Current valuation of hormone replacement therapy
Hormone replacement therapy (HRT) is the most effective
treatment for severe postmenopausal symptoms.
Randomized, placebo controlled intervention studies
demonstrate that HRT is not only effective in osteoporosis
prophylaxis but also in fracture prevention. Latest results
prove that HRT shields from atherosclerosis if this medication
starts immediately with the onset of menopausal hormone
Thrombo-embolic lesions pose the main risks under HRT.
Especially, risks for central nervous apoplexia should be
considered. It is quite difficult to avoid those threats.The
most useful way to quote hazards is a comprehensive
patient's history emphasizing thrombo-embolic events.
It is still a matter of discussion whether estrogens or only
the combination of estrogens and gestagens raise the risk
for breast cancer. It is recommended to apply the lowest
effective dose of estrogens and to check after fixed intervals
(i.e. 1 year) whether a treatment for menopausal symptoms
is still needed. Estrogen only therapy in women with
a uterus is today not advisable. Specific studies which demonstrate
that with lowest estrogen doses endometrial
cancer risks can be avoided are not yet available.
To decide whether oral or transdermal regimes should be
applied, patients characteristics can be taken into account.
With oral HRT, using gestagens without androgen effects,
a rapid positive effect on cholesterol metabolites can be
expected. Under estrogen dominance, LDL-cholesterol will
decrease and HDL-cholesterol will increase.
Androgen effects like hirsutism can be improved by rising
SHBG which will reduce the bio-availablity of testosterone.
To facilitate this anti-androgen effect,HRT regimes without
androgenic partial effects must be applied. Negatively,
during the first pass effect estrogens induce the reninangiotensin
system in the liver thereby rising blood pressure.
If immediate liver effects are not relevant, transdermal
treatment regimes are suitable.
Reviewer: Herbert Kuhl, Frankfurt, und Horst Lübbert, Berlin
CME Praktische Fortbildung Gynäkologie, Geburtsmedizin und Gynäkologische Endokrinologie 1/2006:4-12