|
OB/GYN Editorial September 2004
Caring for the Mature Woman—Here
We Go Again
Lee P. Shulman, MD
 |
Just as we were all getting comfortable with the most
recent data concerning hormone therapy and menopausal
woman, another Women's Health Initiative (WHI)
paper arrives on the scene that puts the management
of the mature woman into another vortex of confusion
and concern. In case you haven't read the newest
WHI installation, I wholeheartedly recommend that you
go to your nearest computer or library and pick up
a copy [Anderson GL, et al. Women's Health Initiative
Steering Committee. Effects of conjugated equine estrogen
in postmenopausal women with hysterectomy: the Women's
Health Initiative randomized controlled trial. JAMA.
2004;291(14):1701-1712]. Please don't rely on
reviews or summaries or opinions (even mine!) for your
own opinion on this paper; read the paper and digest
the information—what you find may surprise you.
Or, rather, what you won't find may surprise
you. There are discrepancies between the WHI
Estrogen plus Progestin study and the more recent
Estrogen-only study; those differences in risk
of heart disease and breast cancer will be easy
to find. What won't be easy to find is
a frank statement by the Writing Group as to
the biases and limitations of their study. On
the contrary, the data from these trials have
been communicated in a manner which strongly
suggests that this information was applicable
to all menopausal women, when in fact, the randomization
process PRECLUDED the inclusion of the symptomatic
patient—the most COMMON type of menopausal
woman that most clinicians care for in their
offices. As such, the study cannot be appropriately
applied to a large portion of menopausal women.
Investigators are supposed to be interested in
the study process, not in the study results.
Science and medicine are advanced only when researchers
are passionate about the processes of their studies
and not about the outcomes of their studies.
However, part of the blame for this irresponsibility
lies with us. If we do not make every good effort
to read the papers, assess the literature, and
apply this information to APPROPRIATE patients,
then we will assuredly be getting most of our
continuing medical education from those paragons
of medical and scientific communication: FoxNews,
NBC, ABC, CBS, CNN, etc.
We cannot control the lay press or the advertising
industry, and we will definitely have to respond
to "newsworthy" health care reports
in the near future. How many of us have spent
hours responding to our patients' questions
regarding the wisdom of Suzanne Somers and her
theories on menopause management? Our best and
only approach to this onslaught of biased communication
and "snake oil" salespeople is by a
working knowledge of the relevant literature.
My friend and colleague, the late Trudy Bush,
often stated that no one study has a cornerstone
on the truth. Every study, no matter how well
done, will have biases and weaknesses that will
prevent it from being applied to all individuals
in all situations. We must be able to identify
those weaknesses and strengths and apply them
to each individual patient.
Our ability to access the peer-reviewed literature
has been greatly facilitated by the Internet
and by publications like The Female Patient that
adhere to strict criteria in publishing works
of medical and scientific information. We must
take advantage of these opportunities and be
lifelong learners if we are to be successful
clinicians.
Lee P. Shulman, MD
Associate Advisory Board Member
back
to top
|
