Women's Health Initiative (WHI) is a trial comparing conjugated equine estrogen plus medroxyprogesterone with placebo as a primary prevention strategy for healthy postmenopausal women with an intact uterus. It showed that in every 10,000 women taking HRT for one year, there were 7 additional coronary heart disease events, 8 more strokes, 8 more pulmonary emboli and 8 more invasive breast cancers which outweighed 6 fewer cases of colorectal cancer and 5 fewer hip fractures. Without scientific clinical trial data, one cannot assume that alternative estrogen with/without progestin preparations are any safer than those studied in WHI. The US Prevention Services Task Force (USPSTF) recommends AGAINST ROUTINE use of estrogen and progestin for the prevention of chronic conditions in postmenopausal women. Clinicians should also consider individual patient's risk factors profile and other effective strategies.

A 65 year old woman who had history of anterior myocardial infarction two years ago seeks your advice on initiating HRT for prevention of recurrent myocardial infarction.

Heart and Estrogen/Progestin Replacement (HERS) is a trial comparing conjugated equine estrogen plus medroxyprogesterone with placebo as a secondary prevention strategy for postmenopausal women with history of coronary heart disease (CHD). During an average of 4.1 years, HRT did not reduce the overall rate of CHD. The treatment caused increased risk of thromboembolic events and gall bladder disease. Moreover, in Estrogen Replacement in Atherosclerosis trial, neither estrogen alone nor estrogen plus medroxyprogesterone affected the progression of coronary atherosclerosis in women with angiographically verified coronary disease. American Heart Association recommends AGAINST initiation of HRT for the secondary prevention of cardiovascular disease.

Reference:

1. Women's Health Initiative. JAMA. 2002;288:321-333.
2. USPSTF on hormone replacement therapy. Ann Intern Med. 2002;137:834-839.
3. Heart and Estrogen/Progestin Replacement Study. JAMA. 1998;280:605-613.
4. Estrogen Replacement in Atherosclerosis trial. N Engl J Med. 2000;343:522-529.
5. American Heart Association statement on Hormone Replacement Therapy. Circulation. 2001;104:499-503.

The clinical diagnosis is lymphoedema.

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What are the possible underlying causes?

Lymphoedema is swelling due to accumulation of fluid within the tissues consequent to inadequate lymphatic drainage. Primary lymphoedema may be congenital, or occurring at puberty (lymphoedema praecox), or after age 35 (lymphoedema tardum). Lymphoedema may also be secondary to obstruction or destruction of lymphatic drainage by surgical removal, malignancies, radiation therapy and recurrent infections including filariasis.

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Lymphoscintigraphy will confirm the lymphatic origin of the oedema. Magnetic resonance imaging or ultrasound examination of the abdomen is performed to rule out tumour or enlarged lymph node.

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Possible complications include recurrent cellulitis and lymphangitis which could further destroy the lymphatic vessels and aggravate the lymphoedema. Lymphangiosarcoma may develop in 1% of cases.

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What are the treatments?

Possible underlying causes should be ruled out. Multi-layer bandaging, elastic hosiery, limb exercises and massage are methods to improve lymphoedema. Low salt diet and use of diuretic may be considered. Good hygiene, regular emollients and wound care are measures to prevent infection. Cellulitis should be treated promptly and antibiotic prophylaxis prescribed for frequent infection. Debulking operation should be considered if physical methods failed. Other treatment options include pneumatic compression, oral coumarin and lymphovenous anastomoses.

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