Am Fam Physician. 2005;72(2):311-316
This statement summarizes the U.S. Preventive Services Task Force (USPSTF) recommendations on hormone therapy for the prevention of chronic conditions in post-menopausal women and the supporting scientific evidence and updates the Task Force’s 2002 recommendations on hormone replacement therapy.1 The updated statement is based on the results of the Women’s Health Initiative randomized controlled trial and the information in the 2002 summary of the evidence on this topic, which is available on the USPSTF Web site (http://www.uspreventiveservicestaskforce.org). Explanations of the ratings and of the strength of overall evidence are given in Tables 1 and 2, respectively. The recommendation statement also is posted on the Web site of the National Guideline Clearinghouse (http://www.guideline.gov).
Summary of Recommendations
The USPSTF recommends against routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women. D recommendation.
The USPSTF found good evidence that the use of combined estrogen and progestin results in both benefits and harms. Benefits include reduced risk for fracture (good evidence) and colorectal cancer (fair evidence). Combined estrogen and progestin has no beneficial effect on coronary heart disease (CHD) and may even pose an increased risk (good evidence). Other harms include increased risk for breast cancer (good evidence), venous thromboembolism (good evidence), stroke (fair evidence), cholecystitis (fair evidence), dementia (fair evidence), and lower global cognitive function (fair evidence). Because of insufficient evidence, the USPSTF could not assess the effects of combined estrogen and progestin on the incidence of ovarian cancer, mortality from breast cancer or coronary heart disease, or all-cause mortality. The USPSTF concluded that the harmful effects of combined estrogen and progestin are likely to exceed the chronic disease prevention benefits in most women.
The USPSTF recommends against the routine use of unopposed estrogen for the prevention of chronic conditions in postmenopausal women who have had a hysterectomy. D recommendation.
The USPSTF found good evidence that the use of unopposed estrogen results in both benefits and harms. The benefits include reduced risk for fracture (good evidence). Harms include increased risk for venous thromboembolism (fair evidence), stroke (fair evidence), dementia (fair evidence), and lowered global cognitive functioning (fair evidence). There is fair evidence that unopposed estrogen has no beneficial effect on coronary heart disease. Because of insufficient evidence, the USPSTF could not assess the effects of unopposed estrogen on the incidence of breast cancer, ovarian cancer, or colorectal cancer, as well as breast cancer mortality or all-cause mortality. The USPSTF concluded that the harmful effects of unopposed estrogen are likely to exceed the chronic disease prevention benefits in most women.
The balance of benefits and harms for a woman will be influenced by her personal preferences, risk for specific chronic diseases, and the presence of menopausal symptoms. A shared decision-making approach to preventing chronic diseases in perimenopausal and postmenopausal women involves consideration of individual risk factors and preferences when selecting effective interventions for reducing the risks for fracture, heart disease, and cancer. Other USPSTF recommendations for prevention of chronic diseases (e.g., screening for osteoporosis, high blood pressure, lipid disorders, breast cancer, and colorectal cancer, and counseling to prevent tobacco use) are available athttp://www.uspreventiveservicestaskforce.org/recommendations.htm.
|The USPSTF grades its recommendations according to one of five classifications (A, B, C, D, or I) reflecting the strength of evidence and magnitude of net benefit (benefits minus harms).|
|A.||The USPSTF strongly recommends that clinicians provide [the service] to eligible patients. The USPSTF found good evidence that [the service] improves important health outcomes and concludes that benefits substantially outweigh harms.|
|B.||The USPSTF recommends that clinicians provide [the service] to eligible patients. The USPSTF found at least fair evidence that [the service] improves important health outcomes and concludes that benefits outweigh harms.|
|C.||The USPSTF makes no recommendation for or against routine provision of [the service]. The USPSTF found at least fair evidence that [the service] can improve health outcomes but concludes that the balance of benefits and harms is too close to justify a general recommendation.|
|D.||The USPSTF recommends against routinely providing [the service] to asymptomatic patients. The USPSTF found at least fair evidence that [the service] is ineffective or that harms outweigh benefits.|
|I.||The USPSTF concludes that the evidence is insufficient to recommend for or against routinely providing [the service]. Evidence that [the service] is effective is lacking, of poor quality, or conflicting, and the balance of benefits and harms cannot be determined.|
• The USPSTF did not consider the use of hormone therapy for the management of menopausal symptoms, which is the subject of recommendations by other expert groups. Women and their physicians should discuss the balance of risks and benefits before deciding to initiate or continue hormone therapy for menopausal symptoms. For example, with combined estrogen and progestin, some risks (e.g., the risk for venous thromboembolism, CHD, or stroke) arise within the first one to two years of therapy, and other risks (e.g., the risk for breast cancer) appear to increase with longer-term hormone therapy. The populations of women using hormone therapy for symptom relief may differ from those who would use hormone therapy for prevention of chronic disease (e.g., age differences). Other expert groups have recommended that women who decide to take hormone therapy to relieve menopausal symptoms use the lowest effective dose for the shortest possible time.
