Further study might also determine whether ERT in patients with high bone density is contraindicated. An interesting point. Obviously, the Framingham study is very well set up to look at the question of coronary disease in this population. The potential for decreased coronary artery disease, increased breast cancer, and decreased osteoporosis must be weighed with appropriate attention to all relevant risk factors and patient values. In most women the decison to use HRT will be life-prolonging, even after considering the potential for increasing breast cancer risk.
Cardiac disease remains a higher risk than breast cancer.
It is also important to consider quality of life in making the decision with your patient. There are probably a minority of women who will have a net decrease in life-expectancy if HRT is chosen. Concern for their safety should not blind physicians to the important cardiac risks of the majority of women who would derive a net longevity benefit from estrogen replacement. It also seems possible that the link between bone density and breast cancer demonstrated in this study identifies a genetic-cellular trait that is more important than the use of physiologic estrogen replacement, i.e., they are more likely to get breast cancer regardless of whether HRT is or was used. Some women's estrogen receptors in bone may be more sensitive or active reflecting similar activity in breast tissue.