0
April 17, 1991, Vol 265, No. 15 >
ARTICLE | April 17, 1991

A Meta-analysis of the Effect of Estrogen Replacement Therapy on the Risk of Breast Cancer FREE

Karen K. Steinberg, PhD, MSc; Stephen B. Thacker, MD, MSc; S. Jay Smith, MS, MIS; Donna F. Stroup, PhD, MSc; Matthew M. Zack, MD; W. Dana Flanders, MD, DSc; Ruth L. Berkelman, MD
[+] Author Affiliations

Use of trade names is for identification only and does not constitute endorsement by the Public Health Service or the US Department of Health and Human Services.

Reprint requests to Center for Environmental Health and Injury Control, Centers for Disease Control, MS F-18,1600 Clifton Rd, Atlanta, GA 30333 (Dr Steinberg).


JAMA. 1991;265(15):1985-1990. doi:10.1001/jama.1991.03460150089030
Text Size: A A A
Published online
Article
References

To quantify the effect of estrogen replacement therapy on breast cancer risk, we combined dose-response slopes of the relative risk of breast cancer against the duration of estrogen use across 16 studies. Using this summary dose-response slope, we calculated the proportional increase in risk of breast cancer for each year of estrogen use. For women who experienced any type of menopause, risk did not appear to increase until after at least 5 years of estrogen use. After 15 years of estrogen use, we found a 30% increase in the risk of breast cancer (relative risk, 1.3; 95% confidence interval [CI], 1.2 to 1.6). The increase in risk was largely due to results of studies that included premenopausal women or women using estradiol (with or without progestin), studies for which the estimated relative risk was 2.2 (CI, 1.4 to 3.4) after 15 years. Among women with a family history of breast cancer, those who had ever used estrogen replacement had a significantly higher risk (3.4; CI, 2.0 to 6.0) than those who had not (1.5; CI, 1.2 to 1.7).

(JAMA. 1991;265:1985-1990)

