Medical Uncertainty and Practice Variation Get Personal: What Should I Do about Hormone Replacement Therapy?

• Estrogen replacement therapy
• Decision making
• Breast neoplasms
• Coronary disease
• Osteoporosis, postmenopausal

Dr. Daley, what should I do about hormone replacement therapy?” As a clinician-teacher for the first 15 years of my career, my practice was devoted mostly to women who chose me to care for them. I saw the ravages of osteoporosis, breast cancer, hyperlipidemia, cardiovascular disease, Alzheimer disease, and depression in my patients who were over 55 years of age, and tried to help. My patients under 40 years of age exercised regularly; took vitamins; read voraciously about women's health; and were determined to improve their sense of well-being, increase their longevity, and “take control” of their health. With women 40 to 55 years of age, long collaborative negotiations evolved about whether to use hormone replacement therapy (HRT) for various reasons: to lessen menopausal symptoms; to reduce the likelihood of osteoporosis; and, more recently, to reduce the risk for cardiovascular disease, and, perhaps, Alzheimer disease. Some women decided “no” up front (I often heard “I can't be bothered” and “I'm afraid of getting cancer”); some started a course of HRT only to stop 6 to 8 months later after experiencing bleeding and other unpleasant side effects; others started HRT, persisted, and continued for years. At the same time, breast cancer was diagnosed in 9 of my friends and 18 of my patients in 1 year.

“What should I do?” Now, in my late forties, I face the same decision. Should I embark on a course of HRT as I navigate through menopause? I am healthy and (so far) have not experienced the troublesome symptoms of menopause. I exercise with both strengthening and weight-bearing exercise almost as often as I should, and take calcium supplements in the correct doses as often as I remember. My mother had breast cancer at 51 years of age, suffered through a disfiguring but curative …