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Healthy Skepticism International News

July

Hormone Replacement Therapy: Fractures

Results:

45% of 1155 respondents indicated that the impact of HRT on increasing or decreasing the risk of fractures was very certain.


58% of 1153 respondents indicated that regarding fractures, HRT was likely to be very beneficial. 

There was a significant positive correlation between respondent’s level of certainty and their estimate of benefit.  (Spearman’s rho = 0.56[1] p

<0.0001) Those who felt more certain were more likely to believe that HRT had a beneficial effect on fracture rates.

Our comment:

The impact of HRT on fracture rates is probably known and may be mildly beneficial. 

Explanation:

All of the evidence from RCTs is consistent with the belief that long term HRT reduces fracture risk but the benefit may be small.  One RCT has suggested that in women with established osteoporosis, HRT may reduce the rate of lower vertebral fractures.[2]  However, hip fractures are more important for patients.  We are not aware of any direct evidence from RCTs of a reduction in hip fractures from HRT even in women with osteoporosis.  Reports of two trials of HRT for women without osteoporosis claim lower rates of non-vertebral fractures of borderline statistical significance.  However the first of these trials used questionable statistical “adjustments”.[3]  The second trial found significantly less forearm fractures in the HRT group but there was no significant difference in the total number of fractures.[4]  Most of the participants in this trial were not randomised and there was no placebo so the results are not reliable.

HRT does reduce loss of bone density.[5]  However, contrary to popular belief, bone density is not good for predicting who is or is not at high risk of fractures as shown in the graph below.[6]  We should also remember that fractures result from many causes and bone density is just one factor along with balance, environment, sedating medications, etc. 

Bone density is not a good test for distinguishing between high and low fracture risk because there is so much overlap between the curves for women who will have hip fractures versus those who will not.[6]

If Ann does not have osteoporosis then the best quality evidence relevant for Ann is the HERS trial.[7]  The HERS trial found no significant difference in the rate of fractures.  10% of women in the placebo group had fractures vs 9.4% in the HRT group. (p = 0.7 ie the probability of the 0.6% difference arising from chance alone is 70%).

Next: Cardiovascular events

 

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Cases of wilful misrepresentation are a rarity in medical advertising. For every advertisement in which nonexistent doctors are called on to testify or deliberately irrelevant references are bunched up in [fine print], you will find a hundred or more whose greatest offenses are unquestioning enthusiasm and the skill to communicate it.

The best defence the physician can muster against this kind of advertising is a healthy skepticism and a willingness, not always apparent in the past, to do his homework. He must cultivate a flair for spotting the logical loophole, the invalid clinical trial, the unreliable or meaningless testimonial, the unneeded improvement and the unlikely claim. Above all, he must develop greater resistance to the lure of the fashionable and the new.
- Pierre R. Garai (advertising executive) 1963