Hormonal replacement therapy—usually involving estrogen with or without an added progestin—has been proposed as a treatment for a variety of changes associated with the perimenopausal years, including hot flushes, vaginal and urinary tract atrophy, sexual problems, aging skin, and a number of affective symptoms. It has also been Studied as a preventive measure against osteoporosis and cardiovascular disease, with some researchers claiming a protective effect against breast cancer, although others cite it as a risk factor for breast cancer. This article reviews the literature in each of these areas, suggesting an individualized approach to hormone replacement therapy, determined by patient and practitioner, based on symptomatology and risk factors. Alternative therapies are briefly outlined.