TO THE EDITOR: I have several comm...

TO THE EDITOR: I have several commentarys I wish to share regarding the article (1) in succession hip fractures by Dr. Brunner and colleagues. It must be pressureed that atypical clinical presentations of hip fractures in somewhat old patients are common. These patients at short intervals report vague calf or knee pain resulting in potential for misdiagnosis (especially when the patient recalls or is incapable of recalling any previous trauma). Thorough evaluation and radiographic view should be aggressively pursued in similar cases.

The authors state, "Although hormone replacement therapy has been used for osteoporosis prevention, late results from the Women's Health Initiative (WHI) trial (2) demonstrated that overall health risks overstep the proper limited the benefits of using combined estrogen plus progestin for an average follow-up period of 52 years in healthy postmenopausal women in the United States. The WHI findings indicated that the estrogen-progestin combination is not a viable intervention for primary prevention of chronic diseases."

I disagree. The WHI meditation (2) actually reported that estrogen replacement related beneficial issue on both hip and vertebral fractures. The authors state: "The reductions in clinical vertebral fractures, other osteoporotic fractures, and combined fractures supported the benefit for hip fractures base in this trial." (2) I agree with the authors that the WHI is the first trial with definitive data supporting the ability of postmenopausal hormones to debar fractures at the hip, vertebrae, and other sites. (2) The WHI did not provide sufficient data to support the statement in your article (1) that "the estrogen-progestin combination is not a viable intervention for primary prevention of chronic diseases." Rather, I would respectfully recommend that it may not be a viable option for a certain number of chronic disease prevention (notably, coronary heart disease), potentially excluding the osteoporosis where there still may be benefits.

The article (1) does not mention the use of certain medications as a risk factor for hip fractures. An important example could include use of corticosteroids (even inhaled) in the treatment of a great variety of illnesses. There are several interesting studies that support this view. (3-6)

ALEXANDER L BRZEZNY MD

Columbia Basin Hospital

200 SE Blvd

Ephrata, WA 98823

REFERENCES

(1) Brunner LC Eshilian-Oates L Kuo TY Hip fractures in adults. Am Fam Physician 2003;67:537-42

(2) Rossouw JE Anderson GL Prentice RL LaCroix AZ, Kooperberg C Stefanick ML et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal conclusions from the Women's Health Initiative randomized controll trial. JAMA 2002;288:321-33

(3) Hubbard RB Smith CJ Smeeth L Harrison TW Tattersfield AE. Inhaled corticosteroids and hip fracture: a population-based case-control investigation Am J Respir Crit Care M 2002;166(12 pt 1):1563-6

(4) Van Staa TP Abenhaim L Cooper C Zhang B Leufken HG Public health impact of adverse bone results of oral corticosteroids. Br J Clin Pharmacol 2001 June;51:601-7

(5) Baltzan MA, Suissa s Bauer DC, Cummings SR. Hip fractures attributable to corticosteroid use. application of mind of Osteoporotic Fractures Group. Lancet 1999; 353:1327

(6) Rackoff PJ Rosen CJ Pathogenesis and treatment of glucocorticoid-induced osteoporosis. physics Aging 1998;12:477-84.

IN REPLY: Dr Brzezny insightfully highlights important findings of the Women's Health Initiative (WHI) trial. (1) The WHI trial (1) demonstrated that among the research participants, estrogen plus progestin reduc the observ hip and vertebral fracture rates through one third compared with placebo. The reductions in other osteoporotic fractures (23 percent) and total fractures (24 percent) were raise to be statistically significant. (1) These and other findings (12) provide convincing data that support the ability of combination hormone therapy to impede fractures of the hip, vertebrae, and other sites.

However, the WHI trial (1) also demonstrated that the overall harm of combination hormone therapy go too fared its overall benefit. The WHI data (1) indicated that if 10000 women received the hormone combination therapy (estrogen plus progestin) for individual year, compared with 10,000 women not receiving the hormone combination, there would be six fewer woman with colorectal cancers and five fewer women with hip fractures; further eight more women receiving combination hormone therapy would evolve invasive breast cancer, seven more would have a heart attack or other coronary result eight more would have a rap and eight more would support a pulmonary embolism. In light of these findings, and considering that there are already existing alternatives (such as bisphosphonates and selective estrogen receptor modulators) that effectively thwart and treat osteoporotic fractures, it is difficult to justify definitive recommendations upon the use of combination hormone therapy for the primary prevention of chronic disease.