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Am Fam Physician. 2001;64(5):737-738

to the editor: The patient information handout published in American Family Physician, entitled “Learning About Menopause,”1 contains misleading and potentially harmful information. It states, unambiguously, that estrogen protects against heart attacks. It also implies that taking a progestin will reduce the increased risk of breast cancer associated with estrogen use.

The best available evidence is that estrogen does not reduce the risk of established heart disease. The results of the Heart and Estrogen/Progestin Replacement Study (HERS),2 the first large-scale, randomized clinical trial that examined the effects of hormones on women with established heart disease, revealed no benefit.

Before the results of HERS were released, the bulk of the evidence for a cardioprotective effect of estrogen came from observational studies. Although researchers had cautioned that these beneficial effects must be confirmed by large-scale, randomized clinical trials before widespread use, this caution had been all but ignored. Many physicians continue to encourage healthy women to take hormones to reduce their risk of heart attacks. The rationale seems to be that because HERS included only women with established heart disease, it cannot be assumed that hormones will not be beneficial in women without heart disease.

Since the publication of “Learning About Menopause,”1 the preliminary results from the Hormone Replacement Therapy Trial of the Women's Health Initiative were released.3 This is a randomized, controlled trial examining the effects of hormones on heart disease in healthy women. The results were surprising. The women randomly assigned to the hormone group had a small but significant increase in heart disease. Jacques E. Rossouw, M.D., the acting director of this trial, states cogently, “Doctors who have prescribed it [estrogen] do so without evidence to back up their bias that it will help.”4

The bulk of research examining the effects of long-term estrogen use on breast cancer shows an increased risk, and this is the major risk included in virtually all risk-benefit analyses. The assumption has been that, for most women, the increased risk of breast cancer is worth the purported benefit of a reduction in heart disease. There have been no large-scale, prospective studies showing that taking a progestin attenuates this risk. In fact, studies are now showing that progestin may actually increase the risk of breast cancer over and above what it would be with estrogen alone.5,6

Physicians have the responsibility to provide women the most accurate and up-to-date information available. This is the only way that women can make truly informed decisions. The paragraph “What About Estrogen?” in the handout falls woefully short and needs to be revised as soon as possible.

editor's note: Dr. Meyer is correct. During editing, the text of the patient information handout was incorrectly modified to imply that estrogens unequivocally protect against heart attacks, and that taking progestins reduces any increased risk of breast cancer associated with estrogen use.1 We apologize to the authors of the accompanying article for this error.

Dr. Meyer recommends that we revise the patient information handout. For the text version, this is obviously not possible, and we rely on printed corrections for this purpose. For the online version, that's another matter. Except for certain circumstances, our policy does not allow for routine revisions of the online version of AFP. First, such revision would lead to two versions of the text: the printed version and the online version. We prefer to have a trail of corrections that link the two together. This is the policy, for example, of the British Medical Journal, which also publishes a full-text online version.2

Next, the concept of revising online material is prohibitively daunting. Our online version goes back years and the process of revising articles based on new research is a Sisyphean task. However, for current errors that have potentially serious clinical implications, we will endeavor to correct the error in the online version, or in some cases simply remove the piece from our Web site.

In the case of the patient information handout on menopause, it has been removed from our Web site.

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This series is coordinated by Kenny Lin, MD, MPH, deputy editor.

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