• Although estrogen alone or in combination with progestin reduces the risk for fractures in women, other effective medications (e.g., bisphosphonates and calcitonin) are available for treating women with low bone density to prevent fractures. The role of chemopreventive agents in preventing fractures in women without low bone density is unclear. The USPSTF addressed screening for osteoporosis in postmenopausal women in 2002.2
• Unopposed estrogen increases the risk for endometrial cancer in women who have an intact uterus. Physicians should use a shared decision-making approach when discussing the possibility of using unopposed estrogen in women who have not had a hysterectomy.3
The median age of menopause in women in the United States is 51 years (range, 41 to 59 years), but ovarian production of estrogen and progestin begins to decrease years before the cessation of menses. The average woman in the United States who reaches menopause has a life expectancy of nearly 30 years. The probability that a menopausal woman will develop various chronic diseases during her lifetime has been estimated to be 46 percent for CHD, 20 percent for stroke, 15 percent for hip fracture, 10 percent for breast cancer, and 2.6 percent for endometrial cancer.4 In North America, an estimated 7 to 8 percent of patients 75 to 84 years of age have dementia, and more than 90 percent of cases of colorectal cancer occur after the age of 50 years.5
BENEFITS OF HORMONE THERAPY
Osteoporosis and Fractures
Good evidence from observational studies and randomized clinical trials demonstrates that estrogen therapy increases bone density and reduces the risk for fractures. The combined estrogen and progestin arm of the Women’s Health Initiative (WHI) trial,6 a fair-quality study, found significant reductions in total fracture risk among healthy women taking estrogen and progestin (hazard ratio [HR], 0.76; adjusted 95 percent confidence interval [CI], 0.63 to 0.92). This arm of the WHI trial also showed reductions for hip and vertebral fracture, although these did not achieve statistical significance.6 (In its analysis, the USPSTF used nominal 95 percent CIs for the primary outcomes and adjusted 95 percent CIs for all secondary outcomes.)
The estrogen-only arm of the WHI trial also reported decreased risk for hip and vertebral fracture, which also did not reach statistical significance.7 A meta-analysis of 22 trials of estrogen reported an overall 27 percent reduction in nonvertebral fractures (relative risk [RR], 0.73; 95 percent CI, 0.56 to 0.94), although the quality of individual studies varied.8 The Heart and Estrogen/progestin Replacement Study (HERS) and its unblinded follow-up study, HERS II,9 a fair-quality trial of combined estrogen and progestin for the secondary prevention of heart disease that reported many other outcomes, found no reduction in hip, wrist, vertebral, or total fractures with hormone therapy (relative hazard [RH] for total fractures, 1.04; 95 percent CI, 0.87 to 1.25). Overall, a good-quality body of evidence supports the efficacy of hormone therapy for increasing bone density and decreasing fracture risk.
|The USPSTF grades the quality of the overall evidence for a service on a three-point scale (good, fair, or poor).|
|Good:||Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes.|
|Fair:||Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, or consistency of the individual studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes.|
|Poor:||Evidence is insufficient to assess the effects on health outcomes because of limited number or power of studies, important flaws in their design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.|
Results from the WHI study6 and HERS9 showed a trend toward reduced incidence of colon cancer, but the trend did not reach statistical significance (HR, 0.63; adjusted 95 percent CI, 0.32 to 1.24 and RH, 0.81; 95 percent CI, 0.46 to 1.45, respectively). The estrogen-only arm of the WHI trial showed neither benefit nor harm for colorectal cancer risk (HR, 1.08; adjusted 95 percent CI, 0.63 to 1.86).7 A meta-analysis of 18 observational studies of postmenopausal women reported a 20 percent reduction in colon cancer (RR, 0.80; 95 percent CI, 0.74 to 0.86) and a 19 percent reduction in rectal cancer (RR, 0.81; 95 percent CI, 0.72 to 0.92) among women who had ever used combined estrogen and progestin or estrogen alone compared with women who had never used hormone therapy.10 This decrease in risk was more apparent when current users were compared with those who had never used hormone therapy (RR, 0.66; 95 percent CI, 0.59 to 0.74). Overall, the evidence suggesting a trend toward reduction of colorectal cancer risk with combined hormone therapy should be interpreted cautiously until controlled trials clarify whether therapy has either no benefit or modest benefit.
