The Periodic Health Examination: 1987 update (1988)
RECOMMENDATIONS
- Unwanted Teen Pregnancy: Physicians who see adolescents should advise those who are sexually active about the correct use of appropriate contraception.
- Endometrial Cancer: There is fair evidence to exclude screening for endometrial cancer from the periodic health examination of asymptomatic postmenopausal women.
- Postmenopausal Osteoporosis and Related Fractures:
The etiologic factor that is most often associated with postmenopausal osteoporosis is estrogen deficiency. The results of clinical trials and case-control studies have supported the beneficial effect of estrogen replacement therapy in reducing the rate of bone loss and the incidence of fractures. However, these reports had many methodologic problems, particularly in the description of and the adjustment for confounding variables and in the definition of estrogen replacement therapy. Few of the reports gave confidence limits to accompany the statistical analyses; therefore, the absolute levels of risk or protection are difficult to determine.
If the use of estrogen were without risk of adverse effects, the accrued evidence might provide weak support for the widespread use of this agent to prevent or retard bone loss in postmenopausal women. The extent of risk related to estrogen use, however, is not clearly defined. Certainly increased risk of endometrial cancer has been associated with estrogen use. However, the addition of progesterone to estrogen replacement therapy may reduce this risk, and the overall risk may be low. Progesterone may also have adverse effects, particularly in relation to ischemic heart disease. However, low doses of progesterone have had little effect on serum lipid concentrations.
Because neither the absolute benefit nor the absolute risk of estrogen therapy is quantified, a recommendation advocating the widespread use of estrogen to prevent osteoporosis appears to be premature. A clinical trial of the effect of estrogen therapy on osteoporosis and related fractures is being considered. Perhaps a more definitive answer will result from this project. Better means of identifying people at risk and of quarantining risk should be developed. Risk factors should be carefully assessed through history taking and physical examination of all postmenopausal women, and clinical judgement should be used in prescribing estrogen replacement therapy for those thought to be at increased risk. The risk-benefit ratio for estrogen therapy in the high-risk group will differ from the ratio in the average-risk population and in the general population.
- Postmenopausal Osteoporosis and Related Fractures: As for other therapies, there is grade I evidence that supplemental calcium therapy may be effective in retarding the rate of cortical bone loss. There is no evidence of its effectiveness in slowing the rate of trabecular bone loss. However, the results of relevant studies are not uniform, and although increased dietary calcium intake may not harm most people, the long-term effects are unknown, and there is no certainty that the treatment will be protective.
- Postmenopausal Osteoporosis and Related Fractures: The results of studies on the effect of exercise are still preliminary, but they suggest a positive effect on the maintenance of bone density. There is little evidence for the effectiveness of vitamin D therapy. Although sodium fluoride therapy appears to be promising, its use is confined to research in a few centres. Further study of these three interventions is warranted.