REFERENCES

1 +
Utian WH.  The true clinical features of postmenopause and oophorectomy and their response to estrogen therapy . S Afr Med J. 1972;;46:732-737.
2 +
Lindsay R, Hart DM, Forrest C, Baird C.  Prevention of spinal osteoporosis in oophorectomized women . Lancet. 1980;;2:1151-1153.
3 +
Genant HK, Camm CE, Ettinger B, Gordon GS.  Quantitative computed tomography of vertebral spongiosa: a sensitive method for detecting early bone loss after oophorectomy . Ann Intern Med. 1982;;97:699-705.
4 +
Henderson BE, Paganini-Hill A, Ross RK.  Estrogen replacement therapy and protection from acute myocardial infarction . Am J Obstet Gynecol. 1988;;159:312-317.
5 +
Bush TL, Barrett-Connor E.  Noncontraceptive estrogen use and cardiovascular disease . Epidemiol Rev. 1985;;7:80-104.
6 +
Henderson BE, Ross RK, Paganini-Hill A, Mack TM.  Estrogen use and cardiovascular disease . Am J Obstet Gynecol. 1986;;154:1181-1186.
7 +
Bush TL, Cowan LD, Barrett-Connor E, et al.  Estrogen use and all-cause mortality: preliminary results from the Lipid Research Clinics Program Follow-up Study . JAMA. 1983;;249:903-906.
8 +
Byrd BF Jr, Burch JC, Vaughn WK.  The impact of long-term estrogen support after hysterectomy . Ann Surg. 1977;;185:574-580.
9 +
Hemminki E, Kennedy DL, Baum C, McKinlay SM.  Prescribing of noncontraceptive estrogens and progestins in the United States, 1974-1986 . Am J Public Health. 1988;;78:1479-1481.
10 +
Thomas DB.  Do hormones cause breast cancer ? Cancer. 1984;;53:595-604.
11 +
Kelsey JL.  Breast cancer epidemiology . Cancer Res. 1988;;48:5615-5623.
12 +
Henderson BE, Ross RK, Pike MC, Casagrade JT.  Endogenous hormones as a major factor in human cancer . Cancer Res. 1982;;42:3232-3239.
13 +
Cutts JH, Noble RL.  Estrone-induced mammary tumors in the rat, I: induction and behavior of tumors . Cancer Res. 1969;;24:1116-1123.
14 +
IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Human Sex Hormones . Lyon, France: International Agency for Research on Cancer; 1979;;21( (suppl 11) ).
15 +
Casagrande J, Gerkins V, Mack T, et al.  Brief communication: exogenous estrogens and breast cancer in women with natural menopause . J Natl Cancer Inst. 1976;;56:839-841.
16 +
Sartwell PE, Arthes FG, Tonascia JA.  Exogenous hormones, reproductive history, and breast cancer . J Natl Cancer Inst. 1977;;59:1589-1592.
17 +
Wynder EL, MacCornack FA, Stellman SD.  The epidemiology of breast cancer in 785 United States Caucasian women . Cancer. 1978;;41:2341-2354.
18 +
Ravinhar BA, Seigel DG, Lindtner J.  An epidemiologic study of breast cancer and benign breast neoplasias in relation to the oral contraceptive and estrogen use . Eur J Cancer. 1979;;15:395-405.
19 +
Kelsey JL, Fischer DB, Holford TR, et al.  Exogenous estrogens and other factors in the epidemiology of breast cancer . J Natl Cancer Inst. 1981;;67:327-333.
20 +
Wallach S, Henneman PH.  Prolonged estrogen therapy in postmenopausal women . JAMA. 1959;; 171:1637-1642.
21 +
Sherman B, Wallace R, Bean J.  Estrogen use and breast cancer . Cancer. 1983;;51:1527-1531.
22 +
Horwitz RI, Stewart KR.  Effects of clinical features on the association of estrogens and breast cancer . Am J Med. 1984;;6:192-198.
23 +
Kaufman DW, Miller DR, Rosenberg L, et al.  Noncontraceptive estrogen use and risk of breast cancer . JAMA. 1984;;252:63-67.
24 +
McDonald JA, Weiss NS, Daling JR, Francis AM, Polissar L.  Menopausal estrogen use and the risk of breast cancer . Breast Cancer Res Treat. 1986;;7:193-199.
