HRT, a general practice approach: how to reach the most vulnerable

Hormone replacement therapy has been shown to be effective in the preservation of bone density and its use should lead to a substantial reduction in the fracture rate of older women. Observational studies have also suggested that it may lead to a reduction in the incidence of coronary heart disease. Both effects are relevant to preventive care in general practice and have been applied within the framework of health promotion clinics. However, the tendencies for patients who are already healthy to select themselves for attendance at these clinics, and for long-term hormone therapy, mean that efforts to improve the health of the population do not reach those most in need. Groups most at risk should be defined by individual practices and identification of high-risk patients be followed by appropriate investigation and treatment. It is possible to identify the following high-risk groups: long-term users of corticosteroid therapy or thyroxine; women who have had an early hysterectomy or oophorectomy; women with known coronary artery disease, diabetes or familial hyperlipidaemia. Methods of ascertainment and investigation are described, as are the various modes of therapy and lifestyle modifications considered appropriate. Health promotion clinics are not currently reaching those most in need, and preventive therapy should be extended to target the most vulnerable.