Hormone replacement therapy: an overview for South African pharmacists

Menopause is a normal physiological process resulting from the cessation of ovarian function and the end of menstrual cycles. By 2030, an estimated 1.2 billion women worldwide will be postmenopausal, underscoring the growing need for effective symptom management. Vasomotor symptoms, including hot flushes and night sweats, affect approximately 80% of women and may be accompanied by insomnia, mood disturbances, sexual dysfunction, and genitourinary symptoms, all of which can significantly impair quality of life. Hormone replacement therapy (HRT) remains the most effective treatment for vasomotor symptoms and has additional benefits for preventing postmenopausal bone loss and reducing fracture risk. Despite its proven efficacy, HRT remains one of the most debated therapeutic interventions. Much of the controversy followed publication of the Women’s Health Initiative (WHI) trial in 2002, which reported increased risks of breast cancer, cardiovascular disease, stroke, and venous thromboembolism. However, subsequent analyses have demonstrated that the benefit-risk profile of HRT varies according to a woman’s age, time since menopause, baseline health status, and treatment regimen, with the greatest benefits generally observed in healthy women younger than 60 years or within 10 years of menopause onset. HRT is therefore recommended for bothersome menopausal symptoms rather than solely because menopause has occurred, and treatment decisions should be individualised through shared decision-making that considers symptoms, medical history, contraindications, and personal preferences. Pharmacists play an important role in supporting the safe and effective use of HRT through patient education, assessment of adherence and administration technique, identification of drug interactions and contraindications, and monitoring of treatment response and adverse effects. Counselling should include discussion of expected benefits, potential risks, common adverse effects, bleeding patterns, and correct use of the prescribed formulation. Women who are unable or unwilling to use HRT should also be informed about appropriate non-hormonal treatment options. Safe menopause care therefore depends on a clear indication for treatment, individualised risk assessment, adequate endometrial protection where required, correct product use, and regular review of treatment goals and outcomes.