USPSTF Draft Recommendation

Don't Use Estrogen/Progestin Therapy for Chronic Conditions in Postmenopausal Women

May 19, 2017 03:45 pm Chris Crawford

On May 16, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on menopausal hormone therapy for the primary prevention of chronic conditions. Based on its review of the evidence, the USPSTF recommended against the use of combined estrogen and progestin therapy to prevent chronic conditions in postmenopausal women -- a "D" recommendation.(www.uspreventiveservicestaskforce.org)

[Older woman posing on sofa]

Furthermore, the task force recommended against the use of estrogen to prevent chronic conditions in postmenopausal women who have had a hysterectomy -- also a "D" recommendation.

The median age for menopause is 51.3. Because the postmenopausal change in hormone levels can raise women's risk for chronic conditions such as heart disease and osteoporosis with attendant fractures, physicians previously recommended hormone therapy for these women. Menopausal hormone therapy refers to the use of estrogen and a progestin in women with an intact uterus, or estrogen alone in women who have had their uterus removed, taken during or after menopause.

After the Women's Health Initiative (WHI) Postmenopausal Hormone Therapy Trial published its findings(www.nhlbi.nih.gov) that hormone therapy is associated with serious adverse health effects, use of menopausal hormone therapy declined sharply. During the years 1988-1994, 44 percent of U.S. women said they used or had used hormone therapy; only 4.7 percent said they used or had used it in 2010.

Story highlights
  • The U.S. Preventive Services Task Force posted a draft recommendation statement against the use of combined estrogen and progestin therapy to prevent chronic conditions in postmenopausal women.
  • Furthermore, the task force recommended against the use of estrogen to prevent chronic conditions in postmenopausal women who have had a hysterectomy.
  • After the Women's Health Initiative Postmenopausal Hormone Therapy Trial published findings that hormone therapy is associated with serious adverse health effects, the percent of U.S. women who said they use or had used hormone therapy declined sharply.

"The benefits of using menopausal hormone therapy to prevent chronic conditions like heart disease and diabetes do not outweigh the harms in women who have gone through menopause," said USPSTF member Maureen Phipps, M.D., M.P.H., in a news bulletin.(www.uspreventiveservicestaskforce.org)

This draft recommendation is consistent with the USPSTF's 2012 final recommendation statement(www.uspreventiveservicestaskforce.org) and also the AAFP's final recommendation statement that year.

"It's important to note that this draft recommendation applies only to women who have gone through menopause and are considering hormone therapy to prevent chronic conditions," said USPSTF member Ann Kurth, Ph.D., M.P.H., in the bulletin. "It does not apply to women who are considering hormone therapy to manage menopausal symptoms, such as hot flashes or night sweats."

The draft recommendation also does not apply to women younger than age 50 who have experienced premature menopause or who have had their ovaries surgically removed before menopause.

Scope of Review

In updating its 2012 final recommendation, the USPSTF reviewed evidence about the benefits and harms of hormone therapy for the prevention of chronic conditions and also examined whether outcomes vary among women in different subgroups or by timing of intervention after menopause.

The scope of review for this recommendation didn't include the use of hormone therapy to treat specific menopausal symptoms, such as vasomotor hot flashes or vulvovaginal complaints, or for other indications.

The task force found 18 fair- or good-quality trials comparing the effects of combined estrogen and progestin or estrogen alone versus placebo on the prevention of chronic conditions in postmenopausal women. The WHI trial was the largest of these reviewed and also was the only trial designed to evaluate the effectiveness of hormone therapy for primary prevention of the conditions the draft recommendation focused on.

Additionally, the draft recommendation said the WHI trial provided most of the estimates of the benefits and harms of menopausal hormone therapy; this trial had up to 13 years of follow-up (including post-trial phases) to assess how risks for chronic conditions changed after women stopped hormone therapy.

Family Physician's Perspective

Jennifer Frost, M.D., medical director for the AAFP Health of the Public and Science Division, told AAFP News that because the new draft recommendation statement remained largely unchanged from the USPSTF's 2012 final recommendation, family physicians won't need to update how they approach prescribing hormone replacement medications to prevent and treat chronic conditions in postmenopausal women. She also reiterated that the benefits just don't outweigh the harms for most women.

"Although estrogen/progesterone may reduce a woman's risk of fractures or diabetes, they also are associated with significant harms," she said. "It's important to note, however, that most of these harms occurred with long-term use (five to 10 years)."

In addition, Frost pointed out that this draft recommendation doesn't cover the benefit of hormone replacement therapy (HRT) in treating menopausal symptoms.

"HRT can effectively treat menopausal symptoms, and frequently this treatment can be short-term, therefore minimizing risk."

Up Next

The USPSTF is inviting comments on its draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review.(www.uspreventiveservicestaskforce.org)

The public comment window is open until 8 p.m. EDT on June 12. All comments received will be considered as the task force prepares its final recommendation.

The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.

Related AAFP News Coverage
USPSTF Issues Final Recommendations Against Hormone Therapy
(10/23/2012)

USPSTF Retains Same Stance on Use of Menopausal Hormone Therapy
New Draft Recommendations Based on Even Stronger Evidence of Risk

(6/5/2012)

More From AAFP
American Family Physician: AFP By Topic: Menopause

Familydoctor.org: Menopause(familydoctor.org)

Familydoctor.org: Hormone Replacement Therapy(familydoctor.org)