Menopause, defined as “the permanent cessation of menstruation caused by a loss of ovarian function,” is the final stage in a woman’s reproductive life [1]. Women going through “the change” may report hot flashes and other vasomotor symptoms (VMS), anxiety, insomnia, and overall reduced quality of life. These same women are also at higher risk of developing certain cancers, cardiovascular disease, and dementia.
A common treatment for women in this stage of life used to be hormone replacement therapy (HRT). But for the past two decades, HRT was believed to be dangerous, especially for women over age 65, and therefore was rarely prescribed. As I’ll cover below, that conclusion has been recently called into question.
We know that for some women, menopause symptoms don’t stop just because they’ve reached retirement age (i.e., age 65). According to The Menopause Society, at least 2-7% of women continue to experience severe symptoms well after this standard cut-off age [2]. Is it safe to keep treating these women? A 2024 observational study conducted and published by The Menopause Society aimed to better understand just how long HRT, which is now referred to as hormone therapy (HT), is appropriate for women with continued menopausal symptoms [2]. The study aimed to answer the questions: Should we be treating women in their 60s? 70s? What medications are best, and does it matter how many years women take them?
How was menopause historically treated?
There have been, and continue to be, major gaps in our understanding of the best ways to prescribe HT for menopausal women [3]. One of the primary reasons for this gap is that HT refers to many different combinations of medications, dosages, and routes of administration. Some are considered bioidentical (molecularly identical to the body’s own natural hormones), while some are not.
As previously mentioned, HT treatment for early menopause was widely accepted in the past [1]. However, in 2002, that view shifted with the publication of the HERS (Heart and Estrogen/Progestin Replacement Study) and WHI (Women’s Health Initiative) randomized trials, which concluded that HT could increase the risk of cardiovascular disease. Since then, many healthcare providers have significantly decreased HT prescriptions for their menopausal patients.
Major medical societies once again recommend HT, but there’s a catch
Over the past 20 years, dozens of studies have been conducted, expanding our knowledge of HT for menopausal women. This research suggests that the findings in the HERS and WHI studies may not have accurately represented the risks and benefits of HT. For example, Northwestern University professor Dr. Lauren Streicher recently told NPR that previous risks were associated with higher hormone doses, plus hormones (she specifically mentioned the Depo-Provera shot) that “we don’t prescribe [for that reason] anymore.”
Because of the encouraging, more recent evidence on HT, four major U.S. medical societies, the American College of Obstetricians and Gynecologists (ACOG), the American Association of Clinical Endocrinology, the Endocrine Society, and The Menopause Society (previously called The North American Menopause Society), all now state that HT is a viable option for treating menopausal symptoms. However, these societies lack agreement on the methodology of how HT should be prescribed [3].
Is HT a good idea after age 65? It depends
I wrote above that 2-7% of women may experience menopausal symptoms after age 65, and that one of the challenges in previous research on menopausal HT is that there are multiple types, routes, and dose options for HT. The aforementioned 2024 observational study, published by The Menopause Society, assessed the various types of HT administered to women beyond the age of 65 years, and aimed to clarify the risk for different combinations of medicines and doses so that women can receive more personalized recommendations [2]. By following the medication and doctor visit records of 10 million senior women on Medicare from 2007-2020, the researchers sought to determine whether HT increased risk of all-cause mortality, five cancers, six cardiovascular-related diseases, and dementia.
They discovered that the benefits and risks of long-term HT after 65 years varied significantly “depending on type, route, and dose prescribed.” This finding was in line with the Menopausal Society’s 2022 HT Statement, which said that HT prescriptions should be individualized—not based on an age cutoff—and continued as long as the woman is regularly assessed by a medical professional well-versed in the risks and benefits of extended HT [4]. Overall, the study found that, compared with women who never used HT or discontinued it before age 65, extended HT was associated with a reduction in negative menopausal symptoms [2].
Specifically, estrogen monotherapy (estrogen alone) was associated with a decreased risk of mortality, cancers, dementia, cardiovascular disease, and VMS [2]. Progestin monotherapy significantly reduced the risk of multiple cancers, congestive heart failure, and venous thromboembolism. Combination (estrogen plus progestin) HT was found to increase the risk of breast cancer, but these risks were mitigated when given in low doses and transdermally (applied topically to the skin) or vaginally.
What were the limitations, and what do we still not know?
This study helped to bridge the gap in understanding appropriate extended menopausal HT. More research is needed to fully understand the benefits and risks of the various HT formulations, as well as the risks of extended HT [2]. The limitations of this study all lie in the fact that this was an observational study; therefore, the researchers were relying on the availability of medical data. Furthermore, their data collection began for participants at age 65 years, so information on past health conditions or hysterectomies could not be noted in the study. They also could not assess variables such as healthy and unhealthy behaviors among the patients.
The bottom line on whether HT should be prescribed after age 65
Like everything else when it comes to women’s reproductive health, every woman’s experience of menopause is unique and requires individualized treatment. Current research points to the safety of continuing to prescribe HT after age 65, with special attention to the type of medicine, route, and dose based on each woman’s medical history and risk factors.
Additional Reading:
Managing perimenopause naturally
What can cause premature and early menopause?
Genitourinary syndrome of menopause: Can vaginal dryness pose a danger to your health?
