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Management of Menopause-Related Symptoms
- Carol M. Mangione, MD, MSPH;
- Donna L. Washington, MD, MPH; and
- Paul Woolf, MD, MBA
- From the David Geffen School of Medicine at University of California at Los Angeles, Los Angeles, CA 90024; VA Greater Los Angeles Healthcare System, Los Angeles, CA 90012; and Crozer Chester Medical Center, Upland, PA 19013.
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
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Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
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IN RESPONSE:
Dr. Danby correctly notes, as reported in our statement, that the Women's Health Initiative randomized, controlled trial revealed an increased risk for breast cancer in women taking estrogen combined with medroxyprogesterone acetate (1). Although the safety profile for this progestin may differ from that of “natural” progesterone, this issue, to our knowledge, has not been studied in adequately powered randomized clinical trials. Of note, small studies that failed to meet established quality grading were excluded from the panel's purview. We feel that Dr. Danby is confusing the lack of well-designed studies to determine the safety and efficacy of other hormonal preparations with evidence of the safety of these preparations. Although large clinical trials of every formulation of estrogen and progesterone are not feasible, we caution the acceptance of this interpretation. We believe that, in the face of the adverse effects demonstrated by the Women's Health Initiative and other studies, the burden of proof may be best placed on demonstrating (rather than presuming) the safety of other formulations.
Dr. Danby cites the paper by Bhavnani (2), which lists the components of conjugated equine estrogens but does not provide any information for or against the safety of this preparation. Because our panel focused on the management of menopause-related symptoms, the correlation between high levels of endogenous estrogen early in life and breast cancer risk was not in our purview.
The panel did not intend to leave the reader with the impression that all hormonal preparations carry the same risk profile; instead, we based our summary on the preparations that have been studied in well-designed large clinical trials. Individual women and their health care providers will have to decide for themselves how far the safety and efficacy data from the Women's Health Initiative and the Heart and Estrogen/progestin Replacement Study (3) can be extrapolated to other formulations for the management of menopausal symptoms.
Carol M. Mangione, MD, MSPH
David Geffen School of Medicine at University of California at Los Angeles; Los Angeles, CA 90024
Donna L. Washington, MD, MPH
VA Greater Los Angeles Healthcare System; Los Angeles, CA 90012
The Editors welcome submissions for possible publication in the Letters section. Authors of letters should:
•Include no more than 300 words of text, three authors, and five references
•Type with double-spacing
•Send three copies of the letter, an authors' form signed by all authors, and a cover letter describing any conflicts of interest related to the contents of the letter.
Letters commenting on an Annals article will be considered if they are received within 6 weeks of the time the article was published. Only some of the letters received can be published. Published letters are edited and may be shortened; tables and figures are included only selectively. Authors will be notified that the letter has been received. If the letter is selected for publication, the author will be notified about 3 weeks before the publication date. Unpublished letters cannot be returned.
Annals welcomes electronically submitted letters.
Article and Author Information
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Potential Financial Conflicts of Interest: None disclosed.
