Optimizing the dose of hormone replacement therapy.

Over the last 5 years we have seen the evolution of several new products and several new regimens for estrogen replacement in menopause. Before this time, the decision surrounding hormone replacement therapy (HRT) mainly focused on whether to take estrogen or not, and if the addition of a progestogen was required. However, with new paradigms we now have several options for HRT, with various doses of estrogen ranging from very low doses of oral estrogen (0.3 mg conjugated equine estrogen [CEE], 0.25 mg 17beta-estradiol), transdermal patches which deliver a minimum of 20 microg of 17beta-estradiol per day, or intranasal methods which deliver 100-400 microg of 17beta-estradiol, to the more commonly prescribed doses of 0.625 mg of CEE or 0.5 mg 17beta-estradiol. The decision to add a progestogen to the regimen of replacement therapy is well accepted, particularly in a woman who has an intact uterus; however, now the controversy has focused on which progestogen least attenuates the lipid benefits received from the estrogen replacement therapy. Estrogen treatment in the postmenopausal woman has several proven benefits. For the woman who has vasomotor symptoms or complaints related to urogenital atrophy, there is little controversy regarding its use. However, a continuing controversial area is that of long-term prevention of osteoporosis and cardiovascular disease. It is in these areas that the decision on the dose and the addition of a progestin to hormone replacement therapy is under review.