[Menopause and hormone replacement]

Considered until recently as a biological fate, menopause has evolved within a decade into a major public health issue at stake. Such an evolution results from various factors that deserve an exhaustive critical approach because the situation is much more complex than it appears to be at first analysis.

1) Ninety-five percent of the available epidemiological information relies on observation or cohort studies, such as case-control studies that do not allow any certitude in regard to therapy. 2) Chronic estrogen deficiency probably plays a pathogenic role in various symptoms or pathological conditions that are associated to menopause. 3) However, behind the paradigm of menopause, there is a whole psychosocial construct that classifies what remains a physiological condition within major risk factors, just as for the most serious chronic diseases. 4) Indeed, menopause cannot be considered as a well-characterized disease, and hormone replacement therapy is undeniably a complex therapeutic intervention that requires proper prescription and careful evaluation of the benefit:risk ratio. 5) While such a treatment is now considered as the gold standard for the prevention of post-menopausal osteoporosis, this does not hold true regarding cardiovascular diseases. 6) Although hormone replacement therapy may lead to the relief of various symptoms associated with menopause, it may also result in side-effects that extreme medication cannot prevent, especially since some of them are not fully known, particularly in the case of either long-term or very long-term treatments.

A more rigorous evaluation of side-effects of hormone replacement therapy in the framework of long-term controlled trials is therefore clearly required. The indications of such a treatment should only rely on objective data and not on questionable studies or impressions at clinical examination.