Is there a place for postmenopausal hormone therapy use in women with lupus?

The Women Health Initiative (WHI) randomized trials have reported increase in cardiovascular and breast cancer risks from the use of post-menopausal hormone therapy (HT). A striking decrease of HT use has been observed worldwide despite the fact that other regimens in younger post-menopausal women could be safer. Systemic lupus erythematosis (SLE) is considered as estrogen sensitive. HT is generally considered as contraindicated in these women who are especially at risk for cardiovascular diseases and osteoporosis. However, recent randomized trials have raised the question of a lack of deleterious effects of estrogen containing oral contraceptives. In view of the recent knowledge and understanding in the field of menopause the authors were interested to examine the HT effects in women with SLE by analysis the published cases control, observational studies and randomized trials. The randomized trials and large observational studies showed a mild increase risk in flares and thrombotic events, whereas retrospective studies did not show increase in these risks but suggesting selection bias. A better profile on the blood clotting parameters and surrogate markers of the arterial risk can be obtained by transdermal estrogen and natural progesterone in non SLE women. Less venous thrombotic events are observed in women at risk for thrombosis with the transdermal estradiol administration in a case control study. However no randomized trial is still available and no epidemiological data are reassuring on the arterial risk. Prescription of HT has to remain especially prudent in women with SLE. If a decision of treatment is taken transdermal estradiol and progesterone or close pregnane derivatives should be probably most valuable but also used at the minimal dose.