Estrogen replacement therapy in postmenopausal women.

The major signs and symptoms in menopausal women are due to estrogen deficiency and aging and the emotional impact of these processes. Hot flushes occur in 50-60% of women and are more severe when the estrogen production is decreased rapidly. Changes in reproductive structures occur more slowly. Osteoporosis is accelerated by estrogen deficiency. Myocardial infarction is 20 times more frequent in men as in women before the menopause but only 3 times as frequent thereafter. Estrogen therapy is the major cause of postmenopausal bleeding. It occurs in 2-20% of treated patients depending on the dose and schedule of therapy. Endometrial carcinoma has been associated with prolonged estrogen exposure in the absence of progesterone. The incidence has been estimated to be 4-8/1000 women treated and higher with therapy of over 5 years duration. Estrogen also increases the risk of gallbladder disease hypertension thrombophlebitis and myocardial infarction. However the risks are accepted by many patients with severe symptoms. Cyclic administration of estrogen is best. When mild atrophic vulvitis and vaginitis are present the topical application of estrogens may be sufficient. For oral administration conjugated estrogens containing large amounts of estrone are widely used. The possibility of pregnancy should be excluded. Severe liver impairment is a contraindication. Preexisting fibroids may increase in size during therapy. Endometriosis may be adversely affected. Optimum amounts of calcium and protein in the diet may prevent osteoporosis. The occurrence of adverse effects requires discontinuing therapy. Belladonna alkaloids and mild sedatives may then be used.