USPSTF Hormone Therapy Recommendations

The use of combined estrogen and progestin has no net benefit for the primary prevention of chronic conditions in postmenopausal persons, the U.S. Preventive Services Task Force (USPSTF) has advised in its update to the 2017 recommendation.

The USPSTF in its report published in JAMA, also recommends against the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy. (D recommendation)

For updating its 2017 recommendation, the USPSTF commissioned a systematic review to assess the harms and benefits of systemic (i.e., oral or transdermal) hormone therapy for the prevention of chronic conditions in postmenopausal persons. They also strive to determine whether outcomes vary by age or by the timing of intervention after menopause.

Menopause is defined as the cessation of the menstrual cycle; it is defined retrospectively, 12 months after the final menstrual period. Perimenopause, or the menopausal transition, is the few-year time period preceding the final menstrual period of a person and is characterized by increasing variability of menstrual cycle length and amenorrhea periods, and often symptoms such as vasomotor dysfunction.

The prevalence and incidence of most chronic diseases increase with age, and US persons who reach menopause are expected on average to live more than another 30 years, Carol Mangione, the University of California Los Angeles, and colleagues reported.

The updated guideline is harmonious with those from several other medical organizations, including:

• The American Academy of Family Physicians
• The North American Menopause Society
• The American College of Obstetricians and Gynecologists

The updated recommendations apply to asymptomatic postmenopausal persons who are considering hormone therapy for the primary prevention of chronic medical conditions. They also don't apply to women who are trying to manage menopause-related symptoms like hot flashes.

The updated recommendation was based on a systematic review of 21 randomized clinical trials and three cohort studies. There was a significantly lower risk seen for:

• Colorectal cancer over 5.6 years
• Diabetes over 5.6 years
• Fractures over 5 years in individuals using estrogen plus progestin compared with placebo

However, this was offset by a significantly higher risk for other conditions, such as:

• Invasive breast cancer
• Stroke
• Venous thromboembolism (VTE)
• Gallbladder disease
• Probable dementia
• Urinary incontinence

Over a 7-year follow-up, those using estrogen alone also saw a significantly lower risk of developing fractures and diabetes. The harms also outweighed the benefits of estrogen-only therapy, as there was a significantly greater risk of developing:

• Gallbladder disease
• Stroke
• VTE
• Urinary incontinence

The USPSTF concluded with moderate certainty that combined estrogen and progestin use for the primary prevention of chronic conditions in postmenopausal persons with an intact uterus has no net benefit.

The USPSTF concludes with moderate certainty that the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy has no net benefit.

Reference

US Preventive Services Task Force. Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons: US Preventive Services Task Force Recommendation Statement. JAMA. 2022;328(17):1740–1746. doi:10.1001/jama.2022.18625