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Biomedical subjects

B Ettinger

Publications and source records attributed to B Ettinger.

At least 19 recordsLinked to original sources
PubMed1995

Estrogen replacement therapy and fractures in older women. Study of Osteoporotic Fractures Research Group.

OBJECTIVE: To determine the relation between estrogen replacement therapy and fractures. DESIGN: Prospective cohort study. SETTING: Four clinical centers in Baltimore County, Maryland; Minneapolis, Minnesota; Portland, Oregon; and the Monongahela Valley, Pennsylvania. PARTICIPANTS: 9704 ambulatory, nonblack women 65 years of age or older. MEASUREMENTS: Estrogen use, medical history, and anthropometric data were obtained by questionnaire, interview, and examination. Appendicular bone mass was measured by single-photon absorptiometry. Incident fractures were validated by radiographic report. RESULTS: After adjustment for potential confounders, current estrogen use was associated with a decrease in the risk for wrist fractures (relative risk [RR], 0.39; 95% CI, 0.24 to 0.64) and for all nonspinal fractures (RR, 0.66; CI, 0.54 to 0.80) when compared with no estrogen use. Results were similar for women using unopposed estrogen or estrogen plus progestin, for women younger or older than 75 years of age, and for current smokers or nonsmokers. The effect of estrogen remained after adjustment was made for appendicular bone mass. The relative risk for hip fracture tended to be lower among current users (RR, 0.60; CI, 0.36 to 1.02) than among never-users. Estrogen was most effective in preventing hip fracture among those older than 75 years. Current users who started estrogen within 5 years of menopause had a decreased risk for hip fractures (RR, 0.29; CI, 0.09 to 0.92), wrist fractures (RR, 0.29; CI, 0.13 to 0.68), and all nonspinal fractures (RR, 0.50; CI, 0.36 to 0.70) when compared with women who had never used estrogen. Previous use of estrogen for more than 10 years or use begun soon after menopause had no substantial effect on the risk for fractures. CONCLUSIONS: Current use of estrogen appears to decrease the risk for fracture in older women. These results suggest that for protection against fractures, estrogen should be initiated soon after menopause and continued indefinitely.

Age Factors↗
PubMed1995

Fracture protection provided by long-term estrogen treatment.

The objective of the study was to determine the incidence rate of osteoporotic fractures among elderly women who had long-term postmenopausal estrogen replacement therapy (ERT) and to compare this with the incidence rate in women who had not used estrogen. In a previous retrospective cohort study based on medical record review in 1982, we showed that long-term ERT was associated with lower incidence of wrist and vertebral fractures. We have extended our follow-up of 490 women by adding a mean 8 years to the observation period, which more than triples the number of osteoporotic fractures. At the Kaiser Permanente Medical Center, San Francisco, a large health maintenance organization, a review of computer pharmacy records from 1968 through 1971 identified 245 postmenopausal women; all had begun estrogen within 3 years of menopause and had used estrogen for at least 5 years. From the same pharmacy records, 245 age-matched postmenopausal non-users were identified. Among estrogen users, mean length of use was 17.0 years, mean follow-up after treatment was 7.3 years and mean dose of conjugated oral estrogen was 0.9 mg daily. We found statistically significant reduction in the incidence of wrist and vertebral fractures in users compared with non-users. The age-adjusted incidence ratios (95% confidence intervals for wrist fractures were 0.55 (0.32-0.92) and for vertebral fractures were 0.57 (0.41-0.80). These results were not statistically significantly altered after adjustment for age of menopause, body mass index and smoking. It is concluded that long-term ERT confers statistically significant protection against wrist and vertebral fractures.

Estrogen Replacement Therapy↗
PubMed1995

Spinal bone mineral loss in estrogen-replete, calcium-replete premenopausal women.

