Panel rules against HRT for preventing chronic disease

23 oct 2012—Postmenopausal women should not use hormone replacement therapy to prevent chronic medical conditions such as heart disease, according to updated recommendations from the U.S. Preventive Services Task Force.

For the update, published online Oct. 23 in the Annals of Internal Medicine, the independent panel of experts reviewed more than 50 articles published since 2002 about estrogen-progestin therapy and estrogen alone for prevention of heart disease, dementia, osteoporosis and other chronic conditions. It recommends against their use for all because of the increased risk of other conditions including stroke.

However, the statement does not address use of hormone replacement therapy, or HRT, for short-term relief of menopausal symptoms such as hot flashes and vaginal dryness.

"The task force does not address treatment, so we do not make recommendations about menopausal symptoms," said Dr. Virginia Moyer, chair of the task force.

The report essentially echoes the task force's 2005 guidelines, while taking into account the more recent research. "It was updated as part of our routine to make sure the data were current," Moyer said.

The debate about the risks and harms of hormone therapy is ongoing. Years ago, hormone therapy was often prescribed to prevent chronic conditions such as osteoporosis and cardiovascular disease. But initial results of the Women's Health Initiative study, published in 2002, found harmful effects for estrogen-plus-progestin therapy. These included increased risk of heart disease and multiple other problems.

Two years later, serious concerns about estrogen-only therapy—often used after a hysterectomy— were also raised.

Here are highlights of the current report:

• Although hormone therapy is of moderate benefit in reducing the risk of osteoporosis-related fractures, that benefit is outweighed by the harms, including an increased risk for stroke, gallbladder disease and urinary incontinence.
• Convincing evidence connects hormone therapy with a small increased risk of breast cancer, and blood clots in the limbs and lungs.
• Estrogen and progestin combined increased risk for probable dementia.
• Hormone therapy appears to have no protective effect against heart disease and likely increases the risk, the task force said.

The updated recommendations are in line with those of many major health organizations, including the American Heart Association, the American Congress of Obstetricians and Gynecologists and the American Academy of Family Physicians.

One expert said the updated recommendations reflect current practice and won't change how he counsels patients.

"We currently aren't using it for chronic disease," said Dr. Michael Nimaroff, vice chair of obstetrics and gynecology at North Shore University Hospital of the LIJ Health System in Great Neck, N.Y., who was not involved with the report.

For certain chronic conditions, he said, hormone therapy may do more harm than good.

For women seeking short-term hormone therapy to relieve symptoms, he said, "we try the lowest dose possible to treat the symptom."

Nimaroff said he and many doctors believe taking hormone therapy for short-term symptom relief for less than five years is reasonable. "But we can't say that it is without risk," he added.

"We really try to discourage women from taking it for long periods of time," he said. "There is clearly a dose response."

Moyer said other experts are researching effective management of menopausal symptoms. That information is expected out in the near future. 

More information: To learn more about the recommendations, visit the U.S. Preventive Services Task Force.