USPSTF Retains Same Stance on Use of Menopausal Hormone Therapy

New Draft Recommendations Based on Even Stronger Evidence of Risk

June 05, 2012 10:00 am Matt Brown
[Hand holding blister pack of HRT drugs]

The latest draft recommendations from the U.S. Preventive Services Task Force(www.uspreventiveservicestaskforce.org) (USPSTF) mirror the AAFP's current position against using menopausal hormone therapy -- whether combination estrogen/progestin or estrogen alone -- to prevent chronic conditions. (Editor's Note: The recommendations of both organizations are now final.)

According to USPSTF Co-vice Chair Michael LeFevre, M.D., M.S.P.H., a family physician from Columbia, Mo., the draft recommendations, which were published May 29 in the Annals of Internal Medicine, simply restate the task force's previous grade D recommendations(www.uspreventiveservicestaskforce.org), albeit with stronger evidence.

Story Highlights
  • The U.S. Preventive Services Task Force's latest draft recommendations mirror the AAFP's position against using menopausal hormone therapy to prevent chronic conditions.
  • The updated recommendations were based on a review of 51 full-text articles from nine trials, as well as one additional article published after the original literature search was conducted.
  • The task force invites public comments on the draft recommendations through June 26.

The latest recommendations -- which were based on a review of 51 full-text articles from nine trials(www.uspreventiveservicestaskforce.org), as well as one additional article that was published after the original literature search was conducted -- were redrafted as part of the USPSTF's standard procedure, said LeFevre.

"We try to update things about every five years," he said. "So as part of our normal process, it was time to update."

LeFevre said that although he doesn't expect the updated recommendations to cause much of a stir, the 2002 and 2005 recommendations on menopausal hormone therapy that came as a result of the Women's Health Initiative(www.nhlbi.nih.gov) (WHI) study caused an almost tectonic shift in women's health care.

"It's almost unparalleled, in my experience, that a study like the WHI would produce such a pronounced change in standard practice," he said. "I think we had already started to see changes in hormone replacement therapy prescribing patterns even before our last recommendation, so I would be surprised if there are any changes based on this new one. I think most people are already on board with this.

USPSTF Updates Falls Prevention Recommendations

The U.S. Preventive Services Task Force (USPSTF) has issued updated final recommendations http://www.uspreventiveservicestaskforce.org/uspstf/uspsfalls.htm(www.uspreventiveservicestaskforce.org) concerning the prevention of falls in community-dwelling adults ages 65 or older.

The USPSTF made a grade B recommendation http://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#brec(www.uspreventiveservicestaskforce.org) supporting exercise or physical therapy and vitamin D supplementation to prevent falls among people in this population who are at increased risk for such events. However, the task force recommended against routinely performing an in-depth multifactorial risk assessment for falls in conjunction with comprehensive management of identified risks because the likelihood of benefit is small.

"In determining whether this service is appropriate in individual cases, patients and clinicians should consider the balance of benefits and harms on the basis of the circumstances of prior falls, comorbid medical conditions, and patient values," the task force said in making this grade C recommendation. http://www.uspreventiveservicestaskforce.org/uspstf/gradespost.htm#crec(www.uspreventiveservicestaskforce.org)

"The evidence changed, but it didn't change the bottom line assessment," LeFevre said. "The words are important here: We recommend against the use of either combined estrogen and progesterone or estrogen alone for the prevention of chronic conditions in postmenopausal women."

"Our update of evidence from trials published since 2002 indicates that both hormone therapy regimens decrease risk for fractures but increase risk for stroke, thromboembolic events, gallbladder disease, and urinary incontinence," said the authors of the evidence review(www.uspreventiveservicestaskforce.org) on which the task force based its recommendations. "Estrogen plus progestin also increases risk for breast cancer and probable dementia, whereas estrogen alone decreases risk for breast cancer."

Calling the recommendation a "classic example" of the need to balance benefit and harm in deciding about preventive services, LeFevre pointed to a table(www.uspreventiveservicestaskforce.org) in the evidence review that clearly lays out the plusses and minuses associated with menopausal hormone therapy.

"Estrogen is one of our more effective ways to prevent hip fractures, and yet that benefit seems to be outweighed by the risk," LeFevre

"So there are many things that get worse, a few things that get better, and the balance comes down on the side of, 'I wouldn't recommend this for an asymptomatic woman for general prevention of chronic conditions,'" he said.

The findings regarding breast cancer, in particular, are of note, said LeFevre.

"(The WHI) actually showed a reduction in the incidence of breast cancer, whereas in the combined therapy group, it showed an increase in risk," he said. "That didn't fit with anybody's thinking on breast cancer at the time and it even panned out in the interval with the other evidence that breast cancer mortality was actually slightly lower in the women who had received estrogen. But nonetheless, the harms still outweigh the benefits, so that's the bottom line -- uterus or no uterus, combined or by itself -- we don’t see that the benefit outweighs the harms when it comes to estrogen."

The AAFP's Commission on Health of the Public and Science is reviewing the hormone therapy recommendation and plans to provide feedback during the comment period, which ends June 26.


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