The AHAH Group Response to the USPTS Update on use of Hormone Therapy

Posted on May 30, 2017

May 2017 -- AHAH (Advancing Health After Hysterectomy) is a non-profit foundation dedicated to the health of women who have had a hysterectomy. In the USA, there are 8 million such women who are under age 60 with half of them age 45 or younger. On behalf of these women, we would urge the USPSTF not to suggest that estrogen therapy (ET) deserves a grade of D for disease prevention because the totality of recent data supports a higher grade. Consider the following:

  1. WHI was designed “to test whether the beneficial associations consistently seen in women starting HRT near menopause would be found in women well beyond menopause” (Climacteric 2017). Currently, WHI investigators urge that findings of harms in older women should not be applied to younger women in whom treatment benefits are greater and adverse effects are much less significant. (NEJM 2016;Climacteric 2017).
  2. WHI findings show that hysterectomized women who start ET between age 50-59 and/or within 10 years of menopause have a reduced risk for osteoporosis and hip fracture, urogenital atrophy, and cardiovascular disease (CVD). These women show a significant reduction in breast cancer risk compared to placebo-treated women. (JAMA 2006;JNCI 2012;JAMA 2013) They also show a reduction in all-cause mortality. (JAMA 2011) These WHI-ET findings are confirmed in cohort and randomized trials. (Cochrane Rev. 2015;Am J Med 2009;Climacteric 2017).
  3. Cohort studies show that untreated, surgically-menopausal women age 45 and younger, compared to women with continuing ovarian function, have increased risks for CVD, stroke, osteoporosis, cognitive decline and dementia, Parkinsonism, sexual dysfunction, psychiatric disorders, lung cancer, and all-cause mortality.(MayoClinProc 2016;Climacteric 2015,2016). The FDA, supported by the totality of data, has approved the use of ET for treatment of premature hypoestrogenism (most commonly due to surgery) for health benefits including symptom control, prevention of bone loss, cognition and mood issues, and heart disease. (JCEM 2016;JAMA Cardiol 2016;Climacteric 2015,2016).
  4. The Task Force recognizes that ET is highly effective at treating hot flashes but does not seem to appreciate that untreated hot flashes pre-dispose to endothelial dysfunction, hypertension, CVD, depression, and cognitive impairment. (Menopause 2011,2012).
  5. Prematurely menopausal women with BRCA mutations show no increased risk with ET(Menopause 2014). ET-treated women with sisters who have breast cancer show a reduced risk for developing breast cancer compared to untreated siblings. (AmJEpidem 2015)
  6. Since 2002, an 80% decline in use of ET by hysterectomized women has led to a public health crisis. A “best-estimate” of over 40,000 excess deaths has been calculated for the non-use of ET by women aged 50-59 between 2002 and 2011. (AJPH 2013)
  7. New statements from professional societies advocate ET for women under 60 :

a. The International Menopause Society (2016): “In women <60 years old, who are recently menopausal and with no evidence of cardiovascular disease, the initiation of estrogen-alone therapy reduces coronary heart disease and all-cause mortality. …the most recent Cochrane analysis, other meta-analyses, and the WHI 13-year results all show a consistent reduction in all-cause, mortality.” A grade of A is given for the data. (Climacteric 2016)

b. The North American Menopause Society (2017): “Estrogen alone in women who have had a hysterectomy under age 60 and/or within 10 years of menopause had fewer breast cancers, less CVD, and less mortality.”(Level 1)(Menopause 2017)

Unwarranted mistrust and fears of ET have become deeply rooted and widespread among health practitioners, women consumers, and the media. The situation poses a major health education challenge, calling for greater dissemination of accurate information and treatment recommendations. The USPSTF has a unique opportunity to correct misunderstandings and to help women make truly informed choices about the use of ET.