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Hormone therapy is still the most commonly used treatment to relieve menopausal symptoms and the consequences of oestrogen deficiency. The decision process is complex and benefits needs to be balanced vs. risks. Not all reported benefits and risks have been as well highlighted by the media throughout recent years, it is therefore important to update regularly the current scientific knowledge. This is an actualization of the last EMAS statement concerning hormone replacement therapy use.

This new statement from EMAS presents the findings reported in recent publications from both WHI trials. In general, the reports do not necessitate a revision of the current EMAS advice. They provide further insight into the ongoing controversy around the possibility that hormone therapy (HT) in the form of estrogen (E) alone or estrogen-progestogen (EP) may influence risk of breast cancer differently. They confirm that the increase of breast cancer diagnosis under EP is only significant after a cumulative use of more than 5 years but suggest that there is no increased risk by E within 10 years.

This new statement from EMAS presents the findings reported in recent publications from both WHI and the Nurses' Health Study to consider if these findings require the EMAS position to be modified. In general the reports do not necessitate a revision of the current EMAS advice but do provide further insight into the ongoing controversy around the possibility that estrogen (E) or estrogen-progestogen (E-P) use in younger postmenopausal women may supply cardiovascular benefit in the younger group.

In women experiencing distressing climacteric symptoms during the peri- and postmenopause there is conclusive evidence from abundant randomised controlled trials that systemic hormone replacement therapy (HRT) of any type affords symptom relief, with no alternative treatment producing similar effect. Though this evidence is accumulating, the question of how to provide best clinical practice in an attempt to both alleviate the menopausal symptoms and prevent the more long-term postmenopausal degenerative diseases is still under debate. When providing climacteric medicine, the dose and regimen of HRT needs to be individualised based on the principle of choosing the lowest appropriate dose in relation to severity of symptoms and on the menopausal age. However, few long-term data on different HRT formulations exist in symptomatic women, which also account for baseline risk of cardiovascular disease (CVD), breast cancer and osteoporosis. In most cases, an individualized prescription together with life-style management will sustain possibilities for net beneficial effects on climacteric symptoms, quality of life (QoL), sexuality and osteoporosis, with only rare risk of severe adverse effects. With the perspective provided by recent epidemiological findings, not least from the estrogen only arm of the Women's Health Initiative Study (WHI), European Menopause and Andropause Society (EMAS) supports research activities in symptomatic women with new HRT formulations in order to affect positively the balance of clinical benefit and risk, including specific information on QoL and also account for the traditional differences in treatment modalities between the US and Europe, and the difference in BMI, life-style and diet. In women experiencing an early menopause (<45 year) current data support a specific overall benefit of HRT. At present, more long-term systemic HRT may be considered in women at high risk of osteoporotic fractures, in particular when alternate therapies are either inappropriate or insufficiently effective, as benefits will outweigh any risks. In contrast, urogenital symptoms may be addressed efficiently and safely with long-term local estrogen therapy.

Hormonal therapy (HT) is one of the most frequently prescribed drug regimens for women after the age of 50 years. HT has been developed progressively since the 1960s to provide estrogen to those women (a) who require relief of symptoms which have resulted from reduced circulating estrogen or (b) to act as an anti-resorptive agent to counteract the effect of the increased bone turnover which occurs with falling menopausal estrogen levels and which results in loss of bone mass leading to postmenopausal osteoporosis. However, a large number of women pass through the menopausal transition without experiencing distress as a result of the natural fall in estrogen hormone levels and since the introduction HT has been thought to be associated with a number of health benefits that have been tested in clinical trials but not substantiated. In women experiencing distressing climacteric symptoms double-blind randomised controlled clinical trials with a variety of HT regimens have shown that HT of any type provides symptom relief with no alternative treatment of similar effect. The dose and regimen of HT need to be individualised and in general the appropriate dose is dependent on the menopausal age. Women experiencing urogenital estrogen deficiency symptoms require long-term treatment which is most easily achieved with local estrogen. With the perspective provided by the most recent epidemiological findings not least from the estrogen only arm of the Women's Health Initiative Study (WHI) EMAS supports research activities generating HT with new compositions including lower doses and a wider range of progestins in order to positively affect the balance of clinical benefit and risk. Currently, however, individualized and appropriate prescription of the available HT products together with life-style management will sustain possibilities for beneficial effects on climacteric symptoms, quality of life and degenerative diseases after the menopause.

Thirty post-menopausal, non-hysterectomised women received a 50 mg oestradiol implant subcutaneously and either 10 mg or 20 mg dydrogesterone daily for 14 days every 28 days for 6 months. Endometrial biopsies were taken during the initial oestrogen-only phase and again during the final progestogen phase. Of the ten initial samples which were adequate for histological diagnosis, nine showed proliferative and one non-secretory endometrium. Of the 28 samples obtained at the end of the study during the progestogen phase, all except one showed satisfactory conversion, irrespective of dose. Acceptable bleeding patterns were seen in both dosage groups. Tolerance was good and no patient discontinued treatment. This study has shown that both 10 mg and 20 mg dydrogesterone for 14 days are potent enough to oppose the proliferative effects of the 50 mg oestradiol implant. In view of the wide inter-patient variation in endometrial response to progestogens, it appears appropriate to choose the dosage of dydrogesterone on the basis of cycle control and tolerability, whilst being able to maintain confidence in endometrial protection.