US task force recommends against HRT prevention of chronic conditions, including osteoporosis

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Oct 17, 2002

US task force recommends against HRT prevention of chronic conditions,

including osteoporosis

Philadelphia, PA Following the results of the Women's Health Initiative

(WHI), the US Preventive Services Task Force (USPSTF) has updated its

guidelines on the use of hormone replacement therapy (HRT) and now

recommends against the routine use of combined estrogen and progestin

preparations for the prevention of chronic conditions in postmenopausal

women. The USPSTF's new recommendations on HRT are available on the websites

of ls of Internal Medicine and the Agency for Healthcare Research and

Quality and will be published in the November 19 issue of the ls of

Internal Medicine journal [1]. This includes the use of HRT for

osteoporosis, even though the results from the WHI provide the first solid

evidence that HRT reduces the risk of fractures.

The USPSTF says it found fair to good evidence that the combination of

estrogen and progestin has both benefits and harms. Benefits include

increased bone mineral density (good evidence), reduced risk for fracture

(fair to good evidence), and reduced risk for colorectal cancer (fair

evidence). Harms include increased risk for breast cancer (good evidence),

venous thromboembolism (good evidence), coronary heart disease (fair to good

evidence), stroke (fair evidence), and cholecystitis (fair evidence).

Evidence was insufficient to assess the effects of HRT on other outcomes,

such as dementia and cognitive function, ovarian cancer, mortality from

breast cancer or cardiovascular disease, or all-cause mortality.

Combined HRT: harmful effects likely to exceed benefits

The organization concluded that the harmful effects of estrogen and

progestin are likely to exceed the chronic disease prevention benefits in

most women. It did not evaluate the use of HRT to treat symptoms of

menopause, such as vasomotor symptoms or urogenital symptoms, and says the

balance of benefits and harms for an individual woman will be influenced by

her personal preferences, individual risks for specific chronic diseases,

and the presence of menopausal symptoms.

Insufficient evidence for unopposed estrogen

The USPSTF concludes that the evidence is insufficient to recommend for or

against the use of unopposed estrogen for the prevention of chronic

conditions in postmenopausal women who have had a hysterectomy. It says

likely benefits include increased bone mineral density, reduced fracture

risk, and reduced risk for colorectal cancer, and likely harms include

increased risk for venous thromboembolism, cholecystitis, and stroke but

that evidence is insufficient to determine the effects of unopposed estrogen

on the risk for breast and ovarian cancer, CHD, dementia and cognitive

function, or mortality. Better data on benefits and harms are expected from

ongoing randomized trials, including the WHI study of unopposed estrogen in

women who have had a hysterectomy.

Increased risk modest

Although concluding that the risks of combined estrogen-progestin therapy

are likely to outweigh the chronic disease prevention benefits, the USPSTF

notes that the absolute increase in risk from HRT is modest and that some

women, depending on their risk characteristics and personal preferences,

might decide that the benefits of taking HRT outweigh the potential harms.

Based on results reported from the WHI study, 10 000 women taking estrogen

and progestin for 1 year might experience 7 additional CHD events, 8 more

strokes, 8 more pulmonary emboli, and 8 more invasive breast cancers but

would also have 6 fewer cases of colorectal cancer and 5 fewer hip

fractures.

Clinicians should develop a shared decision-making approach to preventing

chronic diseases in perimenopausal and postmenopausal women, the USPSTF

says. This approach should consider individual risk factors and preferences

in selecting effective interventions for reducing the risks for fracture,

heart disease, and cancer. Clinicians should discuss with patients other

effective strategies for preventing osteoporosis and fractures.

The USPSTF further states that the 2 large randomized trials of HRT on which

most of these recommendations are based used a combination of daily

conjugated equine estrogen (CEE) and medroxyprogesterone acetate (MPA).

While other regimens may have different effects, until any 1 is shown to

have a favorable risk/benefit ratio, a cautious approach would be to avoid

using HRT routinely for the specific purpose of preventing chronic disease

in women.

Evidence is inconclusive to determine whether phytoestrogens (isoflavones

such as ipriflavone, which are found in soy milk, soy flour, tofu, and other

soy products) are effective for reducing the risk for osteoporosis or

cardiovascular disease, it adds.

Similar to recommendations from other organizations

These new guidelines are similar to those from other organizations, several

of which have already revised their recommendations in light of the findings

from recently reported clinical trials. The American College of

Obstetricians and Gynecologists and the North American Menopause Society now

recommend against the use of HRT for the primary or secondary prevention of

cardiovascular disease and recommend caution in using HRT solely to prevent

osteoporosis, suggesting that alternative therapies should also be

considered. Both organizations consider HRT an acceptable treatment option

for menopausal symptoms but caution against the prolonged use of HRT for the

relief of symptoms. The American Heart Association also now recommends

against the use of HRT for primary or secondary prevention of cardiovascular

disease.

Sue

Cited source

1. US Preventive Services Task Force. Postmenopausal hormone replacement

therapy for primary prevention of chronic conditions: Recommendations and

rationale. Ann Intern Med 2002; 137:834-839.