Steer clear of offering hormone therapy as primary prevention for chronic conditions, the U.S. Preventive Services Task Force (USPSTF) advised in an update to its 2017 recommendation.
After reviewing new evidence, the Task Force felt with "moderate certainty" that the use of combined estrogen and progestin has no net benefit for the primary prevention of chronic conditions in postmenopausal people (grade D recommendation), reported Carol Mangione, MD, MSPH, of the University of California Los Angeles, and colleagues in JAMA.
Also in line with the 2017 recommendations, the Task Force recommended against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy (grade D recommendation).
The updated guideline is largely congruent with those from several other medical organizations, including the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, and the North American Menopause Society.
Instead of hormone therapy (oral or transdermal), the USPSTF said to reference their other prior recommendations on how to prevent cardiovascular disease and other chronic conditions in adulthood. Regular screenings are a common prevention strategy, the group suggested, including screening for breast cancer, colorectal cancer, osteoporosis, high blood pressure, plus prediabetes and type 2 diabetes.
Although the incidence of many of these conditions increases with age, the Task Force pointed out that the average American who reaches menopause at the median age of 51.3 is still expected to live another 30 years.
The updated recommendations only apply to asymptomatic postmenopausal individuals considering hormone therapy to prevent chronic conditions and not for those who experienced premature menopause due to primary ovarian insufficiency or surgically induced menopause. They also don't apply to women who are trying to manage menopause-related symptoms like hot flashes.
This is an important distinction because "despite the efforts of the USPSTF to draw a clear distinction between MHT [menopausal hormone therapy] for prevention vs symptom management, many patients and clinicians conflate these two different indications," wrote Alison J. Huang, MD, MAS, and Deborah Grady, MD, MPH, both of the University of California San Francisco, in an accompanying editorial.
"The notion that 'the net harms of MHT outweigh the benefits,' originally intended to explain the limitations of MHT for routine prevention, is now widely adopted as a rationale for forgoing MHT for symptomatic treatment," they explained.
Huang and Grady said that instead of confirming yet again that hormone therapy shouldn't be used for chronic condition prevention, the USPSTF should instead shift its focus toward developing guidance on which menopausal patients would benefit from this therapy for symptom prevention.
"No longer should patients use hormones to stave off the multidimensional consequences of natural menopause or aging," Huang and Grady stated. "But neither should they be frightened away from considering using MHT for distressing symptoms that emerge in midlife or reflexively urged to use other pharmacologic therapies that, realistically, are also likely to have long-term tradeoffs."
The update was based on a systematic review of 21 randomized clinical trials and three cohort studies. According to studies looking at individuals using estrogen plus progestin compared with placebo, there was a significantly lower risk seen for colorectal cancer over 5.6 years, diabetes over 5.6 years, and fractures over 5 years. However, this was offset by a significantly higher risk for other conditions, such as invasive breast cancer, gallbladder disease, stroke, venous thromboembolism (VTE), probable dementia, and urinary incontinence.
Following a similar pattern, those using estrogen alone also saw a significantly lower risk for developing diabetes and fractures over a 7-year follow-up. The harms also outweighed the benefits with estrogen-only therapy, as there was a significantly greater risk for developing gallbladder disease, stroke, VTE, and urinary incontinence.
Disclosures
The USPSTF is supported by the Agency for Healthcare Research and Quality.
Huang and Grady disclosed no relationships with industry.
Primary Source
JAMA
Source Reference: USPSTF "Hormone therapy for the primary prevention of chronic conditions in postmenopausal persons" JAMA 2022; DOI: 10.1001/jama.2022.18625.
Secondary Source
JAMA
Source Reference: Huang AJ and Grady D "Menopausal hormone therapy for prevention of chronic conditions: when is enough, enough?" JAMA 2022; DOI: 10.1001/jama.2022.19098.
Additional Source
JAMA
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