After peak bone mass in women is attained, the benefits of increased dietary calcium or supplemental calcium are uncertain. In a longitudinal, 4-year study we have investigated the effect of calcium intake on bone mineral in a group of 41 premenopausal women, aged 38-42 years at entry. Skeletal density was measured four times during the 4-year follow-up; spinal trabecular bone density (STBD) was measured by quantitative computed tomography, and midradius bone mineral density (RBMD) was measured by single photon absorptiometry. At baseline, no differences in bone density were observed among subjects in the highest and lowest quartiles of habitual dietary intake. Overall, STBD declined -0.86 +/- 0.15% per year (p < 0.001), but RBMD did not decline. Total calcium intake (dietary calcium plus supplemental calcium) did not correlate with the rate of STBD loss. Serum estradiol level did not decrease during the study, and bone loss did not correlate with the mean estradiol level. We conclude that premenopausal women in the fifth decade lose about 1% of spinal trabecular mineral yearly, in spite of a normal serum estradiol level and ample calcium intake.

Adult↗
PubMed1994

Kyphosis in older women and its relation to back pain, disability and osteopenia: the study of osteoporotic fractures.

To test the hypothesis that thoracic kyphosis is associated with substantial pain, disability, and height loss, we measured thoracic curvature, using an architect's flexicurve, of 610 women aged 65-91 years who were recruited from population-based listings. We assessed study subjects for back pain, back-related disability, height loss since age 25 years, perceived state of health, and bone mineral density (BMD) at the spine, calcaneus, proximal radius, and distal radius. Compared with the rest of the cohort, the 10% of women with the most severe kyphosis had 7%-17% lower BMD (p < 0.001) and had lost an additional 2.4 cm height (p < 0.001). However, kyphotic women had no greater back pain, disability caused by back problems, or poorer health. This cross-sectional study suggests that kyphosis is associated with decreased BMD and loss of height but does not cause substantial chronic back pain, disability, or poor health in older women.

Aged↗
PubMed1994

Cyclic hormone replacement therapy using quarterly progestin.

OBJECTIVES: To determine whether cyclic progestin, when part of postmenopausal hormone replacement therapy, can be used quarterly instead of monthly without increasing the risk of endometrial hyperplasia. In addition, we determined whether this hormone replacement therapy regimen produces an acceptable menstrual pattern. METHODS: The subjects were 214 postmenopausal women, mean (+/- standard deviation) age 56.2 +/- 5.4 years, who had regularly used hormone replacement therapy (consisting of Premarin 0.625 mg/day with monthly cyclic medroxyprogesterone, 5 or 10 mg) for a mean of 5.4 +/- 4.5 years (minimum 1 year). The study intervention consisted of changing the subjects' treatment from the usual monthly progestin to four 3-month (ie, quarterly) cycles of medroxyprogesterone, 10 mg/day for 14 days. Endometrial histology was evaluated by doing endometrial biopsies at study outset and after 1 year. Scheduled and unscheduled vaginal bleeding was reported in daily diaries. RESULTS: Endometrial hyperplasia was found in 1.5% of 199 women completing follow-up, a rate similar to the 0.9% prevalence found at baseline. Compared with monthly medroxyprogesterone, quarterly medroxyprogesterone resulted in longer menses (7.7 +/- 2.9 versus 5.4 +/- 2.0 days) and more reports of heavy menses (31.1 versus 8.0%) and unscheduled bleeding (15.5 versus 6.8%). Despite these problems, women preferred the quarterly regimen by nearly four to one. CONCLUSIONS: In a 1-year trial, quarterly medroxyprogesterone appeared as safe as monthly medroxyprogesterone and was preferred by most women. This schedule may be useful for women seeking relief from monthly use of progestin and monthly menses.

Adult↗
PubMed1993

Gynecologic complications of cyclic estrogen progestin therapy.

We evaluated the long-term gynecologic risks of postmenopausal estrogen therapy in conjunction with cyclic, monthly progestin (progestin-estrogen replacement therapy, or PERT). Our medical record review showed that incidence of abnormal vaginal bleeding necessitating gynecologic procedures for evaluation was significantly higher (RR, 3.1; 95% CI, 2.1-4.5), as was the rate of endometrial biopsy (RR, 3.4; 95% CI, 2.3-5.1), among women receiving PERT than among women not receiving hormone therapy. We also identified a non-significant trend toward a higher rate of dilation and curettage (RR, 1.5; CI, 0.7-3.3) among women receiving PERT. However, rates of endometrial hyperplasia and hysterectomy were similarly low in both groups. PERT apparently protects women against these serious gynecologic consequences previously seen in women taking unopposed estrogen.

