Rockville, MD—In an update of 2017 guidance, the USPSTF once again recommended against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal women.
The individual panel of medical experts also cautioned about the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy. The recommendations were published recently in the Journal of the American Medical Association.
"Now in 2022, after additional review of only 2 additional modest-sized trials as well as ancillary analyses of previous trials, the USPSTF has, for the fifth time, reiterated its guideline. After all this time, some may wonder why a repeat statement of this same recommendation is necessary. Isn't enough, enough" asks an accompanying editorial. "Are there still clinicians who believe, despite the preponderance of evidence to the contrary, that MHT [menopausal hormone therapy] offers a net preventive benefit for postmenopausal persons? Do any important questions about MHT as a preventive intervention remain?"
The two University of California San Francisco commentators, Alison J. Huang, MD, MAS, and Deborah Grady, MD, MPH, responded, "Arguably not. Some menopausal women and their clinicians continue to ask whether MHT may offer preventive benefits in younger postmenopausal patients, even if the net harms outweighed benefits for older women such as those enrolled in the WHI [Women's Health Initiative] and similar trials. Most of these persistent questions center on the potential implications of timing of MHT, namely, whether the use of hormones in the first few years after menopause may offer beneficial preventive effects, even if continued use more than 5 or 10 years after menopause may result in net harm. But as the updated review of evidence supporting the 2022 USPSTF recommendation update indicates, there is little rigorous evidence to support this timing hypothesis."
To update its 2017 recommendation, the USPSTF commissioned a systematic review to evaluate the benefits and harms of systemic (i.e., oral or transdermal) hormone therapy for the prevention of chronic conditions in postmenopausal women. They also sought to find out if vary by age or by timing of intervention after menopause.
"The USPSTF concludes with moderate certainty that the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons with an intact uterus has no net benefit," according to the guidelines. "The USPSTF concludes with moderate certainty that the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal persons who have had a hysterectomy has no net benefit."
Drs. Huang and Grady suggested it is time the UPSTF and others move on. "With this most recent update of the USPSTF guidelines, the scientific and medical community should let go of the past," they advised. "Instead of investing additional resources into trying to parse out subsets of menopausal patients who may derive some preventive benefit from MHT for a limited amount of time, research should focus on developing more thoughtful guidance for individual decision-making about MHT for menopausal symptoms and conducting more rigorous and extended follow-up of other medications used to treat menopausal symptoms."
They added, "Strategies are also needed for starting MHT for symptom management in early menopause but then weaning down therapy when the absolute risks of other chronic diseases affected by therapy are known to increase."
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