Variations on HRT.
Indications for starting HRT
The indications for HRT in this review are wider than those initially recommended by NAMS CSM and EMAS where the advice is a result of the “one dose fits all” WHI study and the incomprehensible data collection of the MWS. An alternative view is that hormone therapy prescribed intelligently is safe and associated with considerable quality of life benefits.
In Europe oestrogen has been principally given for the treatment of climacteric symptoms and for the improvement of low bone density. The symptoms may be due to the vaso-motor instability of hot flushes and sweats with insomnia and tiredness or pelvic atrophy with vaginal dryness, dyspareunia, sexual dysfunction and the urethral syndrome. (16) The oestrogen may also be given for the prevention or the treatment of osteoporosis in women with decreased bone density as estrogens in the appropriate dose has an anabolic as well as an anti-catabolic effect on the skeleton. (17)
More controversial indications would be for peri-menopausal depression (18 19) or premenstrual syndrome, particularly in the years of the peri-menopausal state. (20 21) Loss of energy and loss of libido in association with climacteric symptoms are distressing for the couple and should be indications for oestrogen sometimes with the addition of testosterone. (22)
The value of oestrogen therapy in the prevention of coronary artery disease, Alzheimer’s disease and stroke is now controversial and would not with current knowledge be recommended. Similarly, the belief that oestrogens are of value in the secondary prevention of further coronary artery disease seems no longer valid. Thus, oestrogen therapy for prevention of these chronic cardiovascular and neurological disorders is no longer recommended although many workers cling to the hypothesis of a window of opportunity for prevention if oestrogen therapy is started in the first 10 years after the menopause before irreversible arterial and neurological degeneration has occurred. The different indications are discussed in more detail.