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Postmenopausal Women With Hysterectomy Should Not
Take Estrogen
The U.S. Preventive Services Task Force issued a new
recommendation against the routine use of estrogen by older women
May 17,2005 A government task force that in 2002
found insufficient evidence against the routine use of estrogen by
post-menopause, post-hysterectomy women has now changed its collective
mind. Today they will publish a new recommendation against the routine
use of estrogen to prevent chronic conditions, such as heart disease,
stroke and osteoporosis.
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Recommendations Summary |
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The U.S. Preventive Services Task Force
(USPSTF) recommends against the routine use of combined estrogen
and progestin for the prevention of chronic conditions in
postmenopausal women.
Rationale: The USPSTF found good evidence that the use of
combined estrogen and progestin results in both benefits and
harms.
Benefits include reduced risk for fracture (good
evidence) and colorectal cancer (fair evidence).
Combined estrogen and progestin has no beneficial
effect on coronary heart disease and may even pose an increased
risk (good evidence).
Other harms include increased risk for breast
cancer (good evidence), venous thromboembolism (good evidence),
stroke (fair evidence), cholecystitis (fair evidence), dementia
(fair evidence), and lower global cognitive function (fair
evidence).
Because of insufficient evidence, the USPSTF could
not assess the effects of combined estrogen and progestin on the
incidence of ovarian cancer, mortality from breast cancer or
coronary heart disease, or all-cause mortality.
The USPSTF concluded that the harmful effects of
combined estrogen and progestin are likely to exceed the chronic
disease prevention benefits in most women.
The USPSTF recommends against the
routine use of unopposed estrogen for the prevention of chronic
conditions in postmenopausal women who have had a hysterectomy.
Rationale: The USPSTF found good evidence that the use of
unopposed estrogen results in both benefits and harms.
The benefits include reduced risk for fracture
(good evidence).
Harms include increased risk for venous
thromboembolism (fair evidence), stroke (fair evidence),
dementia (fair evidence), and lower global cognitive functioning
(fair evidence).
There is fair evidence that unopposed estrogen has
no beneficial effect on coronary heart disease.
Because of insufficient evidence, the USPSTF could
not assess the effects of unopposed estrogen on the incidence of
breast cancer, ovarian cancer, or colorectal cancer as well as
breast cancer mortality or all-cause mortality.
The USPSTF concluded that the harmful effects of
unopposed estrogen are likely to exceed the chronic disease
prevention benefits in most women. |
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This recommendation is based on recent evidence
from the National Institutes of Healths Womens Health Initiative
clinical trial and other studies. The new Task Force recommendation is
being published today in the Annals of Internal Medicine.
In 2002, the Task Force found insufficient evidence
to recommend for or against the routine use of estrogen alone to prevent
chronic conditions in women who have completed menopause and had a
hysterectomy. Now, after reviewing new findings from the Womens Health
Initiative, the Task Force noted that, although estrogen can have
positive effects such as reducing the risk for fractures, hormone
therapy should not be used routinely because it appears to increase
womens risk for potentially life-threatening clots that block blood
vessels (venous thromboembolism), stroke, dementia and mild cognitive
impairment.
The Task Force noted that while the use of estrogen
reduces the risk for fracture, drugs such as bisphosphonates and
calcitonin are available and effective in helping prevent fractures in
women diagnosed with osteoporosis.
The Task Force concluded that for most women, the
harmful effects of estrogen therapy outweigh any benefits for fracture
and other chronic conditions.
In addition, the Task Force reaffirmed its earlier
recommendation against the routine use of combined estrogen and
progestin for preventing chronic conditions in postmenopausal women.
Although the combination therapy may reduce risk
for fractures in women diagnosed with osteoporosis and for colorectal
cancer, it has no beneficial effect on heart disease and may even put
women at greater risk for the condition.
Other potential harms of combined estrogen and
progestin include increased risk for breast cancer, venous
thromboembolism, inflammation of the gallbladder, dementia and mild
cognitive impairment. The Task Force concluded that the harmful effects
of combined estrogen and progestin are likely to exceed the chronic
disease prevention benefits for most women.
The available studies have shown that hormone
replacement therapy should not be used to prevent heart disease, cancer,
and bone fractures, said Task Force Chair Ned Calonge, M.D., who is
also Chief Medical Officer and State Epidemiologist for the Colorado
Department of Public Health and Environment. Women should use a shared
decisionmaking approach with their clinicians to decide how best to
prevent these conditions.
AHRQ Director Carolyn M. Clancy, M.D., agreed.
These recommendations expand the evidence base physicians depend on to
deliver good quality medical care that meets the needs of individual
patients, she said. The evidence can also help women become better
informed patients and decide with their clinicians what alternatives are
available to prevent these chronic diseases.
The Task Force did not examine the effects of
estrogen only or combined estrogen and progestin for the treatment of
menopausal symptoms, only for the prevention of chronic disease.
Menopause occurs in most women in the United States
between 41 to 59 years of age, although the bodys production of
estrogen and progestin may begin to decrease years before.
The average woman going through menopause has a 46
percent likelihood of developing heart disease over her lifetime, a 20
percent likelihood of stroke, a 15 percent likelihood of bone fracture,
and a 10 percent chance of developing breast cancer.
The Task Force, which is supported by AHRQ, is the
leading independent panel of private-sector experts in prevention and
primary care. Its recommendations are considered the gold standard for
clinical preventive services. It conducts rigorous, impartial
assessments of the scientific evidence for a broad range of preventive
services.
The Task Force grades the strength of its evidence from A (strongly
recommends), B (recommends), C (no recommendation for or against),
(D recommends against), or I (insufficient evidence to recommend for
or against). The Task Force recommends against the routine use of
unopposed estrogen for the prevention of chronic conditions in
postmenopausal women who have had a hysterectomy (a D recommendation).
The Task Force recommends against the routine use of combined estrogen
and progestin for the prevention of chronic conditions in postmenopausal
women (a D recommendation).
The recommendations and materials for clinicians
is available on the AHRQ Web site at
http://www.ahrq.gov/clinic/uspstf05/ht/htpostmenrs.htm.
Previous Task Force recommendations, including
screening for osteoporosis, high blood pressure, breast cancer,
colorectal cancer and lipid disorders, and summaries of the evidence and
related materials from the AHRQ Publications Clearinghouse by calling
(800) 358-9295 or sending an e-mail to
ahrqpubs@ahrq.gov. Clinical information is also available from
AHRQs National Guideline Clearinghouse at
http://www.guideline.gov.
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