It is justifiable to have reservations about the significance of the data available at this time on a possible increase in the risk of a patient's developing
endometrial cancer if
estrogen replacement therapy has been prescribed for her. Hopefully, additional studies currently being conducted will help to clarify the issue further. In the meantime, clinicians need guidelines on the use of
estrogen replacement therapy.
Estrogen is indicated in the premenopausal woman who has had surgical or radiation
castration for treatment of disease. Menopausal women with severe vasomotor instability or
atrophic vaginitis should also be considered for
estrogen replacement therapy. In the latter situation,
topical administration may be adequate.
Contraindications to
estrogen replacement include undiagnosed
vaginal bleeding,
breast cancer history of thromboembolic
disease, liver disease, uterine leiomyomata,
hypertension, diabetes,
migraine headaches or
gall bladder disease. In patients for whom
estrogens are contraindicated,
atrophic vaginitis can be treated with local
estrogens and vasomotor symptoms with
sedatives such as
phenobarbital and belladonna. Before
estrogen treatment is begun, a medical history and physical examination that look for possible
contraindications are required. Obviously, any woman with abnormal
uterine bleeding in the menopausal age group requires a procedure that provides tissue for histopathologic examination. Although postmenopausal women taking
estrogen may have
uterine bleeding related to the
hormone, such
bleeding cannot be assumed to be due to the
therapy and always requires evaluation. The lowest dose effective in controlling a patient's symptoms should be administered, preferably in cyclic fashion. Whether the addition of a
progestational compound at cyclic intervals has a beneficial effect on the endometrium is a matter of conjecture at this time. Requirement for continuing
therapy should be reevaluated at least on an annual basis and preferably more often. In conclusion, a quote from Graber and Barber is appropriate: "The entire picture of routine postmenopausal
estrogen therapy is in a state of complete
confusion. We must proceed with circumspection and caution. We need less passion, fewer hypotheses, and more facts."