Letters to the Editor

Hormone Replacement Therapy and Risk of Heart Disease

TO THE EDITOR: I found Dr. Havranek's article¹ to be a helpful overview of coronary heart disease (CHD) prevention. However, I am concerned with his conclusion that hormone replacement therapy (HRT) is unlikely to be a beneficial primary prevention strategy for CHD in women.

Dr. Havranek erroneously bases his conclusion on the findings of the Heart and Estrogen/progestin Replacement Study (HERS).² HERS is very specific: the study investigates the effects of HRT on recurrent coronary events in women with known CHD who received a regimen of conjugated equine estrogen (0.625 mg daily dosage) plus medroxyprogesterone acetate (2.5 mg daily dosage). HERS found an increase in CHD events in the hormone-treated group in year 1 of the study and a decrease in CHD events in years 4 and 5. The treatment conclusion was that HRT should not be initiated for secondary CHD prevention, but women already taking HRT should probably continue therapy because of the potential for longer-term benefits in CHD prevention.

Previous studies have shown the benefits of HRT in the prevention of CHD. The National Cholesterol Education Program's adult treatment panel II recommended estrogen therapy for all women with hypercholesterolemia in whom estrogen is not contraindicated.³ Multiple observational studies have shown a consistent decrease in CHD risk among postmenopausal women who take HRT.^4,5 The AAFP's monograph on heart disease in women states, "recent research suggests that the use of estrogen or hormone replacement therapies for postmenopausal women can substantially decrease the risk of cardiovascular disease."⁶ Furthermore, it states that, "HRT has been identified as the most significant factor in the effort to reduce the risk of cardiovascular disease for postmenopausal women."⁶

The final word has certainly not been written on HRT and heart disease. Family physicians need to be aware of ongoing research in order to provide the best opportunity for patients to make informed decisions about HRT.

KRISTIN K. ELLIOTT, M.D.
Duluth Clinic­International Falls
2501 Keenan Dr.
International Falls, MN 56649

REFERENCES

1. Havranek EP. Primary prevention of CHD: nine ways to reduce risk. Am Fam Physician 1999;59:1455-63.
2. Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, et. al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998;280:605-13.
3. Summary of the second report of the National Cholesterol Education Program (NCEP) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel II). JAMA 1993;269:3015-23.
4. Grady D, Rubin SM, Petitti DB, Fox CS, Black D, Ettinger B, et al. Hormone therapy to prevent disease and prolong life in postmenopausal women [Review]. Ann Intern Med 1992;117:1016-37.
5. Sullivan JM, Vander Zwaag R, Hughes JP, Maddock V, Kroetz FW, Ramanathan KB, et al. Estrogen replacement and coronary artery disease. Effect on survival in postmenopausal women. Arch Intern Med 1990;150:2557-62.
6. Heart disease in women [Booklet]. Ruble R, ed.; Kansas City, MO: American Academy of Family Physicians in cooperation with the American Heart Association, 1997.

IN REPLY: Dr. Elliott takes issue with the statement in my article¹ that hormone replacement therapy (HRT) in postmenopausal women is unlikely to be of benefit as primary prevention for coronary heart disease (CHD). She bases her disagreement on the recommendations of two expert panels published before the results of the Heart and Estrogen/ progestin Replacement Study (HERS),² on the fact that the HERS trial was a secondary prevention trial and on the results of observational studies.

It is not at all clear that the cited expert panels would not be more cautious now that HERS has been reported. With regard to the issue of secondary prevention, my article makes it quite clear that HERS was a secondary prevention trial. It is no more erroneous to base recommendations on the basis of secondary prevention trials than it is to base recommendations on the basis of observational studies. In discussing HRT as primary prevention, I made a conscious decision to put more weight on the results of a secondary prevention trial than on the results of observational studies. The article contains several precedents that support such a decision. With cholesterol reduction, secondary prevention trials showed benefit before primary prevention trials. With vitamin E supplementation, observational studies suggested benefit; a randomized primary prevention trial did not.

Dr. Elliott and I agree that no definitive data on the efficacy of HRT for primary prevention of CHD are available. In the absence of definitive data, physicians and patients must make the best use of all available information and support ongoing efforts to arrive at an answer to this important question.

EDWARD P. HAVRANEK, M.D.
Section of Cardiology
Denver Health Medical Center, #0960
777 Bannock St.
Denver, CO 80204

REFERENCES

1. Havranek EP. Primary prevention of CHD: nine ways to reduce risk. Am Fam Physician 1999;59:1455-63.
2. Hulley S, Grady D, Bush T, Furberg C, Herrington D, Riggs B, et. al. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. Heart and Estrogen/progestin Replacement Study (HERS) Research Group. JAMA 1998;280:605-13.