Biopsy↗
PubMed1993

An update for the obstetrician-gynecologist on advances in the diagnosis, prevention, and treatment of postmenopausal osteoporosis.

Improvements in bone densitometry and new biochemical tests allow early detection and prevention of postmenopausal bone loss. Interventions for osteoporosis-prone women include correction of adverse habits and lifestyles, optimization of calcium and vitamin D intake, and prescription of estrogen. Recent studies indicate that elderly women may still obtain significant benefit from estrogen. Calcitonin is an approved alternative to estrogen, and recent studies confirm its ability to prevent bone loss and fractures, even when administered intranasally. This review also summarizes clinical investigation of newer, yet unapproved, methods of treatment; the most promising of these treatments are the bisphosphonates, fluoride, and tamoxifen.

Absorptiometry, Photon↗
PubMed1992

Hormone therapy to prevent disease and prolong life in postmenopausal women.

PURPOSE: To critically review the risks and benefits of hormone therapy for asymptomatic postmenopausal women who are considering long-term hormone therapy to prevent disease or to prolong life. DATA SOURCES: Review of the English-language literature since 1970 on the effect of estrogen therapy and estrogen plus progestin therapy on endometrial cancer, breast cancer, coronary heart disease, osteoporosis, and stroke. We used standard meta-analytic statistical methods to pool estimates from studies to determine summary relative risks for these diseases in hormone users and modified lifetable methods to estimate changes in lifetime probability and life expectancy due to use of hormone regimens. RESULTS: There is evidence that estrogen therapy decreases risk for coronary heart disease and for hip fracture, but long-term estrogen therapy increases risk for endometrial cancer and may be associated with a small increase in risk for breast cancer. The increase in endometrial cancer risk can probably be avoided by adding a progestin to the estrogen regimen for women who have a uterus, but the effects of combination hormones on risk for other diseases has not been adequately studied. We present estimates for changes in lifetime probabilities of disease and life expectancy due to hormone therapy in women who have had a hysterectomy; with coronary heart disease; and at increased risk for coronary heart disease, hip fracture, and breast cancer. CONCLUSIONS: Hormone therapy should probably be recommended for women who have had a hysterectomy and for those with coronary heart disease or at high risk for coronary heart disease. For other women, the best course of action is unclear.

Breast Neoplasms↗
PubMed1992

Contribution of vertebral deformities to chronic back pain and disability. The Study of Osteoporotic Fractures Research Group.

Among 2992 white women aged 65-70 years recruited from population-based listings, we measured radiographic vertebral dimensions of T5-L4 and calculated ratios of heights: anterior/posterior, mid/posterior, and posterior/posterior of either adjacent vertebra. The degree of deformity for each vertebra was analyzed in terms of the number of standard deviations (SD) that ratio differed from the mean ratio calculated for the same vertebral level in this population. We correlated the severity of each woman's worst vertebral deformity with back pain, back disability in six activities of daily living, and height loss since age 25. Only 39.4% of the cohort had no vertebral deformity; 10.2% had a deformity greater than or equal to 4 SD. Vertebral deformities less than 4 SD below the mean were not associated with increased back pain, disability, or loss of height. In contrast, women whose deformity was greater than or equal to 4 SD had a 1.9 (95% CI, 1.5-2.4) times higher risk of moderate to severe back pain and a 2.6 (95% CI, 1.7-3.9) times higher risk of disability involving the back; they were also 2.5 (95% CI, 2.0-3.2) times more likely to have lost greater than or equal to 4 cm in height. All three types of vertebral deformity (wedge, end plate, and crush) were equally associated with these outcomes. Multiple deformities less than 4 SD did not increase the likelihood of these three outcomes, but multiple deformities greater than or equal to 4 SD tended to be associated with increased back pain, disability, and height loss. This large cross-sectional study suggests that vertebral deformities cause substantial pain, disability, or loss of height only if vertebral height ratios fall 4 SD below the normal mean. Much back pain could not be attributed to vertebral deformities, suggesting other causes.

