LETTERS TO medicSA
During a recent non-compensable work acquired acute pyrexial debilitating viral illness in private practice I had the opportunity to belatedly read the Letters on Hormone Replacement Therapy (SA Medical Review October 2002 page 5-6). An important aspect that so far has escaped public awareness is the role of insulin resistance and the associated hyperinsulinaemia, (dare I say it, - Syndrome X).
MIMS Pharmaceutical Database on Medical Director clearly states: 'A worsening of glucose tolerance has been observed in a significant percentage of patients on oestrogen containing oral contraceptives.' Laboratory tests reveal 'impaired glucose tolerance.' Furthermore MIMS states: - 'A decrease in glucose tolerance has been observed in some patients on progestogens.'
The patho-physiological mechanism of these adverse effects of course being mediated by increased insulin resistance caused by both the oestrogen and the progesterone. Jones in the letters referred to, states that 'two thirds were overweight with one third morbidly obese'. These women then would have had increased insulin resistance with associated hyperinsulinaemia which is a known risk factor for carcinoma of the breast and colon.
The message then is simple but impossible for most to implement: if a woman wishes to have the benefits of HRT she must ensure she has an appropriate diet, carries no excess weight and exercises regularly! Or as Tallis comments in his letter, "we now know that it is their healthy lifestyle and other characteristics which confer CHD protection."
This message should be given to all women who take not only HRT but also 'The Pill'. Adversely affected women cannot sue the drug manufacturer since even the ubiquitous bimonthly softcover updates of MIMS clearly states that "reduced glucose tolerance" is an adverse effect of every OCP listed. But successful litigation against the doctor is a risk.
DR. ALLEN E GALE
As a close friend of Allen Gale, I feel free to comment that it would seem that his virus infection has spread to his fingers with the pyrexia flowing onto the page. However, in the heat generated there is some light. In his toxic confusion he wishes to caution about the prescribing of Hormonal Therapy (sorry, the expression Hormone Replacement Therapy is no longer politically correct!) and the oral contraceptive in the same foetid breath. In terms of type of oestrogen and dosage these are two very different animals.
If we were to actually read the product information in MIMS, before reaching for the script pad we might immediately solve the Government's concern over the blow out in the Pharmaceutical's Budget. I accept absolutely his concerns about an adverse effect of oestrogens on the Metabolic Syndrome in the vulnerable individual. For example, I continue to be amazed that the Pill is still freely prescribed for women with Polycystic Ovary Syndrome when all of these women suffer Insulin Resistance and this despite the caution suggested by Kidson! (i)
In the second and, in many ways separate issue of HT and the Women's Health Initiative Study (WHI), that a majority were clearly at risk for hyperinsulinaemia implies that they may well have entered the study with already compromised arteries. The blanket prohibition of HT for the prevention of heart disease is in my view wholly premature. The basic science supporting a beneficial role for oestrogens is still good. We await with the greatest interest the sub group analyses to tell us more about the metabolic background of these casualties. In the meantime, I believe that the women with atheroma should not be denied HT but may require additional medication with statins and aspirin.
On the other hand, we cannot have our cake and eat it since the WHI purported to conclude that there was a decreased incidence of carcinoma of the colon. It may be that this conclusion will prove to be as flawed as that relating to the incidence of heart disease, particularly when the effect of 'confounding risk factors' is taken into the statistical analysis.
I fail to see why he needs to invoke the spectre of litigation into our prescribing practices. We should prescribe to the best of our ethical abilities in which the second best of 'Defensive Medicine' should be unnecessary.
If indeed, "Fever the eternal reproach to the physicians" (ii) , whom shall we reproach when the physician is sick? Certainly not Dr Gale who continues to entertain us with his smoking pen!
DR. ROBERT A. JONES
i Kidson W.: MJA: Vol 169: 537-540
ii Milton J.: Paradise Lost, Bk. XI
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From " medicSA APRIL 2003 p5 "