A Collection of Notes, Essays, and Rants and Raves about Current Topics and Philosophy in Medicine.
Southern Avenue Family Practice, P. C.
Estrogen-Progesterone Combination Therapy
An article in the July 15, 2002 Journal of the American Medical Association reported that there were increases in breast cancer and heart disease in a group of women who took combined estrogen and progesterone. More specifically, the women in the medication group took PremPro, a commonly used estrogen replacement medication. After about five years, the women who took the drug had 15 more cardiovascular events and 8 more breast cancers than the women who were taking a sugar pill. There were also fewer hip fractures in the group taking the drug.
As is so frequently the case, the newspapers responded hysterically that the drugs were dangerous and should not be used. The articles and news programs implied that the increases in disease were completely unexpected, and that the drugs were dangerous. In fact, this article added very little to our understanding of these medications.
Hormone replacement has two goals:
1) Treating or preventing osteoporosis. The study showed that it does so.
2) Treating the side effects of menopause. Although the study did not address this aspect, we know that these drugs do have this effect.
Hormone replacement has several problems:
1) Increases in breast cancer. This study suggested a small increase in breast cancer. A re-evaluation of the data by outside researchers suggests that the cancers that were found would have been present before the start of the study. No deaths were associated with the medications or because of breast cancer.
2) Increases in blood clots. The effect of estrogen and progesterone on clotting has been well known for many years, and has been a limiting factor in their use. Again, the increase was small, and the study did not appear to have controlled for women smoking, which increases this risk unbelievably.
3) Increases in heart disease. This is new, but this did not meet statistical significance. In other words, athough there was an increase, it cannot be proven that it was caused by medication. The researchers were expecting to see an improvement in heart disease, and a few years ago there were articles that appeared to show such improvements in women who took hormones. This time, the group taking hormones had more heart attacks and cardiovascular events than those who were taking a sugar pill. The increases, however, were only in the first year of treatment, and after that time there was no effect.
"So what do I do with all this information?" you ask. I'm glad you asked. These medications can best be described as comfort medications. By that, I mean that they improve the lives of many of the women who take them. For women who have intolerable side effects from estrogen withdrawal due to menopause, estrogen replacement helps them to lead a normal life. And although we have other medications to prevent bone loss, they, too, have side effects. If you have thought of hormone replacement as a way to prevent diseases such as heart disease and Alzheimer's disease, at this point there is no evidence that hormone replacement helps in this way.
On the other hand, if you think that these medications are the newest way to poison the female population with medicine, I hope you will take a course in statistics. In a population of 10,000 women, about 1250 of them will get breast cancer, by the latest estimates. That is, about one woman out of eight will develop such a tumor during her lifetime. The article uses a number of excess cases per 10,000 per year, so exact comparison is difficult. However, although the increase in risk is small, it is real. There was a decrease in the risk from colon cancer in the group of women who were taking the medication, although that did not reach significance. It is important to understand that there was no difference in death rates between the women who were taking the estrogen/progesterone combination and the group that was taking a sugar pill.
Bottom line: If you are taking estrogen and progesterone in combination to prevent diseases other than osteoporosis, understand that the medications do not help, according to this study. If you have a family history or personal history of breast cancer, stop taking the drugs. You shouldn't be on them, anyway, and we have not generally used them in these people for years. If you are taking hormone replacements to help you feel better with menopause, realize that continuing the drugs can increase your risk of breast cancer by a small amount.
If you want to read the article for yourself, go to the following website:
You can do so by clicking on the "OK" button to the right:
Article updated 10/8/2006--Steven C. Burns, M. D.
Quackery
(from mdnetguide.com, June 2002)
For physicians, MDs and DOs, who have spent their lives studying and practicing scientific medicine, it is always discouraging to see our patients led astray by charlatans and fakers. There are far too many unscrupulous people who will take money from desperate patients, promising instant or easy cures, or prevention of illnesses that are supposedly unknown by modern medicine.
