The practicalities of hormone replacement therapy.

ABSTRACT

An appropriate regimen of HRT using oestrogen with or without progestogen can be found for the majority of patients. In many cases this will be the first or second therapy that is chosen and for most women will be one of the combination packs that are commercially available. In a significant number of patients, however, these formulations will either not control symptoms or bleeding or will cause unacceptable progestogenic side-effects. Separate prescribing of oestrogen and progestogen will then be required. We suspect that the reported low compliance of women taking HRT in the general population may be related to the deficiencies of the available combination packs and reluctance of physicians to separately prescribe the oestrogen and progestogen components of HRT. The latter is understandable as the literature contains so few guidelines concerning prescribing. It is hoped that progestogens that have less side-effects than the C-19 steroids (currently universally used in combination packs of HRT) will be incorporated into new formulations. The option of prescribing oestrogens to non-hysterectomized women in the form of continuous combined therapy is not available to many physicians because the necessary endometrial sampling every 12-18 months cannot be arranged; the current outpatient methods of sampling require experience of manipulation of instruments within the uterine cavity that is usually only acquired during gynaecological training. There are still many uncertainties about the appropriate combination of oestrogen and progestogen that should be incorporated into a continuous combined regimen to avoid the troublesome bleeding that occurs in a significant proportion of women when starting this therapy. Many previous studies were seriously flawed and further research, carefully designed and conducted, is urgently needed.