Use of hormone replacement therapy in the asymptomatic postmenopausal woman: what is the current evidence?

The publication of the Women's Health Initiative (WHI) Study results in July 2002 has changed the understanding of the use of hormone replacement therapy (HRT) in the postmenopausal woman, and challenged many of the accepted dogmas culled from decades of observational studies. The results of the WHI demonstrated a small but significant increased risk of coronary heart disease, strokes, pulmonary embolism and breast cancer amongst women who used continuous combined HRT. Conversely, there was a decreased risk of colonic cancer and osteoporotic fractures. However, the net balance of risk and benefit for long-term use of combined HRT has shifted towards the negative. In the light of the above findings, and together with the many associated studies that have since been published, the indications of HRT need to be reviewed. When the patient has disturbing vasomotor symptoms with compromised quality of life, HRT is clearly indicated for the relief of symptoms. As these symptoms are often transient, the period of therapy is usually short term. The situation is less clear among patients who do not have vasomotor symptoms, but nonetheless suffer from long-term degenerative changes of oestrogen deficiency. This article explores the implications for HRT in this post-WHI era, and seeks to define valid indications and conditions for its use.