Now, such activities might be only amusing and silly in most instances--but people with illnesses can be swayed to wasting money and valuable time with false treatments, when there are effective treatments available from their physicians. In some cases, the effects have been fatal.
This is especially true when cancer is the disease, but the 'quacks' can cause problems even for heart disease, diabetes, and infectious diseases. There are even practitioners who attempt to convince people not to immunize their children against childhood illnesses. In countries where the 'quacks' have been most influential, there have been epidemics that have cost the lives of thousands of people. If you are interested, I have the article on which this claim is based, and will provide you with a copy on request.
There are several characteristics of quackery. You will see statements about hidden cures, conspiracies to hide curative powers, energy sources in the body, and treatments that are available only through the organization making the claims. Typically, there is an indictment of drug companies and/or the government for keeping the information from the public. Beware of wild 'scientific' claims. In medicine as in other areas of life, there is no such thing as a free lunch.
The website, www.quackwatch.org, is a frequently updated location for information about the latest and greatest methods followed by 'alternative' gurus. They are all methods designed to separate your wallet from its contents, and they range from 'coral calcium' to chelation therapy. Several other sites are available. Just click on the buttons at the right:
Quackwatch:
The National Council Against Health Fraud:
A U. S. government site from the National Institutes of Health:
The Skeptic's Dictionary:
Article updated 10/8/2006--Steven C. Burns, M. D.
Colon Cancer Screening
Colorectal cancer screening is recommended for all adults over age 50. This can be accomplished in several ways, and no specific method has been recommended more highly than any other method. There are advantages and drawbacks to each type of screening. Here is a listing, with notes:
Stool tests for occult blood. These have been the mainstay of physical examinations for decades, and they still have some benefit. A small amount of feces is obtained either during the examination, or at home, and a test is performed to see whether there is any blood in the specimen. The amount of blood is generally too small to be seen, except when a developer fluid is added. A new form of the test, Insure, is more accurate, and it is performed at home and then the specimen is taken or sent to the laboratory.
Sigmoidoscopy. This method has fallen out of favor. It seems that the locations of colon polyps have changed over the years, such that now, more than 50% of polyps are out of the reach of the short scope.
Colonoscopy. This is usually the preferred method for testing, and it is the method that I recommend at present. Although there is a risk of colon perforation (less than 1% of cases), the ability to see the entire colon is excellent, and biopsies can be performed at the time of the test. The procedure is done by a gastroenterologist or colorectal surgeon, under a type of anesthesia known as "conscious sedation." The vast majority of those who have this done do not remember anything about the procedure, and experience no adverse effects after awakening.
Barium enema. Most authorities do not recommend this procedure for screening purposes, as only very large polyps would be seen, and an abnormal test would end up in colonoscopy anyway. There are, however, cases in which the patient's general medical condition would not allow colonoscopy, but the person could undergo this test.
Virtual colonoscopy. I mention this for completeness, as this procedure is not in use much. It is a CT scan, and is quite expensive. It requires the same preparation as a colonoscopy or barium enema, and does not allow for biopsy.
Pill-Cam. This is a new technology, in which the patient swallows a tiny camera, about the size of a large capsule. The camera transmits images continuously as it passes through the GI tract, and the images are captured by a small device worn on the belt. The images are amazing, and for screening purposes this may become the method that will be preferred, as soon as the insurers catch on and realize it is not experimental. Currently, the Pill-Cam is used for the esophagus, stomach, and small intestine, but the possibility of its use in the colon still exists.
If a patient falls into a high-risk group, that person should obtain screening, usually colonoscopy, at an earlier age than 50. Those in the high-risk groups would include anyone with a first-degree relative (parent or sibling) who developed colon cancer before age 50; any patient with ulcerative colitis or Crohn's disease; and patient with another solid tumor, such as breast or prostate cancer. A patient with bleeding, of course, is not a screening patient, and should not wait until a regular physical exam to discuss this with a physician.
You can get additional information from a new source by one of our local gastroenterology groups, www.coloncancerawareness.com. You can also search one of the links on our Infolinks page.
