The levels of evidence (1 to 4) and the recommendation grades (A to D) are defined at the end of the "Major Recommendations" field. A recommendation grade is linked to the best evidence level (BEL) available.
Executive Summary of Recommendations
Each recommendation is labeled "R" in this summary. All recommendation grades were determined by unanimous consensus of the primary writers and reviewers.
R1. Menopausal hormone therapy (MHT) may be appropriate for the relief of severe menopausal symptoms in selected postmenopausal women, on the basis of an individually determined benefit-versus-risk profile (Grade A; BEL 1).
R2. MHT may be prescribed during the perimenopause and early menopause for relief of menopausal symptoms and treatment of vulvovaginal atrophy (Grade A; BEL 1).
R3. The use of the transdermal route of estrogen administration should be considered in order to avoid the hepatic "first-pass effect," which may theoretically reduce the risk of thromboembolic disease (Grade B; BEL 3).
R4. The use of transvaginal estrogen may be considered to provide topical effects with less systemic absorption (Grade B; BEL 3).
R5. The dose of MHT may be reduced with advancing age (Grade C; BEL 3).
R6. Because of the increased risk of endometrial cancer, unopposed estrogen should not be used in women with an intact uterus (Grade D; BEL 1).
R7. Progestational agents should be used for a minimum of 10 to 14 days per month in women treated with estrogen who have an intact uterus (Grade A; BEL 1).
R8. Long-cycle therapy with use of a progestagen for 14 days every 3 months may be considered, in an effort to reduce breast exposure to progestagens, despite lack of definitive assessment of efficacy (Grade B; BEL 2).
R9. Amenorrhea may be achieved by using a low dose of a progestagen administered continuously (daily) in conjunction with estrogen. Because recent studies suggest adverse breast outcomes with continuous progesterone exposure, this form of therapy is not recommended (Grade D; BEL 2).
R10. MHT should be used in the lowest dose and for the shortest period necessary to control menopausal symptoms (Grade A; BEL 1).
R11. Therapeutic trials of nonhormonal prescription medications, including clonidine, antidepressants (selective serotonin reuptake inhibitors), and gabapentin, may be considered for the relief of menopausal symptoms in women with no specific contraindications (Grade B; BEL 2).
R12. Over-the-counter supplements should be used with caution because they are not regulated by the US Food and Drug Administration (FDA) and have the potential for interactions with drugs and for causing harm (Grade C; BEL 2).
R13. Phytoestrogens, including soy-derived isoflavonoids, result in inconsistent relief of symptoms. Because these compounds may have estrogenic effects, women with a personal or strong family history of hormone-dependent cancers (breast, uterine, or ovarian), thromboembolic events, or cardiovascular events should not use soy-based therapies (Grade D; BEL 1).
R14. Custom compounded "bioidentical hormone therapy" is not recommended (Grade D; BEL 1).
R15. FDA-approved bioidentical hormone preparations may be considered, but evidence is lacking that they are safer or more effective than traditional forms of hormone therapy (Grade C; BEL 2).
R16. MHT should be used for the prevention and treatment of osteoporosis within the context of the overall benefit-versus-risk analysis of each patient. Data from multiple randomized controlled trials (RCTs) substantiate the efficacy of estrogens in preserving bone mass and, less consistently, preventing fractures, but nonhormonal therapeutic options for bone health exist (Grade A; BEL 1).
R17. Hormone therapy for the prevention or treatment (or both) of dementia is not recommended (Grade D; BEL 1).
R18. MHT should be prescribed to women in conjunction with a thorough discussion of the possible relationship of MHT to breast cancer. Current evidence suggests that combination estrogen and progestational agent (E+P) regimens are associated with a possible higher risk of breast cancer than is therapy with estrogen alone (Grade A; BEL 1).
R19. Concordant with current FDA warnings, the task force recommends that women who are at increased risk of thromboembolic disease should not take estrogen-containing therapy (although there is evidence that transdermal estradiol may not increase this risk; see subsequent material) (Grade D; BEL 1).
R20. Women should be advised that smoking increases the risk of cardiovascular and venous thromboembolic disease when taking estrogen, and aggressive smoking cessation programs should be advised (Grade A; BEL 1).
R21. MHT is not recommended for primary or secondary prevention of cardiovascular disease (Grade D; BEL 1).
R22. Lipid profiles, smoking history, and diabetes history as well as family history should be assessed to assist in the determination of individual cardiovascular risk (Grade A; BEL 1).
R23. Women should be advised that cerebrovascular accidents occur with increased frequency in patients taking estrogen alone or E+P combination therapies in an age-dependent manner (Grade A; BEL 1).
R24. Women should be advised that there may be an increase in ovarian epithelial tumors with the use of estrogen for more than 10 years (Grade B; BEL 2).
R25. Women may be advised that several studies including the Women's Health Initiative (WHI) have demonstrated a lower risk of colon cancer in women treated with E+P combination (Grade B; BEL 2).
Definitions:
American Association of Clinical Endocrinologists Evidence Rating Based on Reference Methodologya
Numerical Descriptor (evidence level)b |
Semantic Descriptor (reference method) |
1 |
Meta-analysis of randomized controlled trials (MRCT) |
1 |
Randomized controlled trial (RCT) |
2 |
Meta-analysis of nonrandomized prospective or case-controlled trials (MNRCT) |
2 |
Nonrandomized controlled trial (NRCT) |
2 |
Prospective cohort study (PCS) |
2 |
Retrospective case-control study (RCCS) |
3 |
Cross-sectional study (CSS) |
3 |
Surveillance study (registries, surveys, epidemiologic study) (SS) |
3 |
Consecutive case series (CCS) |
3 |
Single case reports (SCR) |
4 |
No evidence (theory, opinion, consensus, or review) (NE) |
aAdapted from: Mechanick et al., American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Practice Guidelines--2010 update. Endocr Pract. 2010;16:270-283.
b1 = strong evidence; 2 = intermediate evidence; 3 = weak evidence; and 4 = no evidence.
Grading of Recommendations: How Different Evidence Levels Can Be Mapped to the Same Recommendation Gradea
Best Evidence Level |
Subjective Factor
Impactb |
Two-Thirds Consensus |
Mapping |
Recommendation Grade |
1 |
None |
Yes |
Direct |
A |
2 |
Positive |
Yes |
Adjust up |
A |
2 |
None |
Yes |
Direct |
B |
1 |
Negative |
Yes |
Adjust down |
B |
3 |
Positive |
Yes |
Adjust up |
B |
3 |
None |
Yes |
Direct |
C |
2 |
Negative |
Yes |
Adjust down |
C |
4 |
Positive |
Yes |
Adjust up |
C |
4 |
None |
Yes |
Direct |
D |
3 |
Negative |
Yes |
Adjust down |
D |
1, 2, 3, 4 |
Not applicable |
No |
Adjust down |
D |
a Starting with the left column, best evidence level (BEL), subjective factors, and consensus map to recommendation grades in the right column. When subjective factors have little or no impact ("none"), then the BEL is directly mapped to recommendation grades. When subjective factors have a strong impact, then recommendation grades may be adjusted up ("positive" impact) or down ("negative" impact). If a two-thirds consensus cannot be reached, then the recommendation grade is D. For not applicable (regardless of the presence or absence of strong subjective factors), the absence of a two-thirds consensus mandates a recommendation grade D.
b See "Description of Methods Used to Formulate the Recommendations" field for further information.
Adapted from: Mechanick et al., American Association of Clinical Endocrinologists Protocol for Standardized Production of Clinical Practice Guidelines--2010 update. Endocr Pract. 2010;16:270-283.