Estrogen therapy during menopause. Practical treatment recommendations

The potential benefits of estrogen replacement therapy (ERT) for postmenopausal women are now generally recognised, and no scientist involved in this field of research will deny the gratifying results of hormone therapy. However, in the risk-benefit equation the adverse effects of ERT must be carefully considered. Most of the harmful adverse effects of ERT have been related firstly to the absence of progestational balance, and secondly to the fact that most of the estrogens previously available for clinical use were artificial and administered orally, resulting in intensive hepatic metabolism, leading to metabolic disturbances. The need for the addition of progestogen leads also to consideration of the adverse effects of these substances. During the past decade therapeutic improvements have been achieved. Knowledge about the different types of steroids now available, the right choice of dosage and duration of therapy according to the needs of the patient, and the new alternative delivery systems improves day by day. Various steroids are now available for clinical use. Among the estrogens, orally administered drugs, natural derivatives of estradiol, and nonoral drugs delivered by injection, implant, vaginal ring or cream, ointment or transdermal system are at the prescriber's disposal. Among the progestogens available to the prescriber and recommended to be added to ERT, the molecules derived from testosterone [norethisterone (norethindrone), norgestrel] are less prescribed than the molecules derived from progesterone (didrogesterone) or from 17-hydroxyprogesterone (medroxyprogesterone acetate). In menopausal therapy the latter derivatives from progesterone or 17-hydroxyprogesterone are preferable, but low doses of any type of progestogen could be both protective of the target organs and devoid of harmful effects. Careful consideration of contraindications of treatment and regular follow-up are prerequisites for safe therapy. Recent epidemiological data now demonstrate clearly that the use of ERT under these conditions affords protection against osteoporosis and cardiovascular disease. Clear benefits to women's health may therefore be obtained from the adequate choice and surveillance of therapy.