T issue of JCEM again addresses the topic of hormone replacement therapy (HRT) for postmenopausal women. Much has happened since this item was last brought up in 1996, and much remains to be known. Despite our lack of definitive data in key areas, patients continue to require care, and we must help them to make informed choices. The classic, preventive approach to HRT can be summed up in a few phrases: 1, estrogen is good for you; 2, start taking it now; 3, take it for the rest of your life. These tenets come under fire in the present series of articles, and the time is right for a re-evaluation of these principles. Preventive medicine is difficult. Women, by and large, are voting with their feet about this approach to HRT, and only a small minority of women take it, although benefits of HRT are likely to accrue to a majority of women. Our authors do not dispute that HRT will help to prevent osteoporosis and fracture. All anticipate some benefit, though it may be smaller than expected, in cardioprotection from HRT (Dr. Roussow excepted). All authors express great concern that individualization of the treatment decision ought to be considered, and this is the first salient feature that marks a change in the thinking about HRT over the past two years. Dr. Col and colleagues lead off with a specific set of directives aimed at providing individualized estimates of the benefitto-risk ratio for HRT (1). Their risk and benefit estimates are primarily based on data from the Nurses’ Health Study (2, 3). These studies have tended to provide a better-than-average estimate of cardiovascular disease risk reduction and a worse-than-average estimate of breast cancer risk associated with HRT, effects which may cancel each other out. Nonetheless, I find this approach valuable, because it models the behavior of a physician in the office, who must discuss and come up with a recommendation for his or her patients without the benefit of the results of randomized, clinical trials. Dr. Cauley’s presentation also discusses the need to consider the individual’s risk and hormonal profile before concluding that HRT is or is not a wise recommendation. This paradigm shift now leads us to a targeted approach to HRT. I believe that this approach is helpful for several reasons. It articulates which risk factors are modifiable for our patients and may lead them to engage in behaviors that will reduce disease risk. It sends the message to a patient that she is an individual who is not representative of the “everywoman” who will probably benefit from HRT, a message especially welcome by our highly individualistic aging baby boomers. It demystifies the process of decision making and welcomes the patient as a partner in the process, a feature that will probably enhance the ability to stick with the program. A second paradigm shift that is detectable in all of the pieces is an appreciation that nonhormonal therapies are available to treat postmenopausal women. The impact of the “statins” probably contributed to the negative outcome of the HERS study, in which a substantial percentage of the women were being concomitantly treated with additional cardioprotective agents (4). The statins, in particular, have been demonstrated to save lives, something that cannot now be said about HRT, despite the implications of the many observational studies (5, 6). The notion that HRT is a global risk-reduction strategy is being re-evaluated. In a world that is now turning out statins, SERMs, and orally active bisphosphonates, pharmacologic methods to reduce cardiovascular and bone risk that do not involve the use of HRT are available, and there is every reason to believe that the choices will continue to proliferate. As the pharmacologic choices for risk reduction expand, we will be better able to appreciate the real and perceived barriers to long-term preventive treatment of postmenopausal women. Finally, I think that the authors herein reflect a third, significant evolution of thought in this field. The “feminine forever” sentiment has led us to the unnecessarily heavy proposition that women must commit to HRT for the rest of their lifetime. This, in my opinion, presents an impediment Accepted March 11, 1999. Address correspondence regarding these controversies and requests for reprints to: Nanette F. Santoro, Department of Obstetrics, Gynecology and Women’s Health, Albert Einstein College of Medicine, 1300 Morris Park Avenue, Mazer-Room 325, New York, New York 10461. 0021-972X/99/$03.00/0 Vol. 84, No. 6 The Journal of Clinical Endocrinology & Metabolism Printed in U.S.A. Copyright © 1999 by The Endocrine Society