The recommendations that follow are those from the guideline’s executive summary; detailed recommendations can be found in the original guideline document. Each recommendation is rated based on the level of the evidence and the grades of recommendation. Definitions of the grades of the recommendations (A, B, C, Good Practice Points [GPP]) and level of the evidence (Level I–Level IV) are presented at the end of the Major Recommendations field.
A – Hormone replacement therapy (HRT) is recommended for the short-term control of vasomotor symptoms, vaginal dryness, and urinary symptoms in menopause. (Grade A, Level Ib)
C - Combination HRT should not be used to reduce the risk of osteoporosis and subsequent fractures if it is the only indication for starting hormone replacement therapy. Alternatives such as bisphosphonates (Black et al., 1996) and raloxifene (Ettingeter et al., 1999) should instead be considered. (Grade C, Level IV)
A - HRT should not be used for primary or secondary prevention of heart disease. (Grade A, Level Ib)
C - Prevention of colorectal cancer should not be the reason for long-term hormone replacement therapy. (Grade C, Level IV)
A - HRT is not recommended for the prevention of Alzheimer’s disease or dementia. (Grade A, Level Ib)
A - The use of unopposed HRT in a woman with an intact uterus has been shown to increase the risk of endometrial cancer by several fold (Chlebowski et al., 2003; Shields et al., 1999). Therefore combined hormone replacement therapy should be used in patients with intact uteri. (Grade A, Level Ia)
C - HRT is the cornerstone in the management of patients with premature menopause. It is effective in the relief of menopausal symptoms and protects against the long-term risks associated with prolonged estrogen deficiency ("Risks and benefits of estrogen," 2002; Davis, 1996; Willhite & O’Connell, 2001; Cardozo et al, 1998). (Grade C, Level IV)
Grades of Recommendations
Grade A (evidence levels Ia, Ib): Requires at least one randomised controlled trial as part of the body of literature of overall good quality and consistency addressing the specific recommendation.
Grade B (evidence levels IIa, IIb, III): Requires availability of well conducted clinical studies but no randomised clinical trials on the topic of recommendation.
Grade C (evidence level IV): Requires evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities. Indicates absence of directly applicable clinical studies of good quality.
GPP (good practice points): Recommended best practice based on the clinical experience of the guideline development group.
Levels of Evidence
Level Ia: Evidence obtained from meta-analysis of randomised controlled trials
Level Ib: Evidence obtained from at least one randomised controlled trial
Level IIa: Evidence obtained from at least one well-designed controlled study without randomisation
Level IIb: Evidence obtained from at least one other type of well-designed quasi-experimental study
Level III: Evidence obtained from well-designed nonexperimental descriptive studies, such as comparative studies, correlation studies and case studies
Level IV: Evidence obtained from expert committee reports or opinions and/or clinical experiences of respected authorities
