This series of fact sheets is based on the work of the U.S. Preventive Services Task Force (USPSTF). The USPSTF systematically reviews the evidence of effectiveness of a wide range of clinical preventive services—including screening, counseling, and chemoprevention (the use of medication to prevent diseases)—to develop recommendations for preventive care in the primary care setting.
This fact sheet presents highlights of USPSTF recommendations on this topic and should not be used to make treatment or policy decisions.
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The USPSTF recommends against the routine use of combined estrogen and progestin for the prevention of chronic conditions in postmenopausal women because the harms are likely to outweigh the benefits for most women.
Although the combination of estrogen and progestin increases bone mineral density, reduces the risk for fracture, and may reduce the risk for colorectal cancer, there is evidence that estrogen-progestin also increases the risk for blood clots in the veins, pulmonary embolism, breast cancer, stroke, coronary heart disease, and gallbladder disease.
Although the harms are likely to outweigh the benefits for most women, the USPSTF acknowledged that the harms are modest and that some women may decide the benefits outweigh the harms.
The USPSTF concludes that the evidence is insufficient to recommend for or against the use of estrogen alone for prevention of chronic conditions in postmenopausal women who have had a hysterectomy. Although current data from observational studies suggests that estrogen alone also has benefits and harms, the evidence is not sufficient to determine the exact balance of benefits and harms. The likely benefits are increased bone mineral density and reduced risk for fracture and colorectal cancer. The likely harms are increased risk for blood clots in the veins, gallbladder disease, and stroke. Estrogen alone increases the risk for uterine cancer in women who have not had a hysterectomy. The effects of estrogen alone on breast cancer and heart disease are not certain.
Long-term use of HRT has both benefits and harms.
In 1996, the USPSTF recommended that clinicians counsel all women about the potential benefits and harms of HRT, while stating that the evidence was insufficient to recommend for or against HRT for all women after menopause. The Task Force concluded in 1996 that HRT might have long-term benefits on osteoporosis and heart disease, but that it might increase the risk for breast cancer.
Although recent evidence confirmed that HRT reduces the risk for fractures and suggests that it reduces colorectal cancer, the evidence has also confirmed that HRT increases the risk for blood clots in the veins, breast cancer, and stroke. Most importantly, new evidence indicates that HRT does not reduce the risk for coronary heart disease and that combined estrogen and progestin (one of the most commonly prescribed forms of HRT) may actually increase the risk.
Hormone replacement therapy is one of the most commonly prescribed drug treatments for postmenopausal women in the United States. While many women take HRT for a limited time to reduce the acute symptoms of menopause (such as hot flashes, vaginal dryness, and mood and sleep disturbances), many women take HRT for years because they expect it to prevent osteoporosis, heart disease, and other chronic diseases.
Many new studies, including two large randomized trials, have been published that help clarify the benefits and harms of HRT—including evidence from the first large randomized trials of HRT—since the USPSTF released its recommendation on this topic in 1996.
The current USPSTF reviewed recent evidence on the effect of HRT by postmenopausal women on a variety of chronic diseases, including cardiovascular disease, osteoporosis, dementia, and cancer. The benefits of taking HRT to relieve the acute symptoms of menopause were not addressed in this USPSTF recommendation or by the evidence reviewed.
Relief of menopausal symptoms remains the most common reason for taking HRT, but it may not require long-term use of HRT. Clinicians should discuss the potential benefits and harms of long-term HRT, as well as the uncertainties in our current knowledge, with women who may be considering beginning or continuing HRT. This discussion should include alternatives to HRT for preventing and treating osteoporosis, as well as effective measures to reduce the risk for heart disease, cancer, and other chronic diseases.
The balance of benefits and harms of HRT may be different for an individual woman based on her preferences and the presence of underlying conditions. Many important questions remain about HRT, including effects of HRT on dementia and ovarian cancer, and the effects of taking estrogen without progestin. Ongoing randomized trials of HRT are due to report data within several years that should address some but not all of the uncertainties surrounding HRT.
Doctors should talk to their patients about the benefits and potential harms of long-term use of HRT.
For more information on hormone replacement therapy, contact the following organizations:
healthfinder®
http://www.healthfinder.gov
National Institutes of Health
http://www.nih.gov
AHRQ Publication No. APPIP03-0002
Current as of October 2002
Internet Citation:
Postmenopausal Hormone Replacement Therapy for Primary Prevention of Chronic Conditions. What's New from the USPSTF? AHRQ Publication No. APPIP03-0002, October 2002. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/3rduspstf/hrt/hrtwh.htm
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