USPSTF advises against hormone therapy to prevent chronic conditions after menopause

The U.S. Preventive Services Task Force has released two final recommendations on the use of hormone therapy for the primary prevention of chronic conditions in postmenopausal people.

The recommendations advocate against the use of menopausal hormone therapy (MHT) through a combination of estrogen and progestin in postmenopausal people, and MHT through estrogen alone in postmenopausal people who have had a hysterectomy.

Both are D-grade recommendations, and are consistent with the USPSTF’s previous recommendations on the treatment made back in 2017.

“For people who have already gone through menopause, using hormone therapy is not an effective way to prevent chronic conditions because the potential harms cancel out any potential benefit,” USPSTF Chair Carol Mangione, MD, MSPH, said in a press release.

James Stevermer, MD, MSPH, a task force member, also noted in the press release that the recommendations are only for those who are considering hormone therapy to prevent chronic conditions following menopause.

“Those who wish to manage symptoms of menopause with hormone therapy are encouraged to talk with their health care professional,” he said.

Additionally, the recommendations do not apply to those who have had premature menopause or surgical menopause, according to the USPSTF’s statement.

In the evidence report, Gerald Gartlehner, MD, MPH, a senior health research analyst at RTI International, based in North Carolina, and colleagues conducted an analysis of 20 trials (n = 39,145) — 17 of which were conducted in the U.S. — and three cohort studies (n = 1,155,410).

Compared with placebo, the researchers found that participants using estrogen-only MHT experienced lower risks per 10,000 persons of diabetes over 7.1 years (1,050 vs. 903 cases; 134 fewer cases; 95% CI, 18-237) and fractures of 7.2 years (1,413 vs. 1,024 cases; 388 fewer cases; 95% CI, 277-489).

However, compared with participants who received placebo, risks per 10,000 persons for participants on estrogen only increased significantly for:

• gallbladder disease over 7.1 years (1,113 vs 737 cases; 377 more cases; 95% CI, 234-540);
• urinary incontinence over 1 year (2,331 vs. 1,446 cases; 885 more cases; 95% CI, 659-1,135);
• stroke over 7.2 years (318 vs. 239 cases; 79 more cases; 95% CI, 15-159); and
• venous thromboembolism over 7.2 years (258 vs. 181 cases; 77 more cases; 95% CI, 19-153).

Compared with placebo cases, participants on a combination of estrogen and progestin MHT saw lower risks per 10,000 persons for diabetes over 5.6 years (403 vs. 482 cases; 78 fewer cases; 95% CI, 15-133), colorectoral cancer over 5.6 years (59 vs. 93 cases; 34 fewer cases; 95% CI, 9-51), and fractures over 5 years (864 vs. 1,094 cases; 230 fewer cases; 95% CI, 66-372), though experienced significant increased risks for:

• invasive breast cancer over 5.6 years (242 vs. 191 cases; 51 more cases; 95% CI, 6-106);
• gallbladder disease over 5.6 years (723 vs. 463 cases; 260 more cases; 95% CI, 169-364);
• stroke over 5.6 years (187 vs. 135 cases; 52 more cases; 95% CI, 12-104);
• venous thromboembolism over 5.6 years (246 vs. 126 cases; 120 more cases; 95% CI, 68-185);
• probable dementia over 4 years (179 vs. 91 cases; 88 more cases; 95% CI, 15-212); and
• urinary incontinence over 1 year (1,707 vs. 1,145 cases; 562 more cases; 95% CI, 412-726).

In a related editorial, Alison J. Huang, MD, MAS, a professor of medicine at the University of California, San Francisco, and Deborah Grady, MD, MPH, a professor of medicine and of epidemiology and biostatistics at UCSF, questioned the need for continued recommendations on hormonal treatment for chronic disease prevention in postmenopausal people, citing five MHT statements in the past 2 decades.

“Most of these persistent questions center on the potential implications of timing of MHT, namely, whether the use of hormones in the first few years after menopause may offer beneficial preventive effects, even if continued use more than 5 or 10 years after menopause may result in net harm,” Huang and Grady wrote, noting newly added studies in the evidence report provide little evidence to solidify the hypothesis.

“Instead of investing additional resources into trying to parse out subsets of menopausal patients who may derive some preventive benefit from MHT for a limited amount of time, research should focus on developing more thoughtful guidance for individual decision-making about MHT for menopausal symptoms and conducting more rigorous and extended follow-up of other medications used to treat menopausal symptoms,” they concluded.

References:

• Gartlehner G, et al. JAMA. 2022.doi:10.1001/jama.2022.18324
• Huang, A and Grady, D. JAMA. 2022;doi:10.1001/jama.2022.19098
• Mangione C, et al. JAMA. 2022;doi:10.1001/jama.2022.18625
• Task force issues final recommendation statement on hormone therapy for preventing chronic conditions in postmenopausal people. https://www.uspreventiveservicestaskforce.org/uspstf/sites/default/files/file/supporting_documents/hormone-therapy-postmenopause-final-rec-bulletin.pdf. Published Nov. 1, 2022. Accessed Nov. 1, 2022.