Controversies concerning the safety of estrogen replacement therapy

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Coll(rwsrria~tkMfetyofe8trogellnplresaaclltt~y Whit&ad MI; Fraser D Academic Department of Obstetrb and Gynecology, King’s College School of Medicine Dentistry, London SE.5 8RK. United Kingdom AM. J. OBSTET. GYNECOL.; 156/S (1313-1322)/1987/

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Unopposed estrogen replacement is known to cause endometrial carcinoma in a small percentage of postmenopausal women. but the effects on ovarian and breast tissue remain uncertain. The increased risk of endometrial carcinoma seems to be related to both the dosage and duration of unopposed estrogen treatment. Until very recently, the morbidity and costs that result from the need for endometrial biopsy because of abnormal bleeding and from the need for hysterectomy due to hyperplasii have been ignored, but recent data suggest that they are likely to be considerable. Progestogens are known to protect against endometrial hyperstimulation. but the optimal duration of therapy each month and the maximaRy protective agent and dose remain to be determhred. Estrogen replacement therapy may reduce the risk of arterial disease; however, the comparative effects of the various preparations, as well as their respective mechanisms of action, must be subjected to further study.

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Gambrell RD Jr

Depo?tmmt of Endocrinology, Medical College of Georgia, Augusta, GA 30912, United States of America AM. J. OBSTET. GYNEXCOL.; 156/5 (1304-1313)/1987/ Estrogen therapy for postmenopausal women has received adverse publicity since the mid-1970s because several reports Implicated estrogens with an increased tisk of endometrial cancer. Other studies indicated that the risk of endometrial mahgnancy is reduced when a progestogen is added to the estrogen. Not all postmenopausal women need estrogen replacement, since many are symptom free because they continued to produce endogenous estrogens. Within this group may be the women at greatest risk for adenocarcmoma of the endometrium. The progestogen challenge test was devised to identify women at greater risk for endometrial cancer. The number of endomctrial malignancies declined at Wilford Hall U.S. Air Force Medical Center with increasing use of this test from 1975 through 1983. The lowest incidence of endometrial cancer was observed in the estrogen-progestogen users (49.0 per 100,000) and was significantly lower than that found in either the unopposed estrogen users (390.6 per lOO,ooO,P < or = 0.0001) or in the untreated women (245.5 per lOO.ooO;P < or = 0.005). The incidence of breast cancer was also significantIy lower in the estrogen-progestogen users (66.8 per 100.000) than in the untreated group (343.5 per 100,Oo) and lower than that expected from two national cancer surveys (188.3 and 229.2 per lOO.ooO,P< or = 0.01). Progestogens should be added to estrogen replacement therapy in women who have undergone a hysterectomy, as well as in those with an

intactuterus. ovc!wlew of the dfkncy of hormonal rcphcement therapy Ettinger B Kaiser Permanente Medical Center, San Francisco, CA 91115. United States of America AM. J. OBSTET. GYNECOL.; 156/5 (1298-1303)/1987/

The most widely recognixed reason for prescribing estrogen for menopausal women is for control of symptoms. Estrogen effectively reduces the vasomotor, somatic, and associated psychological components of the menopausal syndrome. Recently, however, the role of estrogen in the prevention of disease, parbcularly osteoporosis, urogenital atrophy, and atherosclerotic cardiovascular disease, has prompted consideration of this treatment for a more long-term goal. Bone loss occurring after