#376 Hormone Therapy for Primary Prevention of Chronic Conditions in Postmenopausal Persons – a USPSTF update with Dr. Carol Mangione

January 11, 2023 | By Elena Gibson

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We have better tools for prevention, but let’s talk!

Should we be offering hormone therapy for primary prevention in postmenopausal patients?  Dr. Carol Mangione (UCLA) talks us through the potential benefits and harms, and explains how this can be a jumping off point for important conversations about preventive care.

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Credits

• Producers, Hosts: Elena Gibson MD and Paul Williams MD, FACP
• Writer, Infographic, and Cover Art: Elena Gibson MD
• Show notes: Paul Williams MD, FACP
• Reviewer: Molly Heublein MD
• Production team: Podpaste
• Guest: Carol Mangione MD

Hormone Therapy for Primary Prevention of Chronic Conditions in Postmenopausal Persons

What are the updated recommendations?

• The USPSTF recommends against the use of combined estrogen and progestin for the primary prevention of chronic conditions in postmenopausal persons (Grade D, discourage use of this service)
• The USPSTF recommends against  the use of estrogen alone for the primary prevention of chronic conditions in postmenopausal women who have had a hysterectomy (Grade D, discourage use of this service)

What’s the fine print?

• While there are potential benefits for using hormone therapy to prevent certain health issues, the potential harms cancel out these benefits
  • The moderate harms of estrogen plus a progestin  include increased risk of invasive breast cancer, stroke, venous thromboembolism, dementia, gallbladder disease, and urinary incontinence
  • The moderate harms of estrogen alone include increased risk of increased stroke, venous thromboembolism, gallbladder disease, and urinary incontinence
• The Women’s Health Initiative is the major study that informed these recommendations (Rossouw 2002)
  •  It looked at conjugated estrogens (Premarin) with or without medroxyprogesterone (Provera)
• This recommendation is specifically regarding using hormone therapy to prevent disease, and not at the use of hormone therapy to treat specific health conditions, such as menopausal symptoms
  • When treating menopausal symptoms, the recommendations are generally using the lowest dose for the shortest period of time (ACOG Practice Bulletin 2014)
• Specifically, the USPSTF did not find evidence to support a benefit of cardiovascular disease prevention
  • There is moderate benefit for reducing fractures, and small benefit in reducing risk of diabetes and colon cancer – BUT, we have safer choices to reduce these risks
• It’s worth noting that the participants in the Women’s Health Initiative were somewhat homogeneous
  • As a result, there is an evidence need to study higher risk groups in the future, such as those that experience systemic racism or poverty

How is this different from the last recommendation?

• This is not significantly different from the 2017 recommendation
• Guidelines are typically re-examined every five years, and this did allow for longer-term follow up for the outcomes of interest, and included review of several more studies that reinforced this recommendation

How can this be incorporated into practice?

• These recommendations can be used to have conversations about the effective tools we have for the prevention of conditions such as cardiovascular disease and colorectal cancer

Links

1. USPSTF Final Recommendation Statement: Hormone Therapy in Postmenopausal Persons: Primary Prevention of Chronic Conditions
2. JAMA 2022 evidence report and systematic review for this guideline 
3. JAMA 2022 recommendation statement for this guideline

Goal

Listeners will explain the USPSTF recommendation regarding the use of hormone therapy for the primary prevention of chronic health conditions in postmenopausal persons.

Learning objectives

After listening to this episode listeners will…  

1. Become familiar with the USPSTF recommendation regarding the use of hormone therapy for the primary prevention of chronic health issues
2. Describe the theoretical benefits that may be associated with hormone therapy for primary prevention
3. Recognize the moderate harms associated with chronic hormone therapy use
4. Utilize these recommendations to have important conversations with their patients regarding evidence-based preventive care

Disclosures

Dr. Mangione reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

 Gibson E, Williams PN, and Mangione E. “#TBD Hormone Therapy for Primary Prevention of Chronic Conditions Postmenopausal Persons – a USPSTF update with Dr. Carol Mangione”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list January 4, 2023.