Hormone replacement therapy (HRT), previously a mainstay of treatment for postmenopausal women, recently has come under increased scrutiny. Systemic HRT remains an effective treatment for the common symptoms of menopause, such as hot flashes. The long-term benefits of HRT on osteoporosis and heart disease have been demonstrated in observational studies, but large-scale clinical trials are needed before these findings are confirmed. Although the risk for endometrial cancer is lessened by addition of a progestin, HRT seems to cause a small but significant risk for breast cancer in long-term users, which is a major concern to many women contemplating this therapy. Primary care clinicians should provide detailed risk–benefit information and encourage informed decision making by patients.