Women Are Strong But Not Invincible: Updates to Women’s Health

Guest Commentary

A recent issue of the Annals of Internal Medicine focused on women’s health from a number of perspectives. Among the topics covered were postmenopausal hormone replacement, osteoporosis, emergency contraception, and breast cancer screening. Let’s unpack this important collection.

HORMONE REPLACEMENT
What are the results of recent studies that addressed the pros and cons of postmenopausal hormone replacement?¹ Four studies seem to suggest that replacement is not a good idea. First, 16,608 women aged 50 to 79 years who were receiving either estrogen plus progesterone or no hormonal manipulation were followed up. The hormone group had a 25% increased risk of breast cancer. Second, the hormone group also had a higher death rate on follow-up. Third, another study demonstrated that hormone replacement did not decrease the incidence of coronary artery disease. Finally, the treated women had a higher rate of nephrolithiasis.

OSTEOPOROSIS
The second common problem discussed was osteoporosis.² Appropriate workup for women with osteoporosis includes a search for other diseases that affect bone integrity. Review the complete blood cell count (an underlying malignancy?), the calcium level (is there evidence for hyperparathyroidism?), the phosphate value (osteomalacia), the creatinine level (to implicate bone injury associated with chronic kidney disease), the thyroid-stimulating hormone level (is hyperthyroidism present?), liver tests, and the alkaline phosphatase level (Paget disease). If there is evidence of malabsorption, consider ordering a 24-hour calcium excretion and tests for celiac disease.

EMERGENCY CONTRACEPTION
Recent standard of care has recommended levonorgestrel for emergency contraception. It acts by preventing ovulation; however, it doesn’t always work. A new agent, ulipristal, which works by the same mechanism, in a single study decreased pregnancy 58% compared with levonorgestrel.¹ Ulipristal has been approved by the FDA for prevention of pregnancy up to 120 hours after unprotected sexual intercourse. The study addressing ulipristal was unblinded and should be considered important but preliminary.

BREAST CANCER SCREENING
Finally, another study considered age targets for screening mammography.³ It focused on whether earlier screening mammography (at age 40 rather than age 50) would be beneficial and cost-effective in younger women with selected risk factors—including family history of breast cancer, age, breast density, and history of a previous breast biopsy. The answer is that predictive scoring utilizing these data did improve the yield and number of positive biopsies at the cost of more false-positives. Although it comes early in a newer genetic era that may be characterized by personalizing mammography timing based on risks, as opposed to a “one size fits all” approach, this study may become important if its findings are consistent with data from further trials.

After reading the articles referenced above, I feel more strongly about the inherent dangers of estrogen-progesterone replacement in postmenopausal women; I am also more informed about both the diagnosis (as well as ancillary workup) and the treatment of osteoporosis. Other studies provided in the literature updates for 2010 (Pap plus human papillomavirus testing)¹ will also be of value to primary care physicians. ■