Alternatives for optimal hormone replacement therapy.
To satisfy the needs of women with a wide variety of different medical histories and preferences, a wide choice of various forms of hormone replacement therapy (HRT) is desirable. The potential long-term benefits of HRT, in terms of osteoporosis, cardiovascular disease and dementia, require good compliance, which in turn requires an HRT formulation that is highly acceptable. An absence of weight gain and lack of androgenic effects are of great importance, as are predictable bleeding and positive effects on postmenopausal symptoms and quality of life. HRT should be tailored to each woman's needs by the choice of appropriate estrogens and particularly a progestogen with a suitable pharmacological profile. An ideal progestogen should be targeted at preventing endometrial hyperplasia without opposing the effects of estrogen on the vessels. Several new progestogens have been synthesized in recent years. Dienogest, the progestogenic component of a new hormone replacement therapy with estradiol valerate, has many desirable features, including antiandrogenic properties; in this respect, it is unique amongst progestogens derived from testosterone. Tailored HRT should treat symptoms, minimize risk factors, meet personal preferences and lifestyle needs, and not be contraindicated for concomitant diseases. During the next decade, optimal HRT must match a number of trends, including an aging population, and is likely to be influenced by the outcome of major trials such as the Women's Health Initiative trial whose negative results will impact the prescriptions, the advent of new compounds--particularly the selective estrogen receptor modulators and progestogen receptor modulators--and the introduction of new methods of delivery, including vaginal rings and medicated intrauterine systems.