraceptive pills. Contraception 2003;67:259-65.
4. Raymond E, Taylor D, Trussell J, Steiner MJ. Minimum effectiveness of the levonorgestrel regimen of emergency contraception. Contraception 2004;69:79-81.
5. Stanford JB, Hager WD, Crockett SA. The FDA, politics, and plan B [author reply]. N Engl J Med 2004;350:2413-4.
6. Kahlenborn C, Stanford JB, Larimore WL. Postfertilization effect of hormonal emergency contraception. Ann Pharmacother 2002;36:465-70.
IN REPLY: As with many emotionally fraught issues, we must build on the best evidence available. With regard to advance provision of emergency contraception, we know that the use of emergency contraception does not promote sexually careless behavior. Two recent trials1,2 have added to our knowledge of sexual and contraceptive behavior among adolescents who are given emergency contraception. I cite studies involving adolescents because this is an area of greater controversy than adult sexual behavior. In one randomized study,1 emergency contraception use was not associated with changes in unprotected intercourse or less contraceptive use. Another controlled trial2 of 2,117 women 15 to 25 years of age concluded that emergency contraception access has no impact on acquisition of sexually transmitted infections, patterns of contraceptive use, or sexual behavior. Although pregnancy rates in this study did not differ among groups because of high rates of non- emergency contraception use, high rates of unprotected intercourse, and short study duration, these studies at least pave the way for ready access to emergency contraception, a condition that will form the basis for larger population-based studies of pregnancy rates.
The authors also raise the question of post-fertilization effects, and their implications for informed consent. Definitive evidence for the mechanism of action of emergency contraception is lacking, but the most direct evidence from animal and human studies overwhelmingly suggests that the efficacy of emergency contraception relates to the delay and prevention of ovulation.1-3 Of course, additional mechanisms have been proposed, including thickening of cervical mucus, alterations in tubal transport before and after fertilization, and changes in the endometrium.4 How then is a physician to address the issue of mechanism of action? It seems that this is one of those cases where value implications have become unavoidable despite decades of standard practice and family planning benefits. Given the attention forced on this issue, physicians should certainly strive to separate their own values from those of their patients. A discussion of mechanisms of action should include the American College of Obstetricians and Gynecologists’ definition of an established pregnancy, beginning with implantation on the one hand, and personal or religious beliefs related to post-fertilization effects on the other. In the delicate matter of informed consent, one would want a patient to have access to all the information she needs to decide whether she is comfortable using hormonal contraception. At the same time, one would not want to make a patient feel guilty by insisting on moral concerns she does not share.
REFERENCES
1. Gold MA, Wolford JE, Smith KA, Parker AM. The effects of advance provision of emergency contraception on adolescent women’s sexual and contraceptive behaviors. J Pediatr Adolesc Gynecol 2004;17:87-96.
2. Raine TR, Harper CC, Rocca CH, Fischer R, Padian N, Klausner JD, et al. Direct access to emergency contraception through pharmacies and effect on unintended pregnancy and STIs: a randomized controlled Trial. JAMA 2005;293:54-62.
3. Gemzell-Danielsson K, Marions L. Mechanisms of action of mifepristone and levonorgestrel when used for emergency contraception. Hum Reprod Update 2004;10:341-8.
4. Marions L, Hultenby K, Lindell I, Sun X, Stabi B, Gemzell-Danielsson K. Emergency contraception with mifepristone and levonorgestrel: mechanism of action. Obstet Gynecol 2002;100:65-71.
5. Croxatto HB, Brache V, Pavez M, Cochon L, Forcelledo ML, Alvarez F, et al. Pituitary-ovarian function following the standard levonorgestrel emergency contraceptive dose or a single 0.75-mg dose given on the days preceding ovulation. Contraception 2004;70:442-50.
6. Trussell J, Ellertson C, Stewart F, Raymond EG, Shochet T. The role of emergency contraception. Am J Obstet Gynecol 2004;190(4 suppl):S30-8.
editor’s note: This letter was sent to the author of “Emergency Contraception,” who declined to reply.
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