HARMS OF HORMONE THERAPY
The estrogen and progestin arm of the WHI study was terminated after an average of 5.2 years of follow-up because, “evidence for breast cancer harm, along with evidence for some increase in CHD, stroke, and pulmonary embolism, outweighed the evidence of benefit for fractures and possible benefit for colon cancer.”6 This study showed an increased invasive breast cancer incidence (HR, 1.26; nominal 95 percent CI, 1.00 to 1.59). However, no effect on breast cancer mortality was observed. Comparable increases in breast cancer incidence were observed among women taking estrogen and progestin over 6.8 years of follow-up in HERS.9 The U.K. Million Women Study, a fair-quality study, showed an increased risk for breast cancer in current users of combined estrogen and progestin compared with those who had never used hormone therapy (RR, 2.00; 95 percent CI, 1.91 to 2.09).11 Results from two good-quality cohort studies conflict on the effects of long-term hormone therapy on breast cancer mortality.12,13 Overall, there is a good-quality body of evidence indicating that combined estrogen and progestin increases breast cancer risk. It is unclear whether the combination of estrogen and progestin confers a greater breast cancer risk than estrogen alone. In studies of estrogen alone, the results are conflicting: the Million Women Study showed an increased risk for breast cancer in current users of estrogen only when compared with those who had never used it (RR, 1.30; 95 percent CI, 1.22 to 1.38),11 but the estrogen-only arm of the WHI trial showed a trend toward breast cancer prevention (HR, 0.77; nominal 95 percent CI, 0.59 to 1.01).7
Coronary Heart Disease
In the WHI study, women who took combined estrogen and progestin daily, compared with women taking a placebo, had an increased risk for CHD (fatal and nonfatal myocardial infarctions), which became evident shortly after initiation of the study (HR, 1.29; nominal 95 percent CI, 1.02 to 1.63).6 However, mortality from CHD was not significantly increased among the women taking combined hormone therapy daily. One meta-analysis of observational studies showed a statistically significant reduction in CHD (RR, 0.80; 95 percent CI, 0.68 to 0.95) among current hormone therapy users but not among those who had used hormone therapy in the past or among those who had never used it.14 This meta-analysis also showed that CHD mortality in observational studies was reduced among current hormone therapy users (RR, 0.62; 95 percent CI, 0.40 to 0.90) but was not reduced among those who had used hormone therapy in the past. However, among studies that controlled for socioeconomic status (e.g., social class, education, or income), no CHD benefit was seen among current hormone therapy users, suggesting that the observed difference may be caused by confounding from socioeconomic status and other lifestyle factors (e.g., exercise, alcohol use) rather than use of hormone therapy. Thus, selection bias (in this case, the tendency of healthier women to use hormone therapy) appears to explain the apparent protective effect of estrogen against CHD seen in observational studies. The estrogen-only arm of the WHI trial showed no decreased risk for CHD.7
A meta-analysis of nine observational primary prevention studies suggests that hormone therapy is associated with a small increase in stroke incidence (RR, 1.12; 95 percent CI, 1.01 to 1.23), primarily caused by an increase in thromboembolic stroke (RR, 1.20; 95 percent CI, 1.01 to 1.40).14,15 The risk for subarachnoid bleeding and hemorrhagic stroke was not increased, and the overall stroke mortality was marginally reduced (RR, 0.81; 95 percent CI, 0.71 to 0.92). These results are consistent with findings from the WHI, which reported increased incidence of stroke in women taking combined estrogen and progestin daily (HR, 1.41; adjusted 95 percent CI, 0.86 to 2.31).6 The estrogen-only arm of the WHI trial, which was terminated after an average of 6.8 years of follow-up, showed a trend toward increased stroke risk with unopposed estrogen use (HR, 1.39; adjusted 95 percent CI, 0.97 to 1.99).7
Venous Thromboembolism (Deep Venous Thrombosis and Pulmonary Embolism)
In a meta-analysis of 12 studies (three randomized controlled trials, eight case-control studies, and one cohort study), hormone therapy (estrogen alone or in combination with progestin) was associated with an increased risk for venous thromboembolism (RR, 2.14; 95 percent CI, 1.64 to 2.81).16,17 Five of six studies that examined the effects of hormone therapy over time reported that the risk was highest within the first year of use (RR, 3.49; 95 percent CI, 2.33 to 5.59). These results are consistent with the findings in the estrogen and progestin arm of the WHI trial,6 which reported a twofold increase in the rate of venous thromboembolic disease, including deep venous thrombosis and pulmonary embolism, in women taking combined estrogen and progestin daily. The estrogen-only arm of the WHI trial showed a trend toward increased risk for venous thromboembolism with unopposed estrogen use (HR, 1.33; adjusted 95 percent CI, 0.86 to 2.08).7
Cognition and Dementia
