USPSTF Reaffirms Recommendations Against Hormone Therapy for Primary Prevention in Postmenopausal Persons

Carol Mangione, MD, MSPH

The US Preventive Services Task Force (USPSTF) has finalized their latest recommendations related to use of hormone therapy for the primary prevention of chronic conditions in postmenopausal people, which includes recommendations against use of combined estrogen and progestin for primary prevention of chronic conditions in postmenopausal persons and against use of estrogen alone for primary prevention in postmenopausal persons who have had a hysterectomy.

Released on November 1, the latest recommendations represent the first update on the topic from the USPSTF since 2017 and both of the recommendations included in the latest iteration were awarded a D grade, which indicates moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

“For people who have already gone through menopause, using hormone therapy is not an effective way to prevent chronic conditions because the potential harms cancel out any potential benefit,” said Task Force chair Carol Mangione, MD, MSPH, chief of the Division of General Internal Medicine and Health Services Research at the University California, Los Angeles, in a statement from the USPSTF. “Fortunately, the Task Force has many other evidence-based recommendations on ways people can stay healthy as they age.”

Given the aging population and knowledge of chronic conditions, including cardiovascular disease, osteoporosis, cancer, and diabetes, becoming more common as people age, interventions for primary prevention of these conditions have the potential to have a major impact on public health efforts. With this in mind, hormone therapy has been propositioned as a potential avenue for primary prevention in postmenopausal persons and, as a result, has been the subject of 5 different USPSTF recommendation statements dating back to 2002.

With an interest in updating the evidence base used in their 2017 recommendation, investigators performed a systematic review of published data from the PubMed/MEDLINE, Cochrane Library, EMBASE, and trial registries from January 1, 2016, through October 12, 2021, with surveillance through July 2022. Investigators identified 20 trials and 3 cohort studies with populations of 39,145 and 1,155,410 individuals, respectively, for inclusion in their review.

In the review, investigators found use of hormone therapy in postmenopausal persons for primary prevention was associated with some benefits, such as a reduction in risk for diabetes and fractures, but also several safety concerns, including significantly increased risks of stroke, gallbladder disease, and some cancers.

From their assessment of magnitude of net benefit, the USPSTF made 2 conclusions with moderate certainty:

• The USPSTF concluded use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons with an intact uterus has no net benefit.
• The USPSTF concluded use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy has no net benefit.

“Importantly, this recommendation is only for people who are considering hormone therapy to prevent chronic conditions after going through menopause,” says Task Force member James Stevermer, MD, MSPH, medical director of University of Missouri Health Care Family Medicine–Callaway Physicians, in the aforementioned statement from the USPSTF. “Those who wish to manage symptoms of menopause with hormone therapy are encouraged to talk with their healthcare professional.”

In an accompanying editorial, Alison J. Huang, MD, MAS, and Deborah Grady, MD, MPH, both of the University of California San Francisco, offered their takeaways from the latest recommendations from the USPSTF through a historic perspective.

“For the fifth time, the USPSTF confirms that postmenopausal persons should not be encouraged to use menopausal hormone therapy on the grounds that it will preserve their long-term health and functioning,” wrote the pair. “No longer should patients use hormones to stave off the multidimensional consequences of natural menopause or aging. But neither should they be frightened away from considering using menopausal hormone therapy for distressing symptoms that emerge in midlife or reflexively urged to use other pharmacologic therapies that, realistically, are also likely to have long-term trade-offs.”

These articles, titled “Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons,” and “Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Persons Updated Evidence Report and Systematic Review for the US Preventive Services Task Force,”, were published in Journal of the American Medical Association.