In reply to the letter of Drs Ness and Pan regarding our article,1 I should like to make the following comments.
We agree that the most recent results of the HERS2 are of great importance. Yet, as Ness and Pan themselves pointed out, that study, however well designed and executed, cannot outrightly refute the present policy of giving hormonal replacement therapy (HRT) to postmenopausal women to achieve, among other goals, a significant decrease (30%-50%) in coronary artery disease. It should be noted that HERS is a secondary prevention study with a follow-up period of only 4 years and that it was carried out in a population largely (50%) already treated with hypolipidemic medications. These drugs are probably more effective in reducing low-density lipoprotein–cholesterol than is HRT in postmenopausal women, and they could mask the true effect of HRT. The consequences of HRT on a woman's biological system are probably more pronounced when treatment is begun shortly after menopause. Therefore, HRT should not be expected to have the same dramatic effect when started after 18 years of hypogonadism, a time when atherosclerosis in many individuals is already advanced.