While earlier studies showed a beneficial effect of hormone therapy on cognition, these studies had marked heterogeneity and variation in assessment of outcomes. For example, nine randomized, controlled trials examining the effect of hormone therapy on cognition in women showed improvement in verbal memory, vigilance, reasoning, and motor speed; however, these trials may have biased results because they were conducted with women experiencing menopausal symptoms at baseline. A meta-analysis of 12 observational studies (one of good quality, three of fair quality, and eight of poor quality) showed a reduction in the risk for dementia among postmenopausal women taking hormone therapy (RR, 0.66; 95 percent CI, 0.53 to 0.82).18 Because of issues of internal and external validity from these previous studies, the more recent, fair-quality WHI memory studies are more likely to represent the effects of hormone therapy use in the healthy postmenopausal population. The WHI memory study showed decreased global cognitive function (measured by the modified Mini-Mental State Examination) in women taking estrogen alone and in the pooled group of women taking estrogen alone or estrogen and progestin.19 The WHI memory study also showed an increased risk for probable dementia or mild cognitive impairment in both the estrogen-alone (HR, 1.38; 95 percent CI, 1.01 to 1.89) and estrogen and progestin (HR, 1.44; 95 percent CI, 1.04 to 1.99) arms of the trial.20 The overall evidence supports harmful effects of hormone therapy on cognitive function, although the clinical relevance of this difference in cognitive function is unclear.
Endometrial and Ovarian Cancer
Results of a meta-analysis of 29 good-quality, observational studies of endometrial cancer reported an RR of 2.3 for users of unopposed estrogen compared with nonusers.21 Risks increased with longer duration of use (RR, 9.5 for 10 years of use), and the risk for endometrial cancer remained elevated five or more years after discontinuation of unopposed estrogen therapy. Estrogen and progestin did not increase the risk for endometrial cancer in HERS5 or WHI.6
Data on the association between the use of hormone therapy and the risk for ovarian cancer are inconsistent. Two good-quality cohort studies reported increased risks for ovarian cancer or ovarian cancer mortality among women who had taken hormone therapy for 10 years or more22,23; however, a third study found no effect of hormone therapy on ovarian cancer mortality.24 One study suggested higher risk with unopposed estrogen than with estrogen and progestin therapy,22 but data are insufficient to resolve the effects of different formulations or doses of hormone therapy on ovarian cancer risk. Neither the WHI nor HERS reported risk for ovarian cancer.
Results from the Nurses’ Health Study, a good-quality cohort study, reported an increased risk for cholecystitis among current hormone therapy users and long-term users (longer than five years) compared with nonusers.25 Risk for cholecystitis remained elevated among past users. An increase in biliary tract surgery during 6.8 years of follow-up was reported among women taking estrogen plus progestin compared with those taking placebo in HERS9,26; the WHI has not reported on outcomes for biliary tract disease among women taking hormone therapy.
Combined estrogen and progestin may reduce the risk for fractures and colorectal cancer, but it has no beneficial effect on CHD. The use of combined estrogen and progestin may lead to increased risk for breast cancer, venous thromboembolism, stroke, cholecystitis, dementia, and lower global cognitive function. The excess absolute combined risks for CHD and breast cancer that can be attributed to hormone therapy are low; for example, according to WHI results, there would be seven more CHD events, eight more strokes, eight more pulmonary embolisms, and eight more cases of invasive breast cancer each year for every 10,000 women taking hormone therapy. The absolute risk reduction for every 10,000 women would be six fewer colorectal cancers and five fewer hip fractures. The evidence is insufficient to determine the effects of hormone therapy on the incidence of ovarian cancer, mortality from breast cancer or CHD, or all-cause mortality. Evidence about the effects of different dosages, types, and delivery modes of hormone therapy remains insufficient. Overall, the harmful effects of combined estrogen and progestin are likely to exceed the benefits of chronic disease prevention for most women.
Unopposed estrogen increases a woman’s risk for endometrial cancer; however, it has been used in postmenopausal women without a uterus to prevent chronic disease. Estrogen alone may decrease a woman’s risk for fractures, and it has no beneficial effect on CHD. The use of estrogen alone may lead to increased risk for thromboembolism, stroke, dementia, and lower global cognitive function. The evidence is insufficient to determine the effects of unopposed estrogen on the incidence of breast cancer, ovarian cancer, colorectal cancer, breast cancer mortality, or all-cause mortality. Overall, the harmful effects of unopposed estrogen are likely to exceed the chronic disease prevention benefits in most women.