Clinical Review

Hormone replacement therapy

BMJ 1998; 317 doi: (Published 15 August 1998) Cite this as: BMJ 1998;317:457

Fortnightly review

  1. Elizabeth Barrett-Connor, professor
  1. Department of Family and Preventive Medicine, University of California at San Diego, La Jolla, CA 92093-0607, USA

    The number of women who will live half their adult lives after the menopause increases every year.1 A challenging question for doctors is how women should be counselled about postmenopausal oestrogen therapy.

    Summary points

    Five or more years of postmenopausal oestrogen is the standard of care for the prevention or treatment of osteoporosis; benefit requires continued use

    Oestrogen increases the risk of endometrial cancer during and after use,unless it is taken with adequate progestogen

    It probably increases the risk of breast cancer, but only during current use

    It may reduce the risk of coronary heart disease

    Routine oestrogen treatment should not be recommended until more risk:benefit data are available from clinical trials


    This review is based on observations during 25 years of research into women's health, and on Medline searches on oestrogen or menopause. Only recent publications are cited. Unless otherwise stated, oestrogen therapy refers to treatment of postmenopausal women with pharmacological doses of oral oestrogen taken alone or with an oral progestogen.

    Menopausal symptoms

    About 75% of women in English speaking countries experience no troublesome symptoms during the menopause transition.2 Population studies have shown that symptoms are less common or different in other countries, and more common and more severe after an induced menopause. Hot flushes and night sweats are the only symptoms universally reported to respond (usually almost immediately) to oestrogen. Without treatment, hot flushes typically disappear within 1-2 years, but in some untreated women they continue for more than 20 years.

    After the menopause the vaginal wall becomes thinner and less vascular, changes which may be accompanied by vaginal dryness and dyspareunia. Intravaginal oestrogen prevents and treats these symptoms and also reduces the risk of recurrent urinary tract infection, probably by modifying the vaginal flora.3 Urinary incontinence, which becomes more common with increasing age, is not usually improved …

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