Government panel just says no to hormone replacement therapy
In recent months, the US Preventive Services Task Force (USPSTF) has taken stands on medical issues that have sparked significant controversy. Last week, the task force published a report that claimed that the prostate specific antigen (PSA) cancer screening test did more harm than good. Many urologists and the American Urological Association (AUA) disputed the decision; the AUA responded that they were “outraged” by the recommendation. Earlier this year, the USPSTF recommended against routine breast cancer screenings for most women under the age of 50. This sparked rebuttals from breast cancer surgeons, radiologists, and other healthcare professionals involved in diagnosing and treating breast cancer. It has also urged that the prostate-specific antigen (or PSA) test that has become a standard part of older men’s yearly physicals be abandoned. The USPSTF’s current hot button topic was published on May 29 in the Annals of Internal Medicine. The panel reported that evidence was lacking that hormone replacement therapy (HRT) reduced the incidence of bone fractures, dementia, and cardiovascular disease (i.e., strokes and heart attacks).
In their report, the USPSTF noted that “menopausal hormone therapy to prevent chronic conditions is currently not recommended because of its adverse effects.” The authors noted that the goal of their study was to update evidence regarding the effectiveness of HRT in reducing risk for chronic conditions and adverse effects, and to examine whether outcomes vary among women in different subgroups. The investigators searched out randomized, placebo-controlled trials of menopausal hormone therapy published in English since 2002 that assessed primary prevention of chronic conditions. They reviewed the following data sources: Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews (through the 3rd quarter of 2011); MEDLINE (January 2002 to November 2011); Scopus; and reference lists.
The researchers noted that nine “fair-quality trials” met the inclusion criteria. They noted that the large Women's Health Initiative (WHI) study reported most of the results; this study had 11 years of follow-up and contained had data most applicable to postmenopausal women in the US. They noted that the WHI reported that estrogen plus progestin reduced fractures (46 fewer per 10 000 woman-years); however, it increased invasive breast cancer (8 more per 10 000 woman-years), stroke (9 more per 10 000 woman-years), deep venous thrombosis (12 more per 10 000 woman-years), pulmonary embolism (9 more per 10 000 woman-years), lung cancer death (5 more per 10 000 woman-years), gallbladder disease (20 more per 10 000 woman-years), dementia (22 more per 10 000 woman-years), and urinary incontinence (872 more per 10 000 woman-years). Estrogen-only therapy reduced fractures (56 fewer per 10 000 woman-years) and invasive breast cancer incidence (8 fewer per 10 000 woman-years) and death (2 fewer per 10 000 woman-years); however, it increased stroke (11 more per 10 000 woman-years), deep venous thrombosis (7 more per 10,000 woman-years), gallbladder disease (33 more per 10,000 woman-years), and urinary incontinence (1,271 more per 10,000 woman-years). Outcomes did not consistently differ by age or comorbid conditions.
The authors noted several limitations of the studies: adherence (continued of medication as recommended), high attrition (discontinuance), inadequate power to detect risks for some outcomes, and evaluation of few regimens.