Menopause and hormone replacement therapy are important issues today, both for women and doctors. Natural oestrogens ameliorate (improve) climacteric complaints and substantially reduce osteoporosis and cardiovascular disease. Rational clinical practice during the years of climacteric transition requires counselling on the risks and benefits of hormone replacement therapy (HRT) and proper management of HRT users.
Many questions are put forward and only a few well-documented answers are available in the literature. In our Western society, a substantial minority of perimenopausal women will be either breast cancer patients or may run an increased risk of acquiring breast cancer. Are these women not to receive HRT, or only in a modified form (anti-oestrogens)? How should we treat patients after endometrial cancer or meningioma, how those with leiomyomata, endometriosis, gallstones, liver disease, thrombosis or embolism? And what is the best way to treat premenopausal women with climacteric complaints?
The American College of Physicians has issued guidelines on counselling  (see Chapter 11 of this book), and the American Heart Association has released its recommendations for patients with cardiovascular disease . The European gynaecologist, working in a less litigious (fond of going to law) society with its own specific problems and possibilities, still has to find his or her own way to deal with questions on menopause and HRT. The field is broad and moving rapidly, and final answers to many questions are still lacking.
HRT comes in a bewildering array of forms and variations. Oestrogens may be taken as conjugated equine oestrogen sulphates (the American way) or as (micronized) 17ß-estradiol or estradiol valerate, the European preference. In addition to tablets, other routes of administration (transcutaneous (transdermal), subcutaneous, sublingual, intranasal, vaginal) are available, all avoiding the first-pass modifying effect of oestrogens on liver metabolism.
In order to prevent endometrial cancer, women with a uterus are advised to combine oestrogen replacement therapy with one of the many different progestogens available, either in a continuous daily regimen or for 10-14 days sequentially, in a monthly or (more experimentally) quarterly regimen. Does the addition of progestogen counteract the beneficial effect of oestrogen on the cardiovascular system, and does it also influence breast pathology?
Practical HRT offers an integrated, comprehensive approach to HRT counselling and facilitates correct drug prescription and monitoring of women on HRT. It deals with clinical questions and contributes practical suggestions for identifying and simplifying problems in diagnosis, management and decision analysis. In fact, Practical HRT deals with the questions you are confronted with.
Peter Kenemans, Ronald Barentsen and Peter van de Weijer
Amsterdam, May 1995
1. American College of Physicians. Guidelines for counselling postmenopausal women about preventive hormone therapy. Ann Intern Med 1992;117:1038-41.
2. Eaker ED, Chesebro JH, Sacks FM, Wenger NK, Whisnant JP, Winston M. Cardiovascular disease in women. Circulation 1993;88:1999-2007.