Hormone-replacement therapy: current thinking

Key Points The use of hormone-replacement therapy (HRT) has been vigorously debated Earlier observational data showed many benefits of HRT, which include reduced coronary heart disease (CHD) and mortality Randomized trials in older women (aged >60 years) have shown no benefit and increased harm Reassessment of clinical trials in women initiating treatment close to the onset of menopause and newer studies and meta-analyses now show benefit and rare risks More studies show benefit with oestrogen alone than with oestrogen plus progestogen The effects of reduced CHD and mortality in women initiating therapy around menopause suggest a possible role for HRT in primary prevention Clinical practice regarding the use of hormone-replacement therapy (HRT) has undergone many changes since its introduction in the 1940s. Here, Roger Lobo frames the current thinking on the use of HRT in postmenopausal women, beginning with a historical perspective and then discussing how the interpretation of HRT data has changed over time. For several decades, the role of hormone-replacement therapy (HRT) has been debated. Early observational data on HRT showed many benefits, including a reduction in coronary heart disease (CHD) and mortality. More recently, randomized trials, including the Women's Health Initiative (WHI), studying mostly women many years after the the onset of menopause, showed no such benefit and, indeed, an increased risk of CHD and breast cancer, which led to an abrupt decrease in the use of HRT. Subsequent reanalyzes of data from the WHI with age stratification, newer randomized and observational data and several meta-analyses now consistently show reductions in CHD and mortality when HRT is initiated soon after menopause. HRT also significantly decreases the incidence of various symptoms of menopause and the risk of osteoporotic fractures, and improves quality of life. In younger healthy women (aged 50–60 years), the risk–benefit balance is positive for using HRT, with risks considered rare. As no validated primary prevention strategies are available for younger women (