25 +
Nachtigall LE, Nachtigall RH, Nachtigall RD, et al.  Estrogen replacement therapy, II: a prospective study in the relationship to carcinoma and cardiovascular and metabolic problems . Obstet Gynecol. 1979;;54:74-79.
26 +
Bland KI, Buchanan JB, Weisberg BF, Hagan TA, Gray LA.  The effects of exogenous estrogen replacement therapy on the breast: breast cancer risk and mammographic parenchymal patterns . Cancer. 1980;;45:3027-3033.
27 +
Gambrell RD Jr, Maier RC, Sanders BI.  Decreased incidence of breast cancer in postmenopausal estrogen-progestogen users . Obstet Gynecol. 1983;;62:435-443.
28 +
Buring JE, Hennekens CH, Lipnick RJ, et al.  A prospective cohort study of postmenopausal hormone use and risk of breast cancer in U.S. women . Am J Epidemiol. 1987;;125:939-947.
29 +
DuPont WD, Page DL, Rogers LW, Parl FF.  Influence of exogenous estrogens, proliferative breast disease, and other variables on breast cancer risk . Cancer. 1989;;63:948-957.
30 +
Wilson RA.  The roles of estrogen and progesterone in breast and genital cancer . JAMA. 1962;;182:327-331.
31 +
Hammond CB, Jelocsek FR, Lee KL, Creasman WT, Parker RT.  Effects of long-term estrogen replacement therapy, II: neoplasia . Am J Obstet Gynecol. 1979;;133:537-547.
32 +
Hulka BS, Chambless LE, Duebner DC, Wilkinson WE.  Breast cancer and estrogen replacement therapy . Am J Obstet Gynecol. 1982;;143:638-644.
33 +
Nomura AMY, Kolonel LN, Hirohata T, Lee J.  The association of replacement estrogens with breast cancer . Int J Cancer. 1986;;37:49-53.
34 +
Brinton LA, Hoover R, Fraumeni JF Jr.  Menopausal oestrogens and breast cancer risk: an expanded case-control study . Br J Cancer. 1986;; 54:825-832.
35 +
Jick H, Walker AM, Watkins RN, et al.  Replacement estrogens and breast cancer . Am J Epidemiol. 1980;;112:586-594.
36 +
Hoover R, Glass A, Finkle WD, Azevedo D, Milne K.  Conjugated estrogens and breast cancer risk in women . J Natl Cancer Inst. 1981;;67: 815-820.
37 +
Ross RK, Paganini-Hill A, Gerkins VR, et al.  A case-control study of menopausal estrogen therapy and breast cancer . JAMA. 1980;;243:1635-1639.
38 +
Wingo PA, Layde PM, Lee NC, Rubin G, Ory HW.  The risk of breast cancer in postmenopausal women who have used estrogen replacement therapy . JAMA. 1987;;257:209-215.
39 +
Hiatt RA, Bawol R, Friedman GD, Hoover R.  Exogenous estrogen and breast cancer after bilateral oophorectomy . Cancer. 1984;;4:139-144.
40 +
Hoover R, Gray LA, Cole P, MacMahon B.  Menopausal estrogens and breast cancer . N Engl J Med. 1976;;295:401-405.
41 +
Bergkvist L, Adami HO, Persson I, Hoover R, Schairer C.  The risk of breast cancer after estrogen and estrogen-progestin replacement . N Engl J Med. 1989;;321:293-297.
42 +
LaVecchia C, DeCarli A, Parazihni F, Gentile A, Liberati C, Franceschi S.  Noncontraceptive oestrogens and the risk of breast cancer in women . Int J Cancer. 1986;;38:853-858.
43 +
Thacker SB.  Meta-analysis: a quantitative approach to research integration . JAMA. 1988;; 259:1685-1689.
44 +
Craig TJ, Comstock GW, Geiser PB.  Epidemiologic comparison of breast cancer patients with early and late onset of malignancy and general population controls . J Natl Cancer Inst. 1974;;53:1577-1581.
45 +
Thomas DB, Persing JP, Hutchinson WB.  Exogenous estrogen and other risk factors for breast cancer in women with benign breast diseases . J Natl Cancer Inst. 1982;;69:1017-1028.
46 +
