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To the Editor: Dr Hlatky and colleagues1 reported that postmenopausal hormone therapy improved quality of life only among women who reported flushing at baseline. We suspect that the women in this study who reported flushing were generally thinner than those who did not; thus, we suggest that the results should be reported stratified by body mass index (BMI). Menopausal symptoms, including flushing, are related to the dramatic decrease of estrogen levels due to depletion of ovarian function. After menopause, peripheral aromatization of androgens in adipose tissue is the primary source of endogenous estrogen, and circulating levels of estrogen in postmenopausal women increase with increasing body mass.2 Significantly lower levels of estradiol and estrone are found in women with frequent hot flashes,2 and flushing is more likely among thin women.2
Several observational studies have suggested that both risks and benefits of hormone therapy are observed only in thin women.3 - 4 Breast cancer rates are generally lower among thin postmenopausal women and increase with hormone therapy, while there appears to be no such increase among women with higher BMI.3 Similarly, we have reported that the inverse association between hormone use and coronary heart disease was strongest for thin women.4 These results suggest that there may be a threshold level of estrogen beyond which additional exogenous estrogen has negligible effects.
Women included in the HERS trial, upon which Hlatky et al based their analysis, have higher BMI than average US women; 57% of the women in the treatment group5 had a BMI of greater than 27 kg/m2 compared with 43% of US women in the same age group.6 If there is indeed a threshold in the level of biologically important doses of estrogens, an improvement in mental health and depression associated with hormone use among women in the HERS trial would only be expected in thinner women.
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
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