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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 . . . [Full Text of this Article]