Aged↗
PubMed1992

Low-dosage micronized 17 beta-estradiol prevents bone loss in postmenopausal women.

With the use of a double-blind, randomized, dose-ranging design, we tested during an 18-month period the degree of protection against postmenopausal bone loss afforded by micronized 17 beta-estradiol in dosages of 0.5, 1.0, and 2.0 mg. All subjects received supplementation to ensure a minimum of 1500 mg calcium daily. Fifty-one subjects completed at least 1 year of follow-up bone density measurements by quantitative computed tomography and by single- and dual-photon absorptiometry. In the placebo group spinal trabecular bone density decreased 4.9% annually (p less than 0.001), whereas in those taking micronized 17 beta-estradiol bone density tended to increase (annual increases of 0.3% in the 0.5 mg micronized 17 beta-estradiol group, 1.8% in the 1.0 mg micronized 17 beta-estradiol group, and 2.5% in the 2.0 mg micronized 17 beta-estradiol group). After completing the double-blind phase, 41 subjects completed an additional 18 months of follow-up while taking 1.0 mg micronized 17 beta-estradiol. During this time one third of the subjects were randomly assigned to discontinue calcium supplements. Among those who previously received placebo, trabecular bone density increased 4.3% annually, whereas among those who had used micronized 17 beta-estradiol, trabecular bone density response was inversely related to the dosage previously used. Additionally and independently, the level of calcium intake showed a statistically significant correlation with the change in spinal trabecular bone density (r = 0.37, p = 0.02). We conclude that micronized 17 beta-estradiol has a continuous skeletal dose-response effect in the range of 0.5 to 2.0 mg and that calcium intake positively modifies the skeletal response to 1.0 mg micronized 17 beta-estradiol.

Adult↗
PubMed1992

Role of calcium in preserving the skeletal health of aging women.

During the years from adolescence through senescence, the skeleton passes through identifiable phases: consolidation, maturity, menopause, and senescence. Skeletal dynamics and calcium requirements are different during each phase. A adult woman can avoid the skeletal deterioration caused by calcium deficiency if she maintains a minimum daily calcium intake of 800 mg. Increased calcium intake will not increase skeletal mass in mature, premenopausal women and will not prevent bone loss in postmenopausal women. Because intestinal absorption decreases with age, daily calcium intake of 1000 to 1200 mg is recommended for the elderly. Women can increase their dietary calcium intake in various ways, including increasing intake of dairy products, eating calcium-rich nondairy foods, purchasing foods fortified with calcium, and, if all other methods prove inadequate, using calcium supplements. Physicians must prescribe calcium only after learning what is needed for a particular woman's skeletal health by determining that woman's stage of skeletal development and approximate calcium intake; if intake is insufficient, it should be adjusted to the level appropriate at that stage.

Aging↗
PubMed1991

Evaluation of adverse health outcomes associated with vertebral fractures.

Little is known about the frequency or degree to which vertebral fractures cause pain and physical disability. The purpose of this investigation was to examine the advantages of risk analysis over other statistical techniques (e.g., correlation analysis) for quantifying relationships between vertebral fractures and outcomes such as pain and disability. Subjects who volunteered to participate in studies of osteoporosis were asked about pain and disability. The number and degree of vertebral deformities were assessed from radiographs. Strong associations were observed between the most severe vertebral deformities and the risk of high pain or disability scores, while weaker associations were observed for moderate deformities. There did not appear to be any association between vertebral deformity and risk of moderate levels of pain or disability. Because of the potential for bias in cross-sectional studies such as this, the magnitude of these findings must be considered tentative. We conclude that risk analysis is an appropriate method for quantifying the relationship of vertebral fractures with pain and disability, but that prospective studies are now needed.

Back Pain↗
PubMed1991

Verbal hallucinations in psychotic patients.

