By Dennis Thompson
The U.S. Preventive Services Task Force is standing by its original recommendation that women who have already gone through menopause should avoid using female hormones to guard against osteoporosis or diabetes, said task force chairman Dr. David Grossman, a senior investigator at the Kaiser Permanente Washington Health Research Institute in Seattle.
"Basically, the task force concluded there was no overall benefit from taking hormones to prevent chronic conditions," Grossman said. "There are some benefits, but we believe those potential benefits are outweighed by the harms, making this essentially no net benefit overall."
The advisory covers all formulations of hormone replacement therapy, the task force said. The therapy can consist of pills or patches containing either estrogen or an estrogen/progesterone mix.
However, women undergoing menopause can use hormone replacement therapy short-term to treat symptoms such as hot flashes and vaginal dryness, said Dr. Suzanne Fenske, an assistant professor of obstetrics, gynecology and reproductive science with the Icahn School of Medicine at Mount Sinai in New York City.
"Hormone replacement therapy does still have a benefit to women with menopause whose symptoms do not respond to other treatment options," Fenske said. "It really should be used to manage menopausal symptoms, rather than being used for any sort of preventative medicine."
The task force first recommended against hormone replacement therapy for postmenopausal women in 2012. It updates its recommendations every four years to make sure they reflect the latest medical evidence.
In its evidence review, the task force considered results from 18 clinical trials including more than 40,000 women.
All of the evidence suggests that combined estrogen and progesterone increase older women's risk of breast cancer and heart disease, while estrogen alone increases risk of stroke, blood clots and gallbladder disease, the task force said.
Those risks outweigh hormone therapy's benefits in preventing brittle bones and diabetes, the task force concluded.
"When hormone replacement therapy first was brought out on the market in the 1960s, it was touted as a way to keep feminine forever," Fenske said. "Then in the 1980s they began to see there were some potential benefits otherwise, like [preventing] osteoporosis.
"Then the infamous and famous Women's Health Initiative [WHI] study came out, which kind of put the kibosh on hormone replacement therapy," Fenske added.
Results from the WHI trials were published in the early 2000s; the trials were halted early after linking hormone therapy with increased risk of breast cancer, heart disease and stroke.
The updated task force recommendation contains the latest long-term follow-up data from the WHI trials, Grossman said.
"It didn't change our conclusion, but there is new information available that we incorporated into our evidence review," Grossman said.
Dr. Stephanie Faubion, director of the Mayo Clinic Office of Women's Health in Rochester, Minn., took issue with the task force's recommendation.
"I think this report is going to scare women," Faubion said. "Even those who are having symptoms and not excluded from hormone therapy according to this guideline are going to avoid it because they're afraid of it."
For example, the guideline does not apply to women who go through menopause early or prematurely, at age 45 or younger, Faubion said.
"Those women actually have adverse health consequences if they don't use hormone therapy at least until the natural age of menopause," Faubion said.
She said she also takes issue with a blanket recommendation covering all age groups.
"This is a key issue," Faubion said. "If you do break it down by age, there are more clear benefits for women in their 50s than women in their 60s and 70s.
"The task force is trying to make this more black-and-white than it can ever be," Faubion concluded.
Fenske said women in menopause suffering from hot flashes, vaginal dryness and other related symptoms can still safely turn to hormone therapy to ease their discomfort.
There are no clear guidelines for how long a menopausal woman can remain on hormone replacement therapy, or what dose is best for treating menopause symptoms, Fenske said. In large part, doctors are urged to be cautious because of the long-term health risks.
"It should be the smallest dose possible for the shortest period of time necessary," Fenske said.
Women interested in using hormone therapy to treat their menopause symptoms should talk with their doctor, because there is a lot of false and misleading information out there, Fenske said.
The task force recommendation was published online Dec. 12 in the Journal of the American Medical Association.