A practical guide to prescribing estrogen replacement therapy.

Discounting vaccinations, menopausal hormone replacement constitutes the most widely practiced form of long-term prophylactic therapy. Long acknowledged as a means of retarding net bone density loss, sufficient data have accumulated to document the cardioprotective aspects of estrogen replacement therapy (ERT). Not surprisingly, new questions concerning long-term effects on various tissues and interaction with progestins have arisen. Given that ERT alone increases risk for endometrial cancer to unacceptable levels, addition of progestins can fully obviate that risk. To what extent, however, do various progestins mute the beneficial estrogen effect on cholesterol lipoproteins and locally in the arterial wall? Does long-term ERT increase the risk for breast cancer and who is at greatest risk? Does the route of ERT matter with respect to metabolic changes? Considering that a woman may spend fully one third of her life in the postmenopausal state, it behooves physicians as primary care providers and as consultants to understand the pros and cons of ERT. Modulation of dose, route and agent, as well as the protocol for therapy, all affect long-term patient compliance. In order to sustain motivation, education of the patient is mandatory, and that process starts with the physician.