Hormone replacement therapy and coronary heart disease

Proper use of postmenopausal hormone replacement has been the subject of debate for decades. Prevailing medical opinion has swung between enthusiastic endorsement and extreme caution. The wave of optimism over estrogen's beneficial effects on menopausal symptoms and skeletal health was temporarily set back by the evidence that linked estrogen to endometrial cancer. Once studies showed that progestogen cotherapy could protect against this adverse effect, physicians were again encouraged to prescribe hormone replacement. Since 1980, increasing epidemiologic and experimental evidence has suggested a hitherto unappreciated and immense CHD health benefit from use of postmenopausal estrogen therapy. Although addition of progestogen may offset the cardiovascular benefits of estrogen slightly, its use is reasonable and practical. No woman need be subjected to unopposed estrogen's carcinogenic effects on her endometrium. Based on available evidence, hormone replacement therapy, appropriately administered, is both safe and beneficial. Unfortunately, there is no single way to prescribe it. The treating physician must make a series of best judgments. Practically speaking, this entails, in each case, finding the form of therapy that is acceptable to the patient and that provides the greatest health benefits with the least likelihood of adverse affects. Our prescribing habits have evolved in the last 15 to 20 years. We have better discrimination of the woman most likely to benefit; improved therapy through use of newer formulations, dosages, routes, and schedules; and more appropriate implementation of monitoring procedures. Although questions remain, we should not let our imperfect knowledge dissuade us from more widespread prescribing of hormone replacement therapy.