By contrast, the risk - benefit assessment that precedes the decision to take HRT is a more cognitive and, one would hope, a more rational one. Unquestionably, a significant cause of noncompliance is the related side effects, with withdrawal bleeding being the most unappealing for the majority of women. Another common, if not the most common, reason cited by women declining hormone replacement is the fear of developing an HRT-related malignancy. However, and most importantly, addition of an adequate dosage of progestins throughout the cycle reduces the relative risk to below that of women who take no hormone replacement at all. What women tend to be less aware of is that it is heart disease, not breast cancer, that kills the greatest number of American women each year.
More American women die of heart disease than of any other cause, including breast cancer.
Thus, while breast cancer tends to be what women fear most, the fact is that they have far more to fear from heart disease. This issue is not without controversy, but we can be certain of a few things. First, hormone replacement has been used for more than five decades in the United States, and more than 1,500 peer-reviewed journal articles have examined the association between HRT and breast cancer development. Secondly, from a public health perspective, it is clear that more women-years are saved as a result of the beneficial effects of HRT than are lost from the negative effects of a potential increase in RR of developing breast cancer. There have been no randomized clinical trials examining the potential association between HRT and ovarian cancer, and there is a paucity of reliable historical data.