EXECUTIVE SUMMARY

The U.S. Preventive Services Task Force has issued a final recommendation statement and evidence summary upholding its earlier recommendation against use of hormone therapy for the primary prevention of chronic conditions in postmenopausal women.

  • The current recommendation is consistent with similar Task Force guidance issued in 2012.
  • The recommendation only applies to women who have gone through menopause and are considering hormone therapy to prevent chronic health problems. Women who are considering hormone therapy to manage menopausal symptoms, such as hot flashes or night sweats, are not included in the recommendation and should talk to clinicians about their options.

The U.S. Preventive Services Task Force has issued a final recommendation statement and evidence summary upholding its earlier recommendation against use of hormone therapy for the primary prevention of chronic conditions in postmenopausal women.1,2 The current recommendation is consistent with similar Task Force guidance issued in 2012.

The Task Force recommendation only applies to women who have gone through menopause and are considering hormone therapy to prevent chronic health problems, says Task Force member Maureen Phipps, MD, MPH, department chair and Chace-Joukowsky professor of obstetrics and gynecology and assistant dean for teaching and research on women’s health at the Warren Alpert Medical School of Brown University in Providence, RI. Women who are considering hormone therapy to manage menopausal symptoms, such as hot flashes or night sweats, are not included in this recommendation, she states.

Keep Focus on Menopausal Symptoms

Menopause occurs at a median age of 51.3 years. The average U.S. woman who reaches menopause is expected to live another 30 years.1 By 2020, statistics indicate there will be more than 50 million U.S. women who will be older than 51 years of age.3

While the prevalence and incidence of chronic conditions such as coronary heart disease, dementia, stroke, fractures, and breast cancer increase with age, it is uncertain what risk can be attributed to menopause alone.1

Since the 2002 publication of initial findings from the Women’s Health Initiative, the largest randomized controlled trial on the effects of menopausal hormone therapy conducted to date, use of menopausal hormone therapy has declined steeply among U.S. women. However, clarification of the study’s evidence indicates that for most women in their 50s or within one decade of the onset of menopause, hormone therapy is safe for initiation of treatment for menopausal symptoms.

Andrew Kaunitz, MD, University of Florida Term Professor and Associate Chairman of the Department of Obstetrics and Gynecology at the University of Florida College of Medicine-Jacksonville, expresses concern that the Task Force’s current recommendation against use of hormone therapy for chronic conditions will be misinterpreted as advising against its use for any purpose, including menopausal symptoms.

Clinicians’ understanding of hormone therapy’s benefits and risks has changed over the two decades, notes Kaunitz. Guidance to clinicians and women should reflect such changes, emphasizing the need for individualized care and shared decision-making, facilitating sound decisions regarding hormone therapy use, he says.

Review 2017 Position Statement

When it comes to appropriate use of hormone therapy for menopausal and postmenopausal women, clinicians may want to refer to the 2017 position statement on from the North American Menopause Society.5 According to the evidence-based review, hormone therapy remains the most effective treatment for vasomotor symptoms and the genitourinary syndrome of menopause. The risks of hormone therapy use vary depending on type, dose, duration of use, route of administration, timing of initiation, and whether a progestogen is used; clinicians should keep those risks in mind in individualizing care during lifespans.

For women 60 years of age and younger, or who are within 10 years of menopause onset and have no contraindications, the guidance states that the benefit-risk ratio is most favorable for initiation of treatment in women with bothersome vasomotor symptoms and those at elevated risk for bone loss or fracture. Initiation of therapy more than 10 or 20 years from menopause onset or at age 60 years or older is associated with a less favorable benefit-risk ratio because of heightened absolute risks of coronary heart disease, stroke, venous thromboembolism, and dementia. In the case of longer durations of therapy for such documented indications as persistent vasomotor symptoms or increased risk for osteoporosis, clinicians should perform periodic reevaluation and offer shared decision-making. Vaginal estrogen, or other nonestrogen therapies (oral ospemifene), or vaginal DHEA may be used at any age for prevention or treatment of the genitourinary syndrome of menopause, the guidance states.5

There now are a variety of approved systemic hormone therapy formulations, including lower doses, non-progestin therapy for women with a uterus, and transdermal routes of delivery, notes Kaunitz.

Although there is no conclusive evidence on the risk/benefit ratio for alternative formulations from randomized trials, Kaunitz points out that findings from observational studies indicate lower risks of venous thromboembolism with transdermal therapies compared with oral estrogen.5,6 

REFERENCES

  1. US Preventive Services Task Force, Grossman DC, Curry SJ, et al. Hormone therapy for the primary prevention of chronic conditions in postmenopausal women: US Preventive Services Task Force recommendation statement. JAMA 2017;318:2224-2233.
  2. Gartlehner G, Patel SV, Feltner C, et al. Hormone therapy for the primary prevention of chronic conditions in postmenopausal women: Evidence report and systematic review for the US Preventive Services Task Force. JAMA 2017;318:2234-2249.
  3. Manson JE, Kaunitz AM. Menopause management — getting clinical care back on track. N Engl J Med 2016;374:803-806.
  4. Rossouw JE, Manson JE, Kaunitz AM, Anderson GL. Lessons learned from the Women’s Health Initiative trials of menopausal hormone therapy. Obstet Gynecol 2013;121:172-176.
  5. The NAMS 2017 Hormone Therapy Position Statement Advisory Panel. The 2017 hormone therapy position statement of The North American Menopause Society. Menopause 2017;24:728-753.
  6. Kaunitz AM, Manson JE. Management of menopausal symptoms. Obstet Gynecol 2015;126:859-876.