The role of ERT/HRT.

Given the rapidly increasing number of women above 50 it is of pivotal importance to consider health issues related to gonadal hormone deficiency. The possibility of alleviating such symptoms by hormone replacement therapy (HRT) should be recognized by all physicians, not merely by gynaecologists. But which women should be given what therapy, and for how long? Due to the increased risk of endometrial cancer and bleeding problems when using oestrogen monotherapy, only women who have undergone hysterectomy could use this regimen unless treatment is aimed at amelioration of urogenital symptomatology only. In this case a vaginal administration of low-dose oestrogens is possible as such doses do not induce endometrial proliferation. In all other cases a combination of an oestrogen and a progestogen must be used. There are several options for doing so. During the early phase of the climacteric period when irregular and/or heavy vaginal bleeds are part of the symptomatology a cyclical therapy will often combat these problems. As women pass into the menopause a sequential regimen is often preferred until 1-3 years have elapsed since menopause. With advancing time since menopause women become more and more reluctant to experience monthly bleeds. In such cases a continuous combined regimen may be offered even though it cannot guarantee a bleed-free remedy.Non-oral, particularly transdermal, therapy is an alternative in women with co-existing morbidity such as migraine, diabetes, malfunction of the gastrointestinal tract and liver disease. Oral therapy is preferred particularly in women with elevated plasma levels of LDL-cholesterol, lipoprotein(a) or homocysteine. Oral therapy induces liver protein synthesis. This could be an advantage in cases with low plasma levels of sex hormone-binding globulin (SHBG) as low levels of SHBG may promote androgenic stigmata such as hirsutism and a lowering of the voice. However, in cases with too low an androgen influence the use of a non-oral therapy may counteract symtoms such as low libido.Tibolone could be used for the prevention (and treatment?) of osteoporosis but it will also mitigate the typical climacteric symptoms. Raloxifene is a fairly new type of drug which is classified as a selective oestrogen receptor modulator (SERM). It will reduce vertebral fractures to the same extent as bisphosphonates, albeit the increase in bone density is less. Raloxifene has no effect on climacteric symptoms. Its greatest benefit is a clear reduction of breast cancer in women, which is in contrast to HRT/ERT.There are insufficent data on tibolone and the incidence of breast cancer. Experimental data, however, are intriguing in suggesting less impact on the breast than conventional HRT/ERT.