Brinton LA, Williams RR, Hoover RN, Stegens NL, Feinleib M, Fraumeni JF Jr.  Breast cancer risk factors among screening program participants . J Natl Cancer Inst. 1979;;62:37-43.
47 +
Henderson BE, Powell D, Rosario I, et al.  An epidemiologic study of breast cancer . J Natl Cancer Inst. 1974;;53:609-614.
48 +
Mack TM, Henderson BE, Gerkins VR, et al.  Reserpine and breast cancer in a retirement community . N Engl J Med. 1975;;292:1366-1371.
49 +
Gambrell RD, Massey FM, Castaneda TA, et al.  Estrogen therapy and breast cancer in postmenopausal women . J Am Geriatr Soc. 1980;; 28:251-257.
50 +
Boston Collaborative Drug Surveillance Program, Boston University Medical Center.  Surgically confirmed gallbladder disease, venous thromboembolism, and breast tumors in relation to postmenopausal estrogen therapy . N Engl J Med. 1974;;290:15-19.
51 +
Ewertz M.  Influence of noncontraceptive exogenous and endogenous sex hormones on breast cancer risk in Denmark . Int J Cancer . 1988;;42:832-838.
52 +
Longnecker MP, Berlin JA, Orza MJ, Chalmers TC.  A meta-analysis of alcohol consumption in relation to risk of breast cancer . JAMA. 1988;; 260:652-656.
53 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co; 1986;:344.
54 +
DerSimonian R, Laird N.  Meta-analysis in clinical trials . Controlled Clin Trials. 1986;;7:177-188.
55 +
Dixon WJ.  Processing for outliers . Biometrics. 1953;;9:74-89.
56 +
Statistical Abstract of the United States: 1989 . 109th ed. Washington, DC: US Bureau of the Census; 1989;.
57 +
American Cancer Society.  Cancer statistics, 1986 . CA. 1987;;37:12-13.
58 +
Armstrong BK.  Oestrogen therapy after menopause—boon or bane ? Med J Aust. 1988;; 148:213-214.
59 +
Angell M.  Negative studies . N Engl J Med. 1989;;321:464-466.
60 +
Chalmers TC, Levin H, Reitman D, et al.  Meta-analysis of clinical trials as a scientific discipline, I: control of bias and comparison with large cooperative trials . Stat Med. 1987;;6:315-325.
61 +
Bergkvist L, Persson I, Adami H-O, et al.  Risk factors for breast and endometrial cancer in a cohort of women treated with menopausal oestrogens . Int J Epidemiol. 1988;;17:732-737.
62 +
Brinton LA, Hoover RN, Szklo M, et al.  Menopausal estrogen use and risk of breast cancer . Cancer. 1981;;47:2517-2522.
63 +
Centers for Disease Control.  Long-term oral contraceptive use and the risk of breast cancer . JAMA. 1983;;249:1591-1595.
64 +
Mann JI, Vessey MP, Thorogood M, Doll R.  Myocardial infarction in young women with special reference to oral contraceptive practice . BMJ. 1975;;2:241-245.
65 +
Harlap S, Baras M.  Conception-waits in fertile women after stopping oral contraceptives . Int J Fertil. 1984;;29:73-80.
66 +
Hammond CB, Maxson WS.  Estrogen replacement therapy . Clin Obstet Gynecol. 1986;;29: 407-430.
67 +
Wren BG, Brown LB, Routledge JDA.  Differential clinical response to oestrogens after menopause . Med J Aust. 1982;;2:329-332.
68 +
Ernster VL, Bush TL, Huggins GR, et al.  Benefits and risks of menopausal estrogen and/or progestin hormone use . Prev Med. 1988;;17: 201-223.
69 +
Henderson BE, Ross RK, Lobo RA, Pike MC, Mack TM.  Re-evaluating the role of progestogen therapy after the menopause . Fertil Steril. May 1988;;49( (suppl) ):9S-15S.
70 +
Lufkin EG, Carpenter PC, Ory SJ, Malkasian GD, Edmonson JH.  Estrogen replacement therapy: current recommendations . Mayo Clin Proc. 1988;;27:201-223.
71 +
Hulka BS.  Hormone-replacement therapy and the risk of breast cancer . CA. 1990;;40:289-296.

