Ovarian hormone therapy for osteoporosis
Online posting: January 27, 1997
Published in print: June 1, 1997 (CMAJ 1997;156:1532)
Re: Effects of ovarian hormone therapy on skeletal and extraskeletel
tissues in women, by Dr. Robert G. Josse, CMAJ
1996;155:929-34 [full text]
I read the recent guidelines for management of osteoporosis and
recommendations for ovarian hormone therapy with great interest;
these will be of immediate use in my practice.
I have some questions concerning the recommendations on
follow-up surveillance. The incidence of endometrial cancer is
not increased if a progestin is used in addition to the estrogen,
yet the incidence of postmenopausal bleeding would be
considerably higher. The authors recommend vaginal
ultrasonography, then uterine sampling if needed. Hospital-based
dilatation and curettage is expensive and involves the use of
general anesthetic. Office sampling is not yet common in family
practices. Is the sensitivity and safety of this procedure great
enough to justify its wider use in primary care?
The Ontario Breast Screening Program offers women screening
mammography from the age of 50, every 2 years. Surveillance
recommendations are for a mammogram every 1 to 2 years, yet
breast cancer rates are not increased during the first 5 years of
estrogen therapy.[1] Should a woman 45 years of age be counxelled
to undergo a mammography when hormone therapy is initiated, or
would it be reasonable to wait until she is 50?
The author recommends that annual pelvic examinations be
arranged. The recent guidelines for Papanicolaou smears in
Ontario recommend that samples be taken yearly for 3 years, then
every 2 years if results are normal until age 69.[2] If there is
no history of fibroids or endometriosis, could the same
guidelines be used for Papanicolaou smears and pelvic
examinations once hormone therapy is initiated? There would be no
increased risk of cervical cancer, and rapid growth of fibroids
could be detected at the 1-year follow-up. The pelvic examination
would be done sooner if there was any abnormal bleeding. Perhaps
the reminders for Papanicoloau smears could be included in the
letters sent by the Breast Screening Program, since the target
populations dovetail.
With the increasing use of hormone therapy, follow-up
surveillance and its associated costs are likely to become more
important. I would like to be reassured that the guidelines are
based on sound evidence.
Michelle Greiver, MD
Willowdale, Ont.
74544.2324@compuserve.com
References
1. Steinberg KK, Thacker SB, Smith J. A meta-analysis of the
effect of estrogen replacement therapy on the risk of breast
cancer. JAMA 1991;265;1985-90.
2. Clarke EA. Cervical screening in Ontario. Ont Med
Rev 1996;63(8):40-1.
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