The importance of patient education in improving compliance.
It is self-evident that the benefits of hormone replacement therapy will not be realized if women do not continue taking the therapy for long enough. All surveys show very disappointing levels of compliance or continuance, with typically about 25% of women stopping within 6 months and very few remaining on therapy for more than 1 or 2 years. The main reasons for stopping include unexpected or unacceptable side-effects, bleeding, fears of cancer, ignorance of the effects of hormone replacement therapy and the potential benefits, inappropriate expectations and poor support from medical advisers. With the ever-increasing options for prescribing hormone replacement therapy, including different routes of administration, combinations of hormones and variable dosages, it should be possible to find a regimen of hormone replacement therapy to suit most women. In the long term, poor continuation of hormone replacement therapy is strongly influenced by the presence of bleeding. Continuous combined estrogen/progestogen regimens, which avoid cyclical bleeding, are more acceptable, particularly for the older postmenopausal woman. However, the initial counselling has a most important impact and time taken to explain and to involve the woman in the decision process will encourage greater confidence in the merits of the therapy. The use of informative literature, videos and telephone help-lines, together with regular and close follow-up until a regimen is satisfactorily established, allows reassurance about initial side-effects or worries and adjustment of therapy. Recent developments of lower-dose combination therapy, selective estrogen receptor modulators and intrauterine progestogen-releasing systems should further improve compliance, but the key to continuation with hormone replacement therapy is a well-informed and confident patient.