Figures

Tables

Interactive Graphics

Video

Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature

Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal

1 +
Utian WH.  The true clinical features of postmenopause and oophorectomy and their response to estrogen therapy . S Afr Med J. 1972;;46:732-737.
2 +
Lindsay R, Hart DM, Forrest C, Baird C.  Prevention of spinal osteoporosis in oophorectomized women . Lancet. 1980;;2:1151-1153.
3 +
Genant HK, Camm CE, Ettinger B, Gordon GS.  Quantitative computed tomography of vertebral spongiosa: a sensitive method for detecting early bone loss after oophorectomy . Ann Intern Med. 1982;;97:699-705.
4 +
Henderson BE, Paganini-Hill A, Ross RK.  Estrogen replacement therapy and protection from acute myocardial infarction . Am J Obstet Gynecol. 1988;;159:312-317.
5 +
Bush TL, Barrett-Connor E.  Noncontraceptive estrogen use and cardiovascular disease . Epidemiol Rev. 1985;;7:80-104.
6 +
Henderson BE, Ross RK, Paganini-Hill A, Mack TM.  Estrogen use and cardiovascular disease . Am J Obstet Gynecol. 1986;;154:1181-1186.
7 +
Bush TL, Cowan LD, Barrett-Connor E, et al.  Estrogen use and all-cause mortality: preliminary results from the Lipid Research Clinics Program Follow-up Study . JAMA. 1983;;249:903-906.
8 +
Byrd BF Jr, Burch JC, Vaughn WK.  The impact of long-term estrogen support after hysterectomy . Ann Surg. 1977;;185:574-580.
9 +
Hemminki E, Kennedy DL, Baum C, McKinlay SM.  Prescribing of noncontraceptive estrogens and progestins in the United States, 1974-1986 . Am J Public Health. 1988;;78:1479-1481.
10 +
Thomas DB.  Do hormones cause breast cancer ? Cancer. 1984;;53:595-604.
11 +
Kelsey JL.  Breast cancer epidemiology . Cancer Res. 1988;;48:5615-5623.
12 +
Henderson BE, Ross RK, Pike MC, Casagrade JT.  Endogenous hormones as a major factor in human cancer . Cancer Res. 1982;;42:3232-3239.
13 +
Cutts JH, Noble RL.  Estrone-induced mammary tumors in the rat, I: induction and behavior of tumors . Cancer Res. 1969;;24:1116-1123.
14 +
IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Human Sex Hormones . Lyon, France: International Agency for Research on Cancer; 1979;;21( (suppl 11) ).
15 +
Casagrande J, Gerkins V, Mack T, et al.  Brief communication: exogenous estrogens and breast cancer in women with natural menopause . J Natl Cancer Inst. 1976;;56:839-841.
16 +
Sartwell PE, Arthes FG, Tonascia JA.  Exogenous hormones, reproductive history, and breast cancer . J Natl Cancer Inst. 1977;;59:1589-1592.
17 +
Wynder EL, MacCornack FA, Stellman SD.  The epidemiology of breast cancer in 785 United States Caucasian women . Cancer. 1978;;41:2341-2354.
18 +
Ravinhar BA, Seigel DG, Lindtner J.  An epidemiologic study of breast cancer and benign breast neoplasias in relation to the oral contraceptive and estrogen use . Eur J Cancer. 1979;;15:395-405.
19 +
Kelsey JL, Fischer DB, Holford TR, et al.  Exogenous estrogens and other factors in the epidemiology of breast cancer . J Natl Cancer Inst. 1981;;67:327-333.
20 +
Wallach S, Henneman PH.  Prolonged estrogen therapy in postmenopausal women . JAMA. 1959;; 171:1637-1642.
21 +
Sherman B, Wallace R, Bean J.  Estrogen use and breast cancer . Cancer. 1983;;51:1527-1531.
22 +
Horwitz RI, Stewart KR.  Effects of clinical features on the association of estrogens and breast cancer . Am J Med. 1984;;6:192-198.
23 +
Kaufman DW, Miller DR, Rosenberg L, et al.  Noncontraceptive estrogen use and risk of breast cancer . JAMA. 1984;;252:63-67.
24 +
McDonald JA, Weiss NS, Daling JR, Francis AM, Polissar L.  Menopausal estrogen use and the risk of breast cancer . Breast Cancer Res Treat. 1986;;7:193-199.
25 +
Nachtigall LE, Nachtigall RH, Nachtigall RD, et al.  Estrogen replacement therapy, II: a prospective study in the relationship to carcinoma and cardiovascular and metabolic problems . Obstet Gynecol. 1979;;54:74-79.
