Where are we now with hormone replacement therapy?

It works for symptoms but is not good for future health

Menopausal symptoms can be grim, and the desire to replace the hormonal “deficit” withexogenous hormones remains strong. Since the 1950s, hormone replacement therapy has been used increasingly,1 while evidence on the risks of unwanted side effects has accumulated. Twenty five years ago, the increased risk of endometrial cancer emerged, resulting in the addition of progestogen. Cohort studies had examined oestrogen alone and indicated important benefits, but, since the 1980s, combined preparations have dominated. Interpretations of the evidence were therefore confused, since whatever effects oestrogen or progestogen have on disease will differ. Eventually, evidence of increased risk of combined therapy on breast cancer, coronary heart disease, stroke,and venous thromboembolism from a randomised trial was reported.2 This trial was stopped early, after an average of five years' follow up among 17 000 women, during which around 40% stopped their trial drugs. The results from theoestrogen alone arm of the woman's health initiative study will reassess the role of combined therapy in 2005.

Because it may double the risk of breast cancer for long term use3 and of heart disease in the first year of use, combined therapy is problematic. These risks are incommensurate with debilitating symptoms, but women need to be able to judge the risks for themselves. The balance now seems clearer than it was before we knew these risks; hormone replacement therapy works for symptoms but not for future health, which is not what had …