Gartlehner G, Patel SV, Feltner C, et al.   Hormone Therapy for the Primary Prevention of Chronic Conditions in Postmenopausal Women: Evidence Report and Systematic Review for the US Preventive Services Task Force.
JAMA. 2017 Dec 12;318(22):2234-2249. doi: 10.1001/jama.2017.16952.   (Systematic Review)   PMID: 29234813   
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Physician Disciplines Relevance to practice Is this news?
Gynecology
Family Medicine (FM)/General Practice (GP)
General Internal Medicine-Primary Care(US)
Internal Medicine
Public Health

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Abstract
Importance: Postmenopausal status coincides with increased risks for chronic conditions such as heart disease, osteoporosis, cognitive impairment, or some types of cancers. Previously, hormone therapy was used for the primary prevention of these chronic conditions.
OBJECTIVE: To update evidence for the US Preventive Services Task Force on the benefits and harms of hormone therapy in reducing risks for chronic conditions.
DATA SOURCES: MEDLINE, Cochrane Library, EMBASE, and trial registries from June 1, 2011, through August 1, 2016. Surveillance for new evidence in targeted publications was conducted through July 1, 2017.
STUDY SELECTION: English-language randomized clinical trials reporting health outcomes. Data Extraction and Synthesis: Dual review of abstracts, full-text articles, and study quality; meta-analyses when at least 3 similar studies were available. Main Outcomes and Measures: Beneficial or harmful changes in risks for various chronic conditions.
RESULTS: Eighteen trials (n = 40058; range, 142-16608; mean age, 53-79 years) were included. Women using estrogen-only therapy compared with placebo had significantly lower risks, per 10000 person-years, for diabetes (-19 cases [95% CI, -34 to -3]) and fractures (-53 cases [95% CI, -69 to -39]). Risks were statistically significantly increased, per 10000 person-years, for gallbladder disease (30 more cases [95% CI, 16 to 48]), stroke (11 more cases [95% CI, 2 to 23]), venous thromboembolism (11 more cases [95% CI, 3 to 22]), and urinary incontinence (1261 more cases [95% CI, 880 to 1689]). Women using estrogen plus progestin compared with placebo experienced significantly lower risks, per 10000 person-years, for colorectal cancer (-6 cases [95% CI, -9 to -1]), diabetes (-14 cases [95% CI, -24 to -3), and fractures (-44 cases [95% CI, -71 to -13). Risks, per 10000 person-years, were significantly increased for invasive breast cancer (9 more cases [95% CI, 1 to 19]), probable dementia (22 more cases [95% CI, 4 to 53]), gallbladder disease (21 more cases [95% CI, 10 to 34]), stroke (9 more cases [95% CI, 2 to 19]), urinary incontinence (876 more cases [95% CI, 606 to 1168]), and venous thromboembolism (21 more cases [95% CI, 12 to 33]). Conclusions and Relevance: Hormone therapy for the primary prevention of chronic conditions in menopausal women is associated with some beneficial effects but also with a substantial increase of risks for harms. The available evidence regarding benefits and harms of early initiation of hormone therapy is inconclusive.

Comments from Clinical Raters
Family Medicine (FM)/General Practice (GP)
A good summary of the evidence.
Family Medicine (FM)/General Practice (GP)
This is very important news. Most physicians probably know that HRT has a bunch of risks and benefits, but this systematic review quantifies those risks from across the medical literature. No physician could possibly know all of these results, so this is very helpful. I doubt it will change anyone's mind about the general disdain for HRT, but it will certainly inform clinicians thoroughly.
General Internal Medicine-Primary Care(US)
As a hospitalist, this comprehensive review does not change our practice. While hospitalized, the risk for VTE rises and thus we would discourage the use of HRT. As a former primary care doctor, this review would not change my practice of avoiding HRT since the WHI reports were published. Short-term use for recalcitrant vasomotor symptoms is the only safe role.
General Internal Medicine-Primary Care(US)
The hormone replacement saga continues. This systematic review from the US Preventive Services Task Force updates their 2013 recommendations. It is a complex paper. Fortunately, a crystal clear editorial reviews the history and deconvolutes the paper. In short, use of hormone replacement therapy (HRT) for the prevention of chronic disease has some potential benefits but also severe harms. The editorial concludes that HRT may be considered for severe vasomotor symptoms immediately following the climacteric, however, it is not indicated for the prevention of chronic diseases. As one would expect with a meta-analysis, there are many limitations. Perhaps the most important is that 80% of the women in the studies are white. Another is that the drop-out rate in many of the studies is high. Since the size of the study necessary to answer conclusively the chronic disease risk/reward question is enormous and not feasible, analyses of this sort is likely to be the best we will get.
Gynecology
Extremely important information for all practitioners to give informed consent to patients regarding hormone therapy. Although this is not new information, it is important to have it all in one publication.
Gynecology
Excellent cohesive summary of evidence to date on effects of hormone therapy on chronic health conditions. As an MD in women's health, this will be data that I quote to patients when considering the pros and cons of hormones. Previously, I used just WHI data, but this is more comprehensive. I would love a graphic summary to use in patient education.
Public Health
Promotion of HRT based intervention is increasing, so a high quality review of the high quality studies is welcome.