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Comments on Flexible Sigmoidoscopy

TO THE EDITOR: In addition to my editorial¹ on "Flexible Sigmoidoscopy: The Unkept Promise of Cancer Prevention," which accompanied the recent review article on this subject, ² I would like to offer several clarifications and comments on the techniques and equipment as described by the author.

1. Reflecting the advance to longer scopes, manufacture of the 35-cm flexible sigmoidoscope was discontinued more than five years ago. Short colonoscopes (65 cm) remain on the market. As prices of the longer colonoscopes decrease, the 65-cm scope will also probably be discontinued.

2. Scope diameters vary slightly and have no significant impact on technique or clinical outcome.

3. The descending colon may have a gun-barrel appearance, with concentric ridges separating the pouches (haustrae). In the transverse colon, triangular folds are observed 50 to 60 percent of the time. Clues to anatomic depth can be helpful, but these clues are not constant, particularly in patients 70 years of age or older.

4. Diagnostically, anoscopy is no match for fiberoptic retroflexion, although slotted anoscopes remain helpful for therapeutic surgeries. Otherwise, I have not used an anoscope in 10 years.

5. Physician involvement with cleaning and disinfection is essential, but soapy water is not. At postendoscopy, immediate rinsing and suctioning with tap water works fine.

6. Using clinical judgment to avoid varices, physicians should biopsy lesions that appear abnormal. Too many lesions are missed at a second examination. The physician should perform a biopsy while the lesion is "in your sights." The physician should be careful not to snap the wrist as part of the biopsy technique--these are avulsion, not cutting biopsy forceps.

7. The terms "dithering" and "jiggling" are jargon and describe several mildly effective loop-reduction maneuvers. Formation of a sigmoid loop impedes advancement. Physicians can maneuver the scope right and left, up and down, in and out, and twist right and twist left for advancement of the endoscope. Air insufflation and suction are additional functions. Using all of these maneuvers in an effective manner defines the art of endoscopic insertion.

WM. MACMILLAN RODNEY, M.D.
Department of Family Medicine
University of Tennessee, Memphis
1111 Union Ave.
Suite A
Memphis, TN 38104

REFERENCES

1. Rodney WM. Flexible sigmoidoscopy: the unkept promise of cancer prevention [Editorial]. Am Fam Physician 1999;59:270-3.
2. Johnson BA. Flexible sigmoidoscopy: screening for colorectal cancer. Am Fam Physician 1999;59:313-24.

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Clarification on Strongyloides Quiz Question

TO THE EDITOR: I am concerned that readers might be confused by a last-minute editorial change made in Question 3 in the June 1999 "Clinical Quiz" (page 2974), pertaining to my article "Case Studies in International Medicine."¹ The question, "Which one of the following should be considered a clue to the presence of a Strongyloides infection?" is classified as having only one correct answer (choice A, "perianal or buttock urticaria"). However, I believe answer E, as changed by the editors, is also a correct choice.

I had originally listed option E as "improvement after treatment with pancreatic enzymes," which would make this an incorrect answer; improvement with pancreatic enzyme administration can be expected if the patient has tropical pancreatitis, but generally not if the patient has strongyloidiasis. However, the answer for option E was changed by the editors to "weight loss." Although it is true that weight loss is not one of the "classic" symptoms of strongyloidiasis (perianal/buttock urticaria, abdominal pain and diarrhea), weight loss may occur in patients heavily infected with Strongyloides. Therefore, even though the best choice remains A, "perianal or buttock urticaria," option E is also correct.

LYNN W. KITCHEN, M.D., M.P.H.
Robert C. Byrd Health Sciences Center
West Virginia University
3110 MacCorkle Avenue, S.E.
Room 3056
Charleston, WV 25304-1299

REFERENCES

1. Kitchen LW. Case studies in international medicine. Am Fam Physician 1999;59:3040-4.

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Correction

The article "Current Trends in Cervical Ripening and Labor Induction" (August 1999, page 477) provided incorrect dosage units for misoprostol (Cytotec) in several places (twice in the third paragraph of the text on page 481 and in three places in Table 6). The correct dosage unit for intravaginal misoprostol used in cervical ripening is micrograms. In addition, Table 4 of the same article contained an incorrect key in the footnote. The correct key is as follows: -3 = in the pelvis; +3 = on the perineum; 0 = engaged.

*These corrections have been made to the online version of AFP. The links above will take you to the corrected items, which remain part of the online issues in which they were originally published.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

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