Hormone Replacement Therapy Risks and Benefits

Introduction to HRT

The American College of Physicians suggests that HRT is approved only for menopausal symptom management and osteoporosis prevention, not for chronic disease prevention, and must be prescribed at the lowest effective dose for the shortest duration, according to the FDA black box warning 1

The risk of stroke increases with HRT use, with 33 vs 25 per 10,000 women-years 2
For every 10,000 women taking estrogen-progestin for 1 year, there are 7 additional CHD events, 8 additional strokes, 8 additional pulmonary emboli, and 8 additional invasive breast cancers 1
The risk of breast cancer increases with duration of HRT use, becoming apparent after several years and persisting >10 years after discontinuation, although the exact risk is not specified in the provided text, it is mentioned that the risk increases 4

HRT is appropriate only for moderate to severe vasomotor symptoms, genitourinary symptoms of menopause, and women under age 60 or within 10 years of menopause onset 1, 6
The American College of Obstetricians and Gynecologists recommends that HRT should not be used for primary or secondary prevention of cardiovascular disease, or routine prevention of osteoporosis 6, 7

Women with premature ovarian insufficiency should be initiated on HRT at diagnosis to prevent long-term health consequences, and may continue until average age of menopause (51 years), then reassess 1
Women with non-hormone-sensitive cancers may be considered for HRT for severe vasomotor symptoms, with transdermal routes preferred 1

Clinicians must discuss with patients the early risks (VTE, CHD, stroke) that occur within the first 1-2 years, and late risks (breast cancer) that increase with longer-term use 4, 3
Alternative strategies for osteoporosis (bisphosphonates, calcitonin, weight-bearing exercise) and cardiovascular disease prevention (lipid management, blood pressure control, smoking cessation) should be discussed with patients 10, 7, 4