The benefits of hormone replacement therapy (HRT) include the effective relief of menopausal symptoms and the prevention of osteoporosis in the long term.
Women should be advised that the use of combined HRT can be associated with a duration-dependent increase in the risk of breast cancer. Combined or oestrogen-only treatment may slightly increase the risk of ovarian cancer. Unopposed oestrogens increase the risk of endometrial cancer and should not be given to women with a uterus.
Oral HRT also increases the risk of VTE, especially in the first year of therapy, and oral oestrogen-only treatment is associated with a small increase in the risk of stroke. Transdermal HRT, used at standard doses, does not increase the likelihood of VTE and should be considered in women at increased risk.
HRT does not prevent coronary heart disease or cognitive decline and should not be prescribed for these purposes.
The decision to start HRT should be made on an individual basis after consideration and discussion of the woman's risk factors, and the need for continued therapy should be reviewed at least once per year. It is recommended that HRT be used for the treatment of menopausal symptoms that adversely affect quality of life, but that it is used at the lowest effective dose for the shortest possible time. Women on long-term therapy should be encouraged to participate in national breast and cervical screening programmes and should be instructed in breast self-examination.
In healthy women without symptoms, the balance of risks and benefits is generally unfavourable and HRT is not recommended.
HRT should not be used first-line for the prevention of osteoporosis in women over the age of 50, but can be used second-line when other treatments are ineffective or contraindicated. HRT may be used in women with an early menopause for treating menopausal symptoms and preventing osteoporosis, but at age 50, treatment should be reviewed and HRT considered a second-line choice.
Topical vaginal administration of oestrogens as creams, vaginal tablets or a vaginal ring reduces the risk of systemic side-effects and can be used to relieve local symptoms of post-menopausal atrophic vaginitis. They may also be used as adjuncts to systemic HRT when lower urogenital tract symptoms prove refractory. Endometrial stimulation cannot be ruled out, so regular checks are advised and a progestogen should be considered, particularly if treatment is to be extended beyond three months.
For bisphosphonates, other osteoporosis treatments and calcium and vitamin D supplements used in the treatment of postmenopausal osteoporosis, see the Osteoporosis, other bone disorders section in the Endocrine chapter.