26 +
Bland KI, Buchanan JB, Weisberg BF, Hagan TA, Gray LA.  The effects of exogenous estrogen replacement therapy on the breast: breast cancer risk and mammographic parenchymal patterns . Cancer. 1980;;45:3027-3033.
27 +
Gambrell RD Jr, Maier RC, Sanders BI.  Decreased incidence of breast cancer in postmenopausal estrogen-progestogen users . Obstet Gynecol. 1983;;62:435-443.
28 +
Buring JE, Hennekens CH, Lipnick RJ, et al.  A prospective cohort study of postmenopausal hormone use and risk of breast cancer in U.S. women . Am J Epidemiol. 1987;;125:939-947.
29 +
DuPont WD, Page DL, Rogers LW, Parl FF.  Influence of exogenous estrogens, proliferative breast disease, and other variables on breast cancer risk . Cancer. 1989;;63:948-957.
30 +
Wilson RA.  The roles of estrogen and progesterone in breast and genital cancer . JAMA. 1962;;182:327-331.
31 +
Hammond CB, Jelocsek FR, Lee KL, Creasman WT, Parker RT.  Effects of long-term estrogen replacement therapy, II: neoplasia . Am J Obstet Gynecol. 1979;;133:537-547.
32 +
Hulka BS, Chambless LE, Duebner DC, Wilkinson WE.  Breast cancer and estrogen replacement therapy . Am J Obstet Gynecol. 1982;;143:638-644.
33 +
Nomura AMY, Kolonel LN, Hirohata T, Lee J.  The association of replacement estrogens with breast cancer . Int J Cancer. 1986;;37:49-53.
34 +
Brinton LA, Hoover R, Fraumeni JF Jr.  Menopausal oestrogens and breast cancer risk: an expanded case-control study . Br J Cancer. 1986;; 54:825-832.
35 +
Jick H, Walker AM, Watkins RN, et al.  Replacement estrogens and breast cancer . Am J Epidemiol. 1980;;112:586-594.
36 +
Hoover R, Glass A, Finkle WD, Azevedo D, Milne K.  Conjugated estrogens and breast cancer risk in women . J Natl Cancer Inst. 1981;;67: 815-820.
37 +
Ross RK, Paganini-Hill A, Gerkins VR, et al.  A case-control study of menopausal estrogen therapy and breast cancer . JAMA. 1980;;243:1635-1639.
38 +
Wingo PA, Layde PM, Lee NC, Rubin G, Ory HW.  The risk of breast cancer in postmenopausal women who have used estrogen replacement therapy . JAMA. 1987;;257:209-215.
39 +
Hiatt RA, Bawol R, Friedman GD, Hoover R.  Exogenous estrogen and breast cancer after bilateral oophorectomy . Cancer. 1984;;4:139-144.
40 +
Hoover R, Gray LA, Cole P, MacMahon B.  Menopausal estrogens and breast cancer . N Engl J Med. 1976;;295:401-405.
41 +
Bergkvist L, Adami HO, Persson I, Hoover R, Schairer C.  The risk of breast cancer after estrogen and estrogen-progestin replacement . N Engl J Med. 1989;;321:293-297.
42 +
LaVecchia C, DeCarli A, Parazihni F, Gentile A, Liberati C, Franceschi S.  Noncontraceptive oestrogens and the risk of breast cancer in women . Int J Cancer. 1986;;38:853-858.
43 +
Thacker SB.  Meta-analysis: a quantitative approach to research integration . JAMA. 1988;; 259:1685-1689.
44 +
Craig TJ, Comstock GW, Geiser PB.  Epidemiologic comparison of breast cancer patients with early and late onset of malignancy and general population controls . J Natl Cancer Inst. 1974;;53:1577-1581.
45 +
Thomas DB, Persing JP, Hutchinson WB.  Exogenous estrogen and other risk factors for breast cancer in women with benign breast diseases . J Natl Cancer Inst. 1982;;69:1017-1028.
46 +
Brinton LA, Williams RR, Hoover RN, Stegens NL, Feinleib M, Fraumeni JF Jr.  Breast cancer risk factors among screening program participants . J Natl Cancer Inst. 1979;;62:37-43.
47 +
Henderson BE, Powell D, Rosario I, et al.  An epidemiologic study of breast cancer . J Natl Cancer Inst. 1974;;53:609-614.
48 +
Mack TM, Henderson BE, Gerkins VR, et al.  Reserpine and breast cancer in a retirement community . N Engl J Med. 1975;;292:1366-1371.
49 +
Gambrell RD, Massey FM, Castaneda TA, et al.  Estrogen therapy and breast cancer in postmenopausal women . J Am Geriatr Soc. 1980;; 28:251-257.
