The missing R

The publication of the Women’s Health Initiative (WHI) data1 has generated a series of alarmed reactions among the media, general public and clinicians. Today, the final result is that menopausal women are now fearful about the use of hormones. Clinicians invite their patients to stop the treatment and often prescribe what are termed ‘alternative therapies’. However, it is important to clearly underline that the changes in clinical practice are not justified by the WHI data. First, the results in terms of breast cancer are not alarming, since the increase in risk is lower than expected2. In fact in the WHI study, hormonal treatment resulted in a breast cancer hazard ratio of 1.26, with a nominal 95% CI that includes 1.0 (1.00 to 1.59) and is, thus, not statistically significant. Concerning cardiovascular risk, one must consider that the majority of the adjusted 95% CIs for cardiovascular events include 1.0 and are, again, not statistically significant. In addition, one should consider the patient selection and the doses of hormones prescribed3. The fact is that a range of efficient hormone regimens is available, each studied for a different type of patient. As gynecological endocrinologists we need to put the WHI results into perspective and provide the correct global management of the postmenopausal years, taking into account the biologically relevant differences between our 50-year-old patients and their 80-year-old mothers3. Different opinion leaders have modified their position following the WHI paper, which has also led to a change in terminology. In fact, some colleagues are now referring to hormone prescription in postmenopausal women as ‘hormone therapy’ (HT), instead of the common and widely used ‘hormone replacement therapy’ (HRT). Why have they dropped the word ‘replacement’? The reasons for this semantic change are obscure, but we believe that this change is incorrect. However, we are under the impression that HT has become the ‘politically correct’ term following the results of the WHI trial. It now appears that many of our colleagues are troubled by the WHI results and are now less liberal in indicating and prescribing hormones after the menopause. In fact, it has been suggested that hormones should be prescribed for the shortest period of time possible and only in women suffering from severe climacteric symptoms. On the other hand, in this unsound trial, HRT was given tout court as a therapy. The WHI was not intended to be a study of the menopause; it was designed to determine whether hormones could have any value in the prevention of diseases in older women. This study design overlooks the concepts of replacement and, in some ways, of good clinical practice3. We would like to explain our strong statement and why we should keep the ‘R’. Different international bodies now stress the need to personalize therapy after the menopause according to individual needs and characteristics. As gynecological endocrinologists, we have always individualized our therapies, long before the WHI publication3. Personalization implies that the prescription of hormones takes into account a series of individual variables, such as age, time since menopause, symptoms, needs, preferences, and other relevant characteristics of any given woman. We are aware that, by definition, prescription means therapy. The concept of replacement, however, refers to the choice of the dose, type and combination required Gynecol Endocrinol 2003;17:91–94