"Verbal hallucinations" are sentences that psychotic patients may say repeatedly throughout a conversation which are out of context or unconnected to the topic of conversation. These hallucinations are not the outcome of a remembrance of an experience or an event and do not bring about any emotional relief or catharsis, but they supply valuable information. They resemble Jacques Lacan's description of the psychotic mechanism "Forclusion." This mechanism relates to experiences that did not undergo the process of primary symbolization through language, and experiences where words were attached but were not bound to the language structure. The result being that these experiences did not enter into the unconscious discourse of the subject. This information can reappear as verbal hallucinations in the psychotic patient. In such cases, the therapist, with the assistance of the patient's family, must investigate the meaning of the verbal hallucinations through research into the patient's and family's history in the phase prior to language development. When such a connection is discovered, the therapist must then bridge the hallucinations with the events unknown to the patient but contained in his subconscious. The therapist's role in such cases resembles that of a parent with a child: To translate the subject's experience through language from the physical schema to the body image and symbolic plane and in so doing, give meaning to meaninglessness. In our paper three short clinical cases are presented.

Body Image↗
PubMed1990

Spinal bone mineral density measured with quantitative CT: effect of region of interest, vertebral level, and technique.

This study documents the relationship between different vertebral bone compartments with quantitative computed tomography (CT). Four distinct patient groups were investigated: healthy pre- and early postmenopausal women as well as healthy and osteoporotic late postmenopausal women. Three different regions of interest (ROIs) were employed: the elliptical ROI located in the anterior trabecular portion of the vertebral body, the peeled ROI of irregular shape that circumscribes most of the trabecular bone, and the integral ROI including all bone except for the transverse processes. Both single- and dual-energy quantitative CT techniques were employed at T-12 through L-3. Correlation between measurements in the elliptical and peeled ROIs was high (r = .985). The authors concluded that either ROI is acceptable for clinical use. The decrements in bone mineral density (BMD) for the integral ROI were smaller than those for the elliptical ROI. Dual-energy measurements were consistently higher than single-energy measurements. BMD as a function of vertebral level decreased systematically from T-12 to L-3. However, the average density of T-12 through L-3 can be accurately predicted by the average density of L-1 and L-2 (r = .997). Precision did not deteriorate significantly when BMD was expressed as the average of L-1 and L-2 (1.5%) instead of T-12 through L-3 (1.4%). In this study the data suggest a modified quantitative CT protocol for clinical applications in which BMD of only L-1 and L-2 are measured at a fixed gantry tilt.

Adult↗
PubMed1990

Hormone replacement therapy and coronary heart disease.

Proper use of postmenopausal hormone replacement has been the subject of debate for decades. Prevailing medical opinion has swung between enthusiastic endorsement and extreme caution. The wave of optimism over estrogen's beneficial effects on menopausal symptoms and skeletal health was temporarily set back by the evidence that linked estrogen to endometrial cancer. Once studies showed that progestogen cotherapy could protect against this adverse effect, physicians were again encouraged to prescribe hormone replacement. Since 1980, increasing epidemiologic and experimental evidence has suggested a hitherto unappreciated and immense CHD health benefit from use of postmenopausal estrogen therapy. Although addition of progestogen may offset the cardiovascular benefits of estrogen slightly, its use is reasonable and practical. No woman need be subjected to unopposed estrogen's carcinogenic effects on her endometrium. Based on available evidence, hormone replacement therapy, appropriately administered, is both safe and beneficial. Unfortunately, there is no single way to prescribe it. The treating physician must make a series of best judgments. Practically speaking, this entails, in each case, finding the form of therapy that is acceptable to the patient and that provides the greatest health benefits with the least likelihood of adverse affects. Our prescribing habits have evolved in the last 15 to 20 years. We have better discrimination of the woman most likely to benefit; improved therapy through use of newer formulations, dosages, routes, and schedules; and more appropriate implementation of monitoring procedures. Although questions remain, we should not let our imperfect knowledge dissuade us from more widespread prescribing of hormone replacement therapy.

Aged↗