50 +
Boston Collaborative Drug Surveillance Program, Boston University Medical Center.  Surgically confirmed gallbladder disease, venous thromboembolism, and breast tumors in relation to postmenopausal estrogen therapy . N Engl J Med. 1974;;290:15-19.
51 +
Ewertz M.  Influence of noncontraceptive exogenous and endogenous sex hormones on breast cancer risk in Denmark . Int J Cancer . 1988;;42:832-838.
52 +
Longnecker MP, Berlin JA, Orza MJ, Chalmers TC.  A meta-analysis of alcohol consumption in relation to risk of breast cancer . JAMA. 1988;; 260:652-656.
53 +
Rothman KJ. Modern Epidemiology . Boston, Mass: Little Brown & Co; 1986;:344.
54 +
DerSimonian R, Laird N.  Meta-analysis in clinical trials . Controlled Clin Trials. 1986;;7:177-188.
55 +
Dixon WJ.  Processing for outliers . Biometrics. 1953;;9:74-89.
56 +
Statistical Abstract of the United States: 1989 . 109th ed. Washington, DC: US Bureau of the Census; 1989;.
57 +
American Cancer Society.  Cancer statistics, 1986 . CA. 1987;;37:12-13.
58 +
Armstrong BK.  Oestrogen therapy after menopause—boon or bane ? Med J Aust. 1988;; 148:213-214.
59 +
Angell M.  Negative studies . N Engl J Med. 1989;;321:464-466.
60 +
Chalmers TC, Levin H, Reitman D, et al.  Meta-analysis of clinical trials as a scientific discipline, I: control of bias and comparison with large cooperative trials . Stat Med. 1987;;6:315-325.
61 +
Bergkvist L, Persson I, Adami H-O, et al.  Risk factors for breast and endometrial cancer in a cohort of women treated with menopausal oestrogens . Int J Epidemiol. 1988;;17:732-737.
62 +
Brinton LA, Hoover RN, Szklo M, et al.  Menopausal estrogen use and risk of breast cancer . Cancer. 1981;;47:2517-2522.
63 +
Centers for Disease Control.  Long-term oral contraceptive use and the risk of breast cancer . JAMA. 1983;;249:1591-1595.
64 +
Mann JI, Vessey MP, Thorogood M, Doll R.  Myocardial infarction in young women with special reference to oral contraceptive practice . BMJ. 1975;;2:241-245.
65 +
Harlap S, Baras M.  Conception-waits in fertile women after stopping oral contraceptives . Int J Fertil. 1984;;29:73-80.
66 +
Hammond CB, Maxson WS.  Estrogen replacement therapy . Clin Obstet Gynecol. 1986;;29: 407-430.
67 +
Wren BG, Brown LB, Routledge JDA.  Differential clinical response to oestrogens after menopause . Med J Aust. 1982;;2:329-332.
68 +
Ernster VL, Bush TL, Huggins GR, et al.  Benefits and risks of menopausal estrogen and/or progestin hormone use . Prev Med. 1988;;17: 201-223.
69 +
Henderson BE, Ross RK, Lobo RA, Pike MC, Mack TM.  Re-evaluating the role of progestogen therapy after the menopause . Fertil Steril. May 1988;;49( (suppl) ):9S-15S.
70 +
Lufkin EG, Carpenter PC, Ory SJ, Malkasian GD, Edmonson JH.  Estrogen replacement therapy: current recommendations . Mayo Clin Proc. 1988;;27:201-223.
71 +
Hulka BS.  Hormone-replacement therapy and the risk of breast cancer . CA. 1990;;40:289-296.

Letters

Submit a Letter
CME Course for:


You need to register in order to view this quiz.


To understand the clinical management of acute heart failure syndromes.
Accreditation Information The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
To view and print your certificate and access a summary of your CME courses go to My CME.
NOTE:
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s “Cited By” API will populate this tab (http://www.crossref.org/citedby.html).
Compression-Only CPR: Pushing the Science Forward
Cone
AAM 2010;304:1493-1495.
All you need to read in the other general journals
BMJ 2010;341:c5893-c1494.
Submit a Response

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

© 2012 American Medical Association. All Rights Reserved.
Powered bySilverchair Information Systems