Hormone Replacement Therapy Risks and Benefits for Postmenopausal Women

Risk-Benefit Assessment

The U.S. Preventive Services Task Force (USPSTF) recommends against routine use of estrogen and progestin for prevention of chronic conditions in postmenopausal women (Grade D recommendation) 1, 3
For women who are many years past menopause, the harmful effects of estrogen and progestin are likely to exceed chronic disease prevention benefits 2
The timing of HRT initiation relative to menopause onset is critical - women who start HRT more than 10 years after menopause have increased probability of harm 3
HRT is primarily indicated for management of menopausal symptoms rather than prevention of chronic conditions 2

Combined estrogen-progestin therapy is associated with increased risks of coronary heart disease events (7 additional events per 10,000 women-years), stroke (8 more strokes per 10,000 women-years), pulmonary emboli (8 more PEs per 10,000 women-years), and invasive breast cancer (8 more cases per 10,000 women-years) 1
Long-term use of HRT (≥20 years) of estrogen alone is associated with increased breast cancer risk (relative risk 1.42) 4

While HRT does provide some benefits including increased bone mineral density and reduced risk for fracture (5 fewer hip fractures per 10,000 women-years), these benefits are outweighed by risks in women who are 15+ years postmenopausal 1
HRT also reduces risk for colorectal cancer (6 fewer cases per 10,000 women-years), but this benefit is outweighed by other risks 1

For fracture prevention, other effective interventions include weight-bearing exercise, bisphosphonates, and calcitonin 3, 4
For women with genitourinary symptoms, low-dose vaginal estrogen preparations can improve symptoms with minimal systemic absorption, and vaginal moisturizers and lubricants can be used as non-hormonal alternatives 2

Initiating HRT solely for prevention of chronic conditions like osteoporosis or cardiovascular disease without considering individual risk factors 2, 4
Failing to distinguish between different HRT regimens and routes of administration, which can have varying risk profiles 2

The absolute increase in risk from HRT is modest but significant, especially for women who are many years past menopause 1, 2
The Women's Health Initiative (WHI) study provides much of our evidence on HRT risks, and included women with an average age of 63 years, similar to the age of the woman in question 1