More on HRT: Draft Recommendations Released

The U.S. Preventive Services Task Force (USPSTF) has issued draft recommendations for
postmenopausal hormone therapy for the primary prevention of chronic conditions, such as heart
disease, stroke, dementia, hip fracture, and breast cancer.¹ These recommendations were based on findings from a new study of 9 randomized, placebo-controlled trials conducted since 2002 that
retrospectively analyzed the role of hormone therapy for the prevention of chronic conditions.²
Most of the data used in the analysis came from the Women’s Health Initiative study.³
 

Combined estrogen and progestin is not recommended for the prevention of chronic
conditions in postmenopausal women aged 50 years and older, according to the USPSTF.¹ In
addition, the use of estrogen alone for the prevention of chronic conditions in postmenopausal
women who have had a hysterectomy is not recommended. These draft recommendations are for
the average-risk population. After menopause, the average life expectancy for women is 30 years.
During this time, a woman’s estimated risk for a chronic condition developing is 30% for
coronary heart disease, 22% for dementia, 21% for stroke, 15% for hip fracture, and 11% for
breast cancer.¹

The use of combined estrogen and progestin decreases the risk of fracture in
postmenopausal women (46 fractures prevented for every 10,000 person-years), but the net
benefit does not outweigh the increased risk of stroke, invasive breast cancer, dementia,
gallbladder disease, deep vein thrombosis, and pulmonary embolism that are associated with
combination hormone replacement therapy (HRT).² Use of estrogen alone also is associated with
a decreased risk of fracture in postmenopausal women (56 fractures prevented for every 10,000
person-years).² However, HRT with estrogen alone can increase the risk of stroke, deep vein
thrombosis, and gallbladder disease. Both types of HRTs have been associated with an increase
in urinary incontinence in previously asymptomatic women after 1 year; however, this finding
was based on data gathered through a self-administered questionnaire and needs further study.
 

These draft recommendations come on the heels of another re-analysis of the WHI, which
found that there are some modest benefits to HRT but that its use should be limited to specific
patient populations.⁴

Pertinent Points:
- Estrogen with progestin and estrogen alone decrease risk of fractures but increases risk of
stroke, thromboembolic events, gallbladder disease, and urinary incontinence.
- Estrogen plus progestin increases risk of breast cancer and probable dementia.
- Estrogen alone decreases risk of breast cancer.
 

References:

References 1. U.S. Preventive Services Task Force. Menopausal Hormone Therapy for the Primary Prevention of Chronic Conditions: U.S. Preventive Services Task Force Recommendation Statement (Draft). Available at: http://www.uspreventiveservicestaskforce.org/draftrec.htm. Accessed June 7, 2012. 2. Nelson HD, Walker M, Zakher B, Mitchell J. Menopausal hormone therapy for the primary prevention of chronic conditions: a systematic review to update the U.S. Preventive Services Task Force Recommendations. Ann Intern Med. May 28, 2012. [Epub ahead of print.] 3. Writing Group for the Women’s Health Initiative Investigators. Risks and benefits of estrogen plus progestin in healthy postmenopausal women: principal results from the Women’s Health Initiative randomized controlled trial. JAMA. 2002;288:321-333. 4. Special edition on Women’s Health Initiative and HRT. Climacteric. 2012;15:205-293.