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hormone replacement therapy

Monday 23 March 2009

Hormone Replacement Therapy. In the United States, approximately one third of perimenopausal and postmenopausal women use hormone replacement therapy (HRT), either estrogen in combination with a progestin or a natural estrogen alone. There has been recent controversy about the risks and benefits of HRT. Short-term benefits include reduction in symptoms that accompany menopause, including hot flashes, vaginal dryness, and sleep disturbances. Long-term benefits include maintenance of bone mineral density and prevention of osteoporotic fractures.

The major controversies surrounding HRT are the potential increased risk of cancer versus the potential benefits associated with prevention of ischemic heart disease and dementia.

Recent results from the Women’s Health Initiative and the Heart and Estrogen/Progestin Replacement Study have provided new information about the risks and benefits of HRT:

- Cancer. Unopposed estrogen therapy greatly increases the risk of endometrial hyperplasia and cancer; therefore, most postmenopausal women now use estrogen in combination with a progestin. This combination drastically reduces or eliminates the risk of endometrial cancer. The risk of colon cancer was reduced in women who used HRT in some studies, but not in the Heart and Estrogen/Progestin Replacement Study. Recent results from the Women’s Health Initiative indicate an increased risk of breast cancer in women who used HRT combined therapy for 5 years.

- Venous thrombosis and pulmonary embolism. The risk of thromboembolic events, including deep vein thrombosis, pulmonary embolism, stroke, and retinal thrombosis, is elevated approximated twofold in HRT users, especially within the first 2 years.

- Cardiovascular disease. The recent Women’s Health Initiative reported an approximate 29% increased risk of myocardial infarction, especially during the first year of combined HRT use. This is in contrast to earlier studies in which either no effect or slight protection against cardiovascular diseases was reported. Methodologic differences probably underlie these divergent results.

- Cholecystitis. There is an increased risk of gallbladder disease in HRT users that increases with time.

- Dementia. The current studies are not adequate to evaluate whether HRT use prevents dementia.

Overall, the risks and benefits associated with the use of oral contraceptives and HRT must be evaluated for each individual patient in the context of her overall health, individual risk factors, and family history.