ABSTRACT
It is well known that estrogen alleviates symptoms of the menopause such as vasomotor disturbances and urogenital atrophy. Various articles have also attributed a protective effect on osteoporosis1, cardiovascular disease2 and stroke3 as well as possibly Alzheimer’s disease4. This view, with regard to protection against cardiovascular disease and stroke, has now been challenged by the Women’s Health Initiative study5. It should be stressed that the combination of conjugated equine estrogens and medroxyprogesterone was perhaps not ideal, and additionally the women in this study were too old to allow assessment of primary protection. Various routes of delivering estrogen have been explored over the years: oral tablets, transdermal patches and gel, subcutaneous implants and the vaginal route via creams, tablets, pessaries and rings. The former three are more widely used by physicians. The reason for these different forms of hormone replacement therapy (HRT) is that none of them are totally without problems. Table 1 gives the advantages and disadvantages of the various methods. There are many reasons for discontinuation of HRT6 (Table 2), and rates of discontinuation within 1 year vary between 20 and 60%. Up to 30% of patients do not even pick up their prescription from the pharmacy7. It has also been recognized by many that some women require relief from, for example, urogenital symptoms without wanting to suffer the common sideeffects of HRT such as the return of monthly bleeds and fear of cancer. A further 10-25% of women receiving systemic HRT with adequate control of symptoms such as hot flushes still suffer from the symptoms of urogenital aging8.
