CHICAGO—Contrary to findings in several previous studies, estrogen therapy does not decrease, but may increase, the risk for dementia in older, postmenopausal women, according to a study in the June 23/30 issue of the Journal of the American Medical Association (JAMA).

Dementia is an age-associated illness that imposes severe functional impairment on individuals, according to background information in the article. In the year 2000, more than 4 million people in the United States had Alzheimer disease (AD), and that number is expected to increase to 13 million by 2050. Milder cognitive impairment affects between one-fifth and one-third of older adults and strongly predicts dementia and subsequent institutionalization. Previous studies have reported an association between lower risk of dementia and postmenopausal estrogen use.

In this study, Sally A. Shumaker, Ph.D., of the Wake Forest University School of Medicine, Winston-Salem, N.C., with investigators from the Women's Health Initiative Memory Study (WHIMS) sought to determine whether conjugated equine estrogens (CEE) alone decreased an older woman's risk for dementia or mild cognitive impairment (MCI). The WHIMS previously found an increased risk for dementia and no effect on MCI in women treated with CEE plus medroxyprogesterone acetate (MPA).

The WHIMS is an ancillary study to the larger Women's Health Initiative (WHI) randomized clinical trials of hormone therapy that include a geographically diverse group of approximately 27,000 women. The estrogen plus progestin trial of the WHI was terminated in July 2002 due to significantly more noncognitive adverse events associated with CEE plus MPA compared with placebo. The WHI estrogen-alone trial was terminated on February 29, 2004, because the National Institutes of Health considered the excess risk of stroke in the active hormone group to be unacceptable in healthy women in the absence of benefit for coronary heart disease, the primary outcome.

The WHIMS consisted of randomized, double-blind, placebo-controlled clinical trials of CEE or CEE plus MPA (estrogen plus progestin trial) in community-dwelling women aged 65 to 79 years, conducted from June 1995 to July 8, 2002 (estrogen plus progestin; n=4,532), or to February 29, 2004 (estrogen-alone; n=2,947) in 39 of the 40 WHI clinical centers. Participants in the estrogen-alone trial received either 1 daily tablet containing 0.625 mg/d of CEE or matching placebo; in the estrogen plus progestin trial, they received either 1 daily tablet containing CEE (0.625 mg/d) plus MPA (2.5 mg/d) or matching placebos.

The researchers found that in the estrogen-alone trial, 47 participants were diagnosed with probable dementia, of whom 28 were assigned to receive CEE and 19 to receive matching placebo. During follow-up, the incidence of probable dementia was 49 percent higher among women assigned to receive CEE compared with those receiving placebo, but this difference was not significant. Incidence rates for probable dementia in the estrogen-alone trial were statistically similar to those in the estrogen plus progestin trial. When data from the 2 trials were pooled, the overall risk for probable dementia was significantly increased by 76 percent. After excluding participants with certain baseline scores at or below the cut point, suggesting early cognitive decline, risk for probable dementia increased a nonsignificant 77 percent in the estrogen-alone trial and a significant 2.19 times in the pooled trials.

CHICAGO—Obese men with erectile dysfunction may be able to improve their sexual function with exercise and weight loss, according to a study in the June 23/30 issue of the Journal of the American Medical Association (JAMA).

Erectile dysfunction (ED) is an important cause of decreased quality of life in men, and may affect an estimated 30 million men in the United States, according to background information in the article. In a previous study, moderate-to-severe erectile dysfunction was reported by 12 percent of men younger than 59 years; 22 percent of men aged 60 to 69 years; and 30 percent of men older than 69 years.

Katherine Esposito, M.D., of the Center for Obesity Management, Second University of Naples, Italy, and colleagues conducted a study to determine if lifestyle changes designed to obtain a sustained and long-term reduction in body weight and an increase in physical activity would improve erectile function and endothelial (cells lining the inside of blood vessels) function in obese men.

The randomized trial included 110 obese men (body mass index 30 or greater) aged 35 to 55 years, without diabetes, hypertension, or hyperlipidemia, who had erectile dysfunction that was determined by having a score of 21 or less on the International Index of Erectile Function (IIEF). The study was conducted from October 2000 to October 2003 at a university hospital in Italy.

The 55 men randomly assigned to the intervention group received detailed advice about how to achieve a loss of 10 percent or more in their total body weight by reducing caloric intake and increasing their level of physical activity. Men in the control group (n = 55) were given general information about healthy food choices and exercise.

The researchers found that after 2 years, weight and body mass index decreased significantly more in the intervention group than in the control group. The average level of physical activity increased more in the intervention group (from 48 to 195 min/wk) than in the control group (from 51 to 84 min/wk). The average IIEF score improved in the intervention group (from 13.9 to 17), but remained stable in the control group (from 13.5 to 13.6). Seventeen men in the intervention group and 3 in the control group reported an IIEF score of 22 or higher. In multivariate analyses, reductions in body mass index and increases in physical activity were independently associated with changes in IIEF score.

CHICAGO—Many women in the United States who have had a hysterectomy are undergoing Papanicolaou (PAP) smear screening even though they are not at risk of cervical cancer, according to a report in the June 23/30 issue of the Journal of the American Medical Association (JAMA).

Pap smear screening for cervical cancer was introduced in the 1940s and has become a widely accepted cancer screening test that has substantially decreased the number of cases and deaths since its introduction, according to background information in the article. In 1996, "based on accumulated evidence from observational studies, the U.S. Preventive Services Task Force recommended that routine Pap smear screening is unnecessary for women who have undergone a complete hysterectomy for benign (non-cancerous) disease." The authors add that most women who have undergone hysterectomy are not at risk of cervical cancer because they no longer have a cervix.

Brenda E. Sirovich, M.D., M.S., and H. Gilbert Welch, M.D., M.P.H., from the VA Outcomes Group, White River Junction, Vt. and Dartmouth Medical School in Hanover, N.H., analyzed data from the Behavioral Risk Factor Surveillance System (1992 - 2002), an annual, population-based telephone survey of U.S. adults conducted by the Centers for Disease Control and Prevention. The authors evaluated the information from 187,670 women who reported having a hysterectomy and answered questions about the timing of their last Pap smear.

"Twenty-two million U.S. women 18 years and older have undergone hysterectomies, representing 21 percent of the population," the authors found. "The proportion of these women who reported a current Pap smear [within the last 3 years] did not change during the 10-year study period. In 1992 (before the U.S. Preventive Services Task Force recommendations), 68.5 percent of women who had undergone hysterectomy reported having had a Pap smear in the past 3 years; in 2002 (6 years after the recommendation), 69.1 percent had had a Pap smear during the same period."

After accounting for Pap smears that may have preceded a recent hysterectomy and hysterectomies that spared the cervix or were performed for cervical neoplasia (tumors), we estimate that approximately 10 million women, or almost half of all women who have undergone hysterectomy, are being screened unnecessarily, the authors report. Although estimates based on patient self-report may over-estimate actual screening rates, these results suggest that millions of women are being screened unnecessarily, and the amount of screening has not declined following the task force recommendation, the authors note.

ESTROGEN ALONE WILL NOT PROTECT ELDERLY WOMEN AGAINST DEMENTIA OR MEMORY LOSS - CAN INCREASE RISK INSTEAD