LETTER
Postmenopausal Hormone Therapy and Systemic Lupus Erythematosus
Jean-Charles Piette, MD;
Le Thi Huong Du, MD; and
Thomas Papo, MD
15 December 1995 | Volume 123 Issue 12 | Pages 961-962
TO THE EDITOR:
Sanchez-Guerrero and colleagues [1] reported that postmenopausal estrogen replacement therapy increases the risk for developing systemic lupus erythematosus. Some unmentioned confounding factors related to the nurses' medical histories should be discussed.
The risk might have been underestimated because a history of thrombosis could have discouraged physicians from prescribing estrogen replacement therapy. Some of these thromboses may have been related to an unrecognized antiphospholipid syndrome, which sometimes precedes full-blown systemic lupus erythematosus [2].
However, the risk may have been overestimated because of the possible inclusion of nurses with other autoimmune but nonrheumatic disorders for which estrogen replacement therapy is favored. Such disorders include "idiopathic" thrombocytopenia requiring steroids and Graves disease; both increase the risk for osteoporosis. In addition, no mention was made of premature ovarian failure, a condition for which hormone replacement therapy is commonly used. This condition sometimes results from autoimmune reactions directed against the ovaries. Antiovarian antibodies are frequently found in the sera of patients with systemic lupus erythematosus [3], and 10% of women with premature ovarian failure have antibodies to native DNA [4]. Moreover, some case reports have described an association between premature ovarian failure and systemic lupus erythematosus [5].
Because of these factors, systemic lupus erythematosus was more likely to occur in patients with previous thrombocytopenia and probably in those with organ-specific disorders such as Graves disease or premature ovarian failure. Although autoimmune premature ovarian failure is rare, so was the occurrence of systemic lupus erythematosus in the study by Sanchez-Guerrero and colleagues, even when only three American College of Rheumatology criteria were used to define the disease.
To exclude assessable potential biases, data should be given on women aged 40 years or older at menopause who never received steroids and had no previous autoimmune disorders.
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Author and Article Information
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Groupe Hospitalier Pitie-Salpetriere, 75013 Paris, France
1. JorgeSanchez-Guerrero, Matthew H.Liang, Karlson EW, Hunter DJ, Graham A.Colditz. Postmenopausal estrogen therapy and the risk for developing systemic lupus erythematosus Ann Intern Med. 1995;122:430-3.[Abstract/Free Full Text]
2. Alarcon-Segovia D, Perez-Vazquez ME, Villa AR, Drenkard C, Cabiedes J. Preliminary classification criteria for the antiphospholipid syndrome within systemic lupus erythematosus Semin Arthritis Rheum. 1992;21:275-86.[Medline]
3. Moncayo-Naveda H, Moncayo R, Benz R, Wolf A, Lauritzen C. Organ-specific antibodies against ovary in patients with systemic lupus erythematosus Am J Obstet Gynecol. 1989;160:1227-9.[Medline]
4. Blumenfeld Z, Halachmi S, Peretz BA, Shmuel Z, Golan D, Makler A, et al. Premature ovarian failure—the prognostic application of autoimmunity on conception after ovulation induction Fertil Steril. 1993;59:750-5.[Medline]
5. Case records of the Massachusetts General Hospital. Case 46-1986. A 26-year-old woman with secondary amenorrhea. N Engl J Med. 1986; 315:1336-43.
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