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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 loss.

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.

Joseph Neulen

Reviewer: Herbert Kuhl, Frankfurt, und Horst Lübbert, Berlin

CME Praktische Fortbildung Gynäkologie, Geburtsmedizin und Gynäkologische Endokrinologie 1/2006:4-12