[Indications for hormone replacement therapy]

Postmenopausal primary ovarian insufficiency may lead to the clinical picture of the climacteric syndrome and to metabolic changes inducing specific diseases due to oestrogen deficiency. In symptomatic states of oestrogen deficiency, Hormone Replacement Therapy (HRT) is indicated for therapeutic reasons. If there is an increased risk for osteoporosis, for cardiovascular diseases or for Alzheimer's Disease, the preventive administration of HRT has to be discussed. In the combined presence of an increased metabolic risk and of subjective symptoms, HRT is still the best choice. Recent alternatives to classical HRT are Tibolone and, in the later postmenopause, Raloxifene. Incorrect media reports lead to insecurity and to concerns about the use of sexual steroids after menopause. HRT can be accompanied by a small weight increase of 200-500 g. However, more important in most women is the normal trend to weight gain in the 40s and 50s. HRT does not increase blood pressure. If there are some hints for an abnormal coagulation system in the personal or family history of a patient, thrombophilia should be excluded before the begin of HRT. The risk to have an endometrial carcinoma during HRT is not increased, but endometrial cancers are more frequent with unopposed estrogen administration. The incidence of breast cancer increases continuously with ageing. If 1000 women start HRT at the age of 50 and continue for five years, two more cases of breast cancer are diagnosed within the next 20 years. This small increase of morbidity is not accompanied by an increased mortality due to breast cancer: mortality does not change. The data available today show a clear decrease of total mortality up to the age of 75 years in women using oestrogens and speak in favour of HRT. If HRT is used for less than five years, cancer risk is not increased. The gain in Life Quality primes significantly. For the indication of long term HRT, the risks and benefits have to be evaluated individually.