How to prescribe and manage estrogen or hormone replacement therapy

Cardiovascular disease remains the major cause of mortality and morbidity for women in industrialized societies. Most epidemiological studies associate hormone replacement therapy (HRT) with a 50% reduction in risk for cardiovascular disease, and a recent major trial has shown a reduction of cardiovascular disease risk factors. Estrogens improve lipoprotein lipid profiles in the plasma and help to impede the formation of atherosclerotic plaque. Estrogens alter endothelial function, Vascular reactivity and fibrinolysis, but these changes are also seen with a reduction in low-density lipid (LDL) cholesterol and may partly reflect the altered LDL concentrations in the plasma. Oral estrogens have more favorable effects on LDL and high-density lipid than do transdermal preparations but result in greater hypertriglyceridemia. Most progestins antagonize the beneficial effects of estrogen, but cyclic use of progestins with estrogens generally retains a net beneficial effect. Animal studies suggest that progestins do not substantially reverse the beneficial effects of estrogens on the atherogenesis. HRT is a tool to potentially reduce morbidity and mortality in women, and unless contraindications exist the benefit usually outweighs the risk.