Objectives: The objective of this four part series is to review for the practicing clinician the extensive and sometimes contradictory literature on the effects of estrogen replacement therapy and hormone replacement therapy (HRT) in the postmenopausal woman. This final article reviews the role of long-term HRT in stroke, Alzheimer's disease (AD), and overall mortality as well as strategies to guide decision-making for the individual patient.
Design: Studies reviewed were obtained through Medline searches, examination of citations in the articles reviewed from those searches, interviews with local experts in geriatrics, cardiology, and women's health.
Conclusions: Evidence for benefit from HRT in delaying onset of and preventing AD in aging women is inconclusive. No consistent trend for beneficial or harmful effect of HRT on stroke risk has been demonstrated. HRT does seem to be beneficial in decreasing overall mortality risk, especially in women with coronary heart disease risk factors. The overall health and functioning of the geriatric patient and the presence of co-morbid conditions must be factored into clinical decisions. The decision to initiate HRT is complex, requires thoughtful assessment of net benefit and risk for the individual patient, and should accommodate the individual's personal preferences. Forthcoming results from the Women's Health Initiative HRT trial and observational study will help resolve some of the ambiguities in this decision-making process.