What is the safest & most effective replacement for ERT?

None. There is no "safe" ERT (estrogen replacement therapy). Unopposed estrogen has long been known to cause endometrial carcinoma and other cancers (i.e. ovarian). If you must be on HRT at all, consider only a combined therapy (estrogen and progestins), rather than unopposed estrogen or progestin therapy alone.

From the Data:

"Two studies reported in the June 25, 2003 edition of the Journal of the American Medical Association held more bad news for women getting hormone replacement therapy. One study of women who took a combination of estrogen and progestin, a synthetic form of progesterone, showed they were at risk of getting a more aggressive form of breast cancer than women who didn't get HRT.

Not only were women more likely to develop breast cancer if they took the hormones, researchers wrote, but their tumors tended to be larger and more advanced than breast cancers that developed in women who took a placebo. Women on combination hormone therapy were also more likely to have abnormal mammograms -- even in the first year of treatment -- than women taking a placebo, according to the same study.

Another study of 975 women conducted by researchers at the Fred Hutchinson Cancer Research Center and reported in the same issue of JAMA found that the increased risk of breast cancer from the combination hormone therapy remained the same, whether the two hormones were taken at the same time or one after the other in the course of a month.

The news was one in a series of setbacks in less than a year for combination HRT. In July 2002, researchers called a halt to a government-run study of a hormone therapy used by millions of older women after they found that long-term use of estrogen and progestin raised the risk of heart disease, stroke and blood clots, and invasive breast cancer. And in May 2003 a study reported that combination HRT appeared to increase the risk of Alzheimer's disease or other forms of dementia.

The bad news continued in 2004, with a study in the February 23, 2004 edition of the Archives of Internal Medicine. Reviewing data collected over eight years from over 120,000 women, researchers found that those who used HRT after menopause were more than twice as likely to develop asthma as women who didn't take hormones. The increased risk of asthma was about the same whether women took estrogen only, or took a combination of estrogen and progestin.

Some women may be able to take hormone replacement therapy to treat hot flashes and other menopausal symptoms in the short term without any ill effects. However, the latest news about associated health risks has led doctors to believe that the risks are serious enough to outweigh the benefits of the therapy for many women. After five years of taking a combination of estrogen and synthetic progesterone, women in a national clinical trial known as the Women's Health Initiative were found to be at such high risk for life-threatening diseases that their portion of the trial was halted three years early in May 2002. "We conclude that estrogen plus progestin does not prevent heart disease and is not beneficial overall," the researchers wrote.

Estrogen taken without progestin can cause uterine cancer. Therefore, for some years doctors have recommended that the only women who should take estrogen without progestin on a continuous basis are women who have had a hysterectomy. For women without a hysterectomy, the only recommended hormone replacement therapy is the combination of estrogen and progestin, which does not cause an increased risk of uterine cancer.

But a study reported in the July 17, 2002 issue of the Journal of the American Medical Association links the use of estrogen alone as a hormone replacement therapy to a possible increase in the risk of ovarian cancer. Researchers studied medical records dating as far back as 1973 of 44,421 women on ERT and found they had at least a 60 percent higher risk of ovarian cancer than women who had never used hormone replacement therapy. In view of this latest news, some doctors are reevaluating the safety of estrogen replacement therapy for everyone except women who have had a hysterectomy and who have had both ovaries removed.

The Woman's Health Initiative Study is the largest and most definitive study to date on hormone replacement therapy. In a study of more than 16,000 women, sponsored by the National Heart, Lung and Blood Institute, the test group was given a pill containing a combination of estrogen and progestin. A control group was given a placebo, or dummy pill.

Compared with the women who took placebos, the rate of coronary heart disease among women in the test group was 29 percent higher. The same group had a 41 percent increase in the rate of strokes, twice the number of blood clots, and a 26 percent increase in invasive breast cancer rates. The rate of cardiovascular disease increased by 22 percent.

That's not all. In a sub-study of 4,500 women aged 65 and older in the Women's Health Initiative, those on the HRT regimen were found to be twice as likely to develop Alzheimer's disease or another form of dementia within five years compared with women who took a placebo. This part of the study, reported in the May 28, 2003 edition of the Journal of the American Medical Association (JAMA), also found that the estrogen/progestin therapy was ineffective in preventing mild cognitive impairment, a dimming of cognitive function that is less severe than dementia and which sometimes occurs as we age.

HRT has often been prescribed for the treatment of urinary incontinence. A recent analysis by Women's Health Initiative investigators found that HRT caused or worsened urinary incontinence in participants in the trial. Researchers found that women taking estrogen combined with progesterone had a 39 percent greater risk of urinary incontinence than participants taking a placebo. Women taking only estrogen had a 52 percent greater risk than women not taking the hormone, according to the study in the February 23, 2005 JAMA.

The Women's Health Initiative study did find a few benefits from the HRT regimen, including a 37 percent reduction in the rate of colorectal cancer, one-third fewer hip fractures, and a 24 percent reduction in total fractures. The authors of an article on the trial's results, published in the July 17, 2002 issue of JAMA, stress that even though the percentage of risk was high compared to women who didn't take hormones, the actual number of women getting these illnesses was small.

This means that out of 10,000 women taking HRT, seven more would be expected to have coronary heart disease events, eight more would have breast cancer, eight more would have strokes, and eight more would have blood clots. And 22 more women over 65 would develop Alzheimer's disease or another form of dementia.

On the plus side, six fewer women would have colorectal cancer and five fewer women would have hip fractures. But the difference between the women taking HRT and those on placebo was alarming enough to halt at five years a portion of the study that was supposed last more than eight years.

In another study of over 1,800 women conducted by the Duke Clinical Research Institute, women who began hormone replacement therapy after having a heart attack were more likely to die or have other heart attacks than women who had never been on HRT, or who began the therapy before developing heart problems. Up until recently, many women without prior heart problems had been prescribed HRT to help prevent heart disease. But doctors now know that it may raise the risk."