Hormone replacement therapy in the menopause

The failure of follicular development that characterizes the menopause leads to a marked reduction in serum levels of estradiol and progesterone. As a result, the majority of women develop symptoms, including hot flushes, sleep disturbance, and vaginal dryness. Long-term consequences of ovarian insufficiency include genital atrophy, osteoporosis, and increased rates of myocardial infarction. Estradiol replacement (ERT) has proved effective in treating and preventing these problems. ERT has, however, led to increased risk of endometrial carcinoma. Consequently, treatment regimens now include progestins (HRT) to protect women who have a uterus. Progestins act by down-regulation of estradiol receptor activity, which is an advantage for preventing endometrial hyperstimulation, but a potential disadvantage when beneficial effects of estradiol are opposed. Current menopause health care includes assessment, treatment, and follow-up. Signs and symptoms of estradiol deficiency are evaluated during initial history-taking and physical examination. The MENSI (Menopause Symptom Index) has proved an efficient questionnaire for both initial assessment and monitoring of treatment effects. Vaginal cell maturation index (M.I.) can be helpful in determining need for hormonal treatment and for assessing response to treatment. A "therapeutic range" for ERT can be achieved with the availability of a variety of hormone preparations administered in different ways (oral, transdermal, skin gel, implants, etc.), thus avoiding the problems of both inadequate and excessive hormonal doses. This paper will describe a structured approach to the delivery of health care in the menopause.