Who should be prescribed HRT?

If there is no contraindications short-term HRT is appropriate for perimenopausal and postmenopausal women, who have moderate to severe vasomotor symptoms (hot flushes and sweats). Decisions to initiate or continue HRT should be made on the basis of discussions between a woman and her doctor. It is important to inform women that there are some risks (venous thrombosis, coronary heart disease and stroke) within the first 1 to 2 years of therapy and these should be balanced against the severity of symptoms and expected benefit of treatment. Risk for breast cancer appears to increase with longer-term HRT use (after four to five years, although earlier harm cannot be definitely excluded). Women's Health Initiative (WHI) study provided data only on oral HRT (Premarin alone or combined with Provera). There is a possibility that other routes of administration might be safer, at least there is such evidence for transdermal estrogen in terms of risk of thrombosis. We recommend prescribing the lowest effective dose of HRT for six months to maximally four or five years. Women should be reviewed annually aiming to discontinue or decrease the dose of HRT.

HRT is effective for prevention or treatment of osteoporosis, but should be used for this purpose only short-term in women who also have menopausal symptoms. Serious harms, including breast cancer and cardiovascular disease, appear to outweigh benefits such as prevention of fractures. Therefore long-term use of HRT should be discontinued in women who do not have significant hot flushes and sweats.

Results from the Women's Health Initiative (WHI) and similar studies should not be extrapolated to women with premature or early menopause (before the age of 45), so there is no need at present to change our usual practice of prescribing HRT to these women.