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Although I found your outline of the issues related to the WHI estrogen studies to be thorough and succinct, ["WHI: The 'other shoe' drops," 2004;49(April):6-9], I find myself troubled by your apparent unwillingness to state an opinion of your own. As a highly regarded clinician provided with the rare opportunity to edit a major OB/GYN publication, your candid views on these highly contentious findings could have done a world of good both for us in practice and for our highly confused and worried patients. Granted you have posited the relevant questions, but I don't think that's satisfactory. I think I speak for many of us in the trenches who have searched in vain for leadership to say the things we all believe, and that is that these studies were profoundly flawed and should not be taken seriously. When, for example, you ask whether it is appropriate to withhold ET from someone with over a 0.08% risk of stroke, why couldn't you have just said NO like the rest of us say to our patients? Likewise, when we ponder the construction of a study in which patients are not started on HRT until the age of 60, why can't you just state that such a study cannot yield conclusions regarding what actually goes on in the real world; i.e., the 45- to 50-year-old healthy woman who wants relief from hot flashes?
Rather than "move on" beyond the WHI, which would imply our tacit approval of the studies, wouldn't it be preferable to continue to dissect them and point out their deficiencies first? Otherwise, won't NIH simply "move on" to more studies that fail to properly address these important issues?
While I appreciate your frank comments and ardor, your assumptions about my underlying feelings on the safety of HRT are wrong. I still have concerns about its role in exacerbating heart disease and breast cancer, and really do think additional studies are needed, particularly with new-generation agents. On the other hand, as a first-hand witness to the miserable symptomatology of the menopause, I think highly symptomatic women should be given the option of HRT, after assessment of their individual risks and adequate informed consent.
I enjoyed your editorial in the May 2004 issue of Contemporary OB/GYN, "Six steps to state-based tort reform," pages 1115, and I agree this litigation problem is the greatest threat to our specialty and medicine. This problem has developed during my time in medicine (Nebraska 1971). I totally support the attempts at tort reform and have written Sen. Ben Nelson (D-Neb.) repeatedly. I fear even the proposed reform is but a stopgap measure. Nebraska has had a cap on total damages for over 15 years, yet malpractice payouts have risen tenfold over the last decade.
Please keep up the fight!
Dr. Lockwood's reply:
I agree my recommendations for state-based reforms are, to quote Winston Churchill, "not the end, nor the beginning of the end, but it may well be the end of the beginning" of a solution to the current death spiral of litigation we are now in.
Letters to the Editor.
Jul. 1, 2004;49:34.