Here is one more menopause hormone therapy (MHT) myths is it relates to duration of MHT.
Myth: Women who take MHT should stop by the age of 60. 
There is no such guideline from the main menopause expert organizations. There is no general rule for stopping systemic hormone therapy in a woman aged 60, or even 65 years. The Beers criteria from the American Geriatrics Society does list a warning for the use of MHT in women 65 and older. However, any routine discontinuation of systemic MHT is not cited by evidence nor supported by the American College of OB/Gyns (ACOG) or the North American Menopause Society (NAMS). However, the continued use of MHT in a healthy woman older than 65 and at low risk of breast cancer and cardiovascular disease is limited by insufficient evidence for safety, risks and benefits but is now supported by a significant study published in April 2024.
This study aimed to assess the use of menopausal hormone therapy beyond age 65 years and its health implications by types of estrogen/progestogen, routes of administration, and dose strengths. Using prescription drug and encounter records of 10 million senior Medicare women from 2007-2020 and Cox regression analyses adjusted for time-varying characteristics of the women, the researchers examined the effects of different preparations of menopausal hormone therapy on all-cause mortality, five cancers, six cardiovascular diseases, and dementia. Results: Compared with never use or discontinuation of menopausal hormone therapy after age 65 years, the use of estrogen monotherapy beyond age 65 years was associated with significant risk reductions in mortality (19% ), breast cancer (16%), lung cancer (13%), colorectal cancer (12%), congestive heart failure (CHF) (5%), venous thromboembolism (3%), atrial fibrillation (4%), acute myocardial infarction (11%), and dementia (2%). For the use of estrogen and progestogen combo-therapy, both E+ progestin and E+ progesterone were associated with increased risk of breast cancer by 10%-19%, but such risk can be mitigated using low dose of transdermal or vaginal E+ progestin. Moreover, E+ progestin exhibited significant risk reductions in endometrial cancer (45%), ovarian cancer (21%), ischemic heart disease (5%), CHF (5%), and venous thromboembolism (5%), whereas E+ progesterone exhibited risk reduction only in CHF (4%).
Conclusions: Among senior Medicare women, the implications of menopausal hormone therapy use beyond age 65 years vary by types, routes, and strengths. In general, risk reductions appear to be greater with low rather than medium or high doses, vaginal or transdermal rather than oral preparations, and with estradiol rather than conjugated estrogen.
If a woman is considered healthy and has persistent vasomotor symptoms, continuing MHT is a reasonable option with evaluation or risk and benefit yearly. MHT is also a treatment option for osteoporosis and prevention of hip and spine fractures. MHT would need to be continued in order to get that fracture risk reduction. Long term MHT is not indicated or considered appropriate for reduction of dementia or CHD. However, there is an increasing amount of biologic plausibility and data on the benefits of systemic estrogen to the brain, if started in perimenopause or within the first 10 years of last menstrual period and perhaps even within the last 5 years or before age 60. If a woman has a family history of Alzheimer’s disease (AD) and has initiated MHT within the optimal window of before age 60 and before 10 years postmenopause, it is this practitioner’s opinion and recommendation that she continue on MHT long term, in order to reduce her risk of AD. This is not yet an FDA approved use of MHT nor is it a standard of care guideline from the advisory organizations. However, given we have a terrible disease, with no cure, and my patient is at increased risk, this is a topic I’m going to discuss. However, if she is > 60 or past 10 years postmenopause, I will not initiate it, even with her family history, because initiating outside of the window, may actually increase her risk. See the next myth for more.
Women should be evaluated at minimum, once per year, to weigh the benefits and risks with their health care provider. Women can continue if there are appropriate indications including severe vasomotor symptoms, and/or as a treatment option for osteoporosis of the lumbar spine.
What is true relative to stopping systemic estrogen is that by age 65, if women are on oral or sublingual, they need to switch to transdermal delivery of that estrogen. Her aging vessels and metabolism of estrogen are now more subject to higher effects of oral/sublingual estrogen on atherosclerosis and risk for DVT and stroke. The pharmacokinetics of estrogen metabolism (and of many drugs), in the liver, changes with age and warrants transdermal delivery of that estrogen to mitigate the stimulation of clotting factors by oral estrogen, and to mitigate more variable absorption issues.
References and Resources:
“The 2022 Hormone Therapy Position Statement of The North American Menopause Society” Advisory Panel. The 2022 hormone therapy position statement of The North American Menopause Society. Menopause 2022 Jul 1;29(7):767-794.
Baik S, et al. Use of menopausal hormone therapy beyond age 65 years and its effects on women’s health outcomes by types, routes, and doses. Menopause 2024